Professional Organizations Supporting Critical Care Nursing Practice, Exams of Nursing

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Dysrhythmia Interpretation and Management

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1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Society of Critical Care Medicine ANS: A The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist. DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in certification. Which credential would be most applicable for her to seek? a. ACNPC b. CCNS c. CCRN d. PCCN ANS: C The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings. DIF: Cognitive Level: Application REF: p. 5 OBJ: Explain certification options for critical care nurses. TOP: Nursing Process Step: N/AMSC:

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NCLEX: Safe and Effective Care EnvironmentLack of day-night cues c. Sounds from the mechanical ventilator d. Visiting hours tailored to meet individual needs ANS: A, B, C, D Adjustment of visiting hours to meet needs of patients and families assists in reducing the stress of critical illness. All other responses are environmental stressors that increase anxiety, affect sleep, and the like. DIF: Cognitive Level: Comprehension REF: pp. 15 - 16 OBJ: Describe stressors in the critical care environment and strategies to reduce them. TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

6. A patient and his family are excited that he is transferring from the critical care unit to the intermediate care unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress the nurse can: (Select all that apply.) a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. c. ensure that the patient will be located near the nurses station in the new unit. d. invite the nurse who will be assuming the patients care to meet with the patient and family in the critical care unit prior to transfer. ANS: A, D Patients often have stress when they are moved from the safety of the critical care unit. Introducing the patient and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation stress. Although the patient and his family may feel safer in a room near the nurses station, bed placement is determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and once the physician has determined that the patient no longer meets critical care admission requirements, it is essential that transfers be made once a bed on the intermediate care unit is available. DIF: Cognitive Level: Analysis REF: p. 17 OBJ: Describe stressors in the critical care environment and strategies to reduce them. TOP: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 7. The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.) a. Adjust lighting to promote normal sleep-wake cycles. .

49 of 392 49 Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing. DIF: Cognitive Level: Analysis REF: p. 38 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance

15. The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following? a. Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering. ANS: A Any treatment that is used to sustain life, including nutrition, fluids, antibiotics, blood products, and respiratory support, may be withdrawn in consultation with the patient and/or surrogate provided that the patient has been deemed terminal or persistently vegetative. Any dose of anxiolytics or analgesics may be used to relieve suffering, although these may have the potential to hasten death. Life-sustaining treatment should not be withdrawn while the patient is receiving paralytic treatments. Death occurs as a consequence of the underlying disease, and the goal of care is to relieve suffering, not hasten death. DIF: Cognitive Level: Analysis REF: p. 40 | Box 4 - 3 OBJ: Describe ethical and legal concerns related to end-of-life care. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment
16. The patients husband is terrified by the prospect of removing life-sustaining treatments from the patient. He asks why anyone would do that. The nurse explains, a. It is to save you money so you wont have such a large financial burden. b. It will preserve limited resources for the hospital so other patients may benefit from them. c. It is to discontinue treatments that are not helping your wife and may be very uncomfortable for her. d. We have done all we can for your wife and any more treatment would be futile.

75 of 392 75 ANS: D Mucosal villi replenish every 3 to 4 days; without nutritional stimulation, they atrophy. DIF: Cognitive Level: Comprehension REF: p. 80 OBJ: Review the anatomy and physiology related to utilization of nutrients. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. An important nutritional consideration in the elderly population is: a. decreased protein requirements. b. increasing caloric requirements with age. c. potential for drug-nutrient interaction related to polypharmacy. d. presence of other diseases that decrease caloric needs. ANS: C Patients taking multiple medications have a greater potential for drug-nutrient interactions; elderly persons may be taking multiple medications. DIF: Cognitive Level: Analysis REF: Geriatric Considerations box OBJ: Describe interventions to achieve nutritional goals. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. Objective data designating that the nutrition goals are not being met include: a. hyperglycemia, normovolemia, and increased protein level. b. overhydration, hypoglycemia, and weight gain. c. weight gain, inconsistent glucose, and normovolemia. d. weight loss, elevated glucose, and dehydration. ANS: D When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and either overhydration or dehydration. DIF: Cognitive Level: Analysis REF: p. 90 OBJ: Describe interventions to achieve nutritional goals. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
17. In trauma patients, enteral nutrition via nasogastric tube feedings into the small bowel is best initiated

99 of 392 Test Bank - Introduction to Critical Care Nursing 8e () 99 d. Sinus arrhythmia ANS: C Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone. DIF: Cognitive Level: Analysis REF: p. 112 | Figure 7 - 25 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

32. Interpret the following rhythm: a. Normal sinus rhythm b. Sinus bradycardia c. Sinus tachycardia d. Sinus arrhythmia ANS: B Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0. 10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. DIF: Cognitive Level: Analysis REF: pp. 112 - 113 | Figure 7 - 26 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

123 of 392 123 b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patients head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side- lying position and record hemodynamic values. ANS: C Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air- fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient. DIF: Cognitive Level: Application REF: p. 152 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

13. The nurse is educating a patients family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? a. The catheter will provide multiple sites to give intravenous fluid. b. The catheter will allow the physician to better manage fluid therapy. c. The catheter tip comes to rest inside my brothers pulmonary artery. d. The catheter will be in position until the heart has a chance to heal. ANS: B A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy. DIF: Cognitive Level: Comprehension REF: p. 160 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated .

152 of 392 ) 152 c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation. ANS: D Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room. Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached. DIF: Cognitive Level: Analysis REF: pp. 190 - 191 OBJ: Formulate a plan of care for the mechanically ventilated patient. TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

31. The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale for this assessment is to: a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patients work of breathing. ANS: C The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing. DIF: Cognitive Level: Comprehension REF: p. 197 OBJ: Formulate a plan of care for the mechanically ventilated patient. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk

176 of 392 176 MSC:NCLEX: Physiological Integrity: Physiological Adaptation

11. The nurse is caring for a renal transplant recipient in the post-anesthesia care unit. Blood pressure is 125/ mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO 2 ) is 95% on 3 L/min of oxygen via nasal cannula, temperature is 97.8 F, and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered. ANS: A Fluid replacement therapy is a priority in a postoperative renal transplant patient with a CVP of 2 mm Hg and elevated heart rate. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario. DIF: Cognitive Level: Analysis REF: Chap 11 OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP: Nursing Process Step: Evaluation MSC:NCLEX: Physiological Integrity: Physiological Adaptation
12. The nurse is caring for a postoperative renal transplant recipient in the critical care unit. After seeing minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse? a. Your kidney has unfortunately failed and will be removed. b. It can take a few days for your kidney to start working c. You are experiencing an acute rejection episode. d. You will have to undergo daily hemodialysis treatments. ANS: B There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold times, altered perfusion states during surgery). It can take a few days for the transplant to function optimally. Low urine output alone is not the sole indicator of kidney failure or an acute rejection episode. Hemodialysis treatments are not routine in the presence of low urine output following a renal transplant. DIF: Cognitive Level: Comprehension REF: Chap 11 OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP: Nursing Process Step: Evaluation .

202 of 392 202 b. Nitroglycerin infusion titrated at a rate of 5 - 10 mcg/min as needed for chest pain c. Dobutamine (Dobutrex) infusion at a rate of 2 - 20 mcg/kg/min as needed for CI < 2 L/min/m^2 d. Dopamine (Intropin) infusion at a rate of 5 - 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg ANS: B The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options. DIF: Cognitive Level: Analysis REF: Table 12 - 4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central lineassociated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management ANS: A Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia. DIF: Cognitive Level: Application REF: p. 282 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales. TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO 2 28 mm Hg, HCO 3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state?

b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary. DIF: Cognitive Level: Application REF: p. 370 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO 2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO 2 of 60 mm Hg is normal) ANS: C Cerebral vessels dilate when PaCO 2 levels increase, increasing cerebral blood volume. Cerebral vessels dilate when CO 2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO 2 ) on cerebral blood flow. PaCO 2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume. DIF: Cognitive Level: Knowledge REF: p. 366 OBJ: Describe the pathophysiology of increased intracranial pressure. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO 2 ) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? .

254 of 392 ) 254 c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family ANS: A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position. DIF: Cognitive Level: Comprehension REF: p. 412 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

26. During rounds, the physician alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is: a. an optional treatment if the PaO 2 /FiO 2 ratio is less 100. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from co-workers. d. used to provide continuous lateral rotational turning. ANS: A Proning is considered if the PaO 2 /FiO 2 ratio is low. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protecting the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed. DIF: Cognitive Level: Application REF: p. 412 OBJ: Discuss medical management of the patient with acute respiratory failure. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
27. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the: a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea. .

280 of 392 280 Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate solutions can be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high. DIF: Cognitive Level: Comprehension REF: p. 457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity

42. The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patients temperature is elevated. The nurse should: a. assess peritoneal dialysate return. b. check the patients blood sugar. c. evaluate the patients neurological status. d. inform the provider of probable visceral perforation. ANS: A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever andchills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity. DIF: Cognitive Level: Analysis REF: p. 457 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
43. The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should: a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patients lungs. d. insert an indwelling catheter. ANS: C .

309 of 392 309 DIF: Cognitive Level: Application REF: p. 539 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

47. Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse: a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks. ANS: C Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment. DIF: Cognitive Level: Application REF: p. 539 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess ANS: B, C, D Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with .

333 of 392 333 Seroconversion is manifested by the presence of HIV antibodies and usually occurs 2 to 4 weeks after the initial infection. Symptoms associated with seroconversion include flu-like symptoms such as fever, sore throat, headache, malaise, nausea and usually last 1 to 2 weeks. The earlier stages of HIV infection may last as long as 10 years and may produce few or no symptoms, although viral particles are actively replacing normal cells. AIDS is the final stage of HIV infection. It is estimated that 99% of untreated HIV-infected individuals will progress to AIDS. Treatment regimens with combined antiviral drug regimens are controlling the progression to AID. AIDS is now considered, for many infected individuals, a chronic disease. DIF: Cognitive Level: Comprehension REF: p. 490 OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

40. When caring for a patient with HIV, the nurse should: a. not focus on the mouth, as infections of the mouth are rare. b. assure the patient that infections are not a major problem at this point. c. inform the patient that the disease does not affect the respiratory system. d. monitor the patients medication regimen. ANS: D Nursing assessment includes evaluation of the neurological status, mouth, respiratory status, abdominal symptoms, and peripheral sensation. As with all immunosuppressed patients, those with HIV infection must be protected from infection. These patients provide additional clinical challenges because of their multisystemic, clinical complications. For unclear reasons, persons with HIV infection have a higher propensity for adverse drug reactions than other patient groups and require careful monitoring of all medication regimens. DIF: Cognitive Level: Application REF: p. 492 OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that: a. all patients with bleeding disorders demonstrate active bleeding. b. many patients have bleeding that is not obvious. c. mucous membranes have a high threshold for bleeding. d. capillaries in mucous membranes lie deep in the membrane. ANS: B .

362 of 392 362 has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV ANS: A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower level trauma centers. DIF: Cognitive Level: Analysis REF: p. 589 | Table 19 - 1 OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment

4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6 - foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel ANS: B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column. DIF: Cognitive Level: Analysis REF: p. 594 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
5. A 24 - year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED: a. includes a cervical spine x-ray study to determine the presence of a fracture.

386 of 392 386 statement indicates the nurses knowledge of nutritional goals? a. Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal. b. Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal. c. It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster. d. Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing. ANS: B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body. DIF: Cognitive Level: Application REF: p. 650 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for: a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder. ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia. DIF: Cognitive Level: Application REF: pp. 650 - 651 OBJ: Formulate a plan of care for the patient with a burn injury. TOP: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity
21. The nurse is planning care to meet the patients pain management needs related to burn treatment. The .