Complex E2 Jeopardy Flashcards
The nurse is caring for a patient in shock. Which is a priority action by the nurse?
Maintain adequate tissue perfusion
The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve CO by increasing the contractile force of the heart?
Dobutamine (Dobutrex)
A patient with acute pancreatitis has hypovolemic shock. Which order will the nurse implement first?
Fluid bolus
What hemodynamic monitoring parameter indicates to the nurse that administering large amount of crystalloid fluids to a patient in septic shock has been effective?
Elevated CVP
Which laboratory test result indicates to the nurse sepsis as a cause of shock?
Thrombocytopenia (low plt count)
Polydipsia, polyuria, abdominal pain, nausea, and “fruity” breath are typical findings in…?
DKA
The patient is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). What manifestation should the nurse expect to find?
With increased AHD, the permeability of renal distal tubules is increased, so water is reabsorbed into circulation. Decreased output of concentrated urine with increased urine osmolality and specific gravity occur. In addition, fluid retention with weight gain, serum hypoosmolality, dilutional hyponatremia, and hypochloremia occur.
A patient with diabetes insipidus (DI) is treated with nasal desmopressin acetate (DDAVP). The nurse determines that the drug is not having an adequate therapeutic effect when the patient experiences
A urine with a specific gravity of 1.002 is very dilute, indicating there there continues to be excessive loss of water and that treatment of DI is inadequate
In HHS, laboratory results are similar to those in DKA, but with three major exceptions. Which lab findings should the nurse anticipate in a patient with HHS?
Higher serum glucose, higher osmolality, and minimal ketosis
A patient with SIADH is treated with water restriction. Which three findings would indicate that treatment has been effective?
Improvement in the patient’s condition is reflected by increased UO, normalization of serum Na, and more water in the urine, thus decreasing the specific gravity
Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include
Bladder distention
The nurse is educating a new RN on the therapeutic effect of head-of-bed elevation and neutral head and neck alignment on a patient with increased ICP. Which statement by the new RN indicates that teaching has been effective?
- Facilitating venous drainage
- Decreasing venous obstruction
The nurse is monitoring a patient’s ICP. While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action?
Cease stimulating the patient
What is the priority intervention in the ED for the patient with a stroke?
Maintaining respiratory function with a patent airway and oxygen administration
What should the nurse do when providing care for a patient with an acute attack of trigeminal neuralgia?
Maintain a quiet, comfortable, draft-free environment.
Because attacks of trigeminal neuralgia may be precipitated by hot or cold air movement on the face, jarring movements, or talking, the environment should be of moderate temperature and free of drafts. The patient should not be expected to converse during the acute period. Patients often prefer to carry out their own oral care because they are afraid someone else may inadvertently injure them or precipitate an attack. The nurse should stress that oral hygiene be done because patients often avoid it. Residual food in the mouth after eating occurs more often with Bell’s Palsy.
A patient has sustained deep partial thickness and full thickness burns over 60% of her body. Shortly after admission, her blood pressure drops rapidly to a systolic pressure of 70 mm Hg. You know this is primarily due to
Hypovolemic shock
Your patient weighs 60 kg and has a 40% total body surface area (TBSA) burn injury. Fluid resuscitation orders are for 4 mL/kg/% burn of a Lactated Ringer’s solution. What volume should the nurse anticipate infusing during the first 8 hours?
4800 mL
Which type of burn injury would cause myoglobinuria, long bone fractures, dysrhythmias, and/or cardiac arrest?
Electrical
Which burn patient should have endotrachial intubation?
Thermal burn injuries to the face, neck, or airway
All burn patients are at increased risk for acute respiratory distress syndrome (ARDS) due to
Increased capillary permeability
A 53-year old patient has kidney and ureteral stones and is hospitalized for urinary retention and severe flank pain. The nurse interprets the level of kidney injury to be
Postrenal
The patient is admitted for general malaise and low urine output. The patient is alert and oriented and states that he has lost 5 pounds over the past few days. His hear rate is 124 beats/min. His blood pressure is 88/40 mm Hg. His mouth is dry and he has flat neck veins and poor skin turgor. The nurse interprets that his low UO is due to
Prerenal causes
The patient is admitted with generalized edema and hypertension. The patient states that his UO has been less than normal. An indwelling urinary catheter is inserted, but very little urine is obtained. The patient has distended neck veins, and his blood pressure is 210/110 mm Hg. The nurse interprets that the patient’s fluid retention is due to
Intrarenal causes
The patient has a potassium level of 7 mEq/L but is not scheduled for a dialysis treatment for the next 3 days. To reduce plasma and body potassium levels, the nurse prepares to administer
Sodium polystyrene sulfonate (Kayexalate)
A patient with AKI is a candidate for continuous renal replacement therapy (CRRT). What is the most common indication for the use of CRRT?
Fluid overload.
CRRT is indicated for the patient with AKI as an alternative or adjunct to HD to slowly remove solutes and fluid in the hemodynamically unstable patient. It is especially useful for treatment of fluid overload, but HD is indicated for treatment of hyperkalemia, pericarditis, or other serious effects of uremia
When a nurse is performing a primary survey in the ED, what is being assessed?
The status of airway, breathing, circulation, disability, and exposure/environmental control
When is the placement of a nasograstic tube contraindicated during emergency care?
Head or facial trauma
In which patient situation would therapeutic hypothermia be started in the ED?
Postcardiac arrest for 24 hours after the return of spontaneous circulation (postdefibrillation) improves mortality and neurologic outcomes.
I.e.: 62-year-old man defibrillated by emergency medical technicians (EMTs); on ED arrival, he is not responsive, his heart rhythm and BP are stable
A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous, and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect
Compartment syndrome
Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation?
Vasopressors
The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer what medication?
H2-histamine receptor blockers
The patient is admitted with upper GI bleeding following an episode of forceful retching associated with excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware of what related fact?
A Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa
Lactulose is considered the first-line treatment for hepatic encephalopathy and works by what process?
Trapping ammonia in the bowel for excretion
The nurse is caring for a patient with severe ascites secondary to chronic liver failure. The patient lying supine in bed reports difficulty breathing. The nurse’s first action should be to take what action?
Position the patient in a semi-Fowler’s position
Why is pain control a nursing priority in patients with acute pancreatitis?
Pain increases pancreatic secretions
What is the best action by the nurse to level and zero a hemodynamic monitoring system transducer?
Position the air-fluid interface of the zeroing tranducer at the phlebostatic axis (fourth intercostal space, midaxillary line)
The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC?
“The catheter will allow the primary health care provider to better manage fluid therapy.”
Which of the following situations may result in a low cardiac output and low cardiac index?
Hypovolemia, myocardial infarction, and shock
What is the primary reason that hemodynamic monitoring is used to severe respiratory failure?
To evaluate cardiac status and blood flow to tissues
During hemodynamic monitoring, the nurse finds that the patient has a decreased CO with unchanged pulmonary artery wedge pressure (PAWP), HR, and SVR. The nurse identifies that the patient has a decrease in what?
Contractility
Identify at least 3 nursing interventions indicated for the following desired outcomes of prevention of aspiration for enteral feedings
X-ray confirmation of tube location before feeding. Recheck the tube’s insertion length at regular intervals. Position the patient with the HOB elevated 30-45 degrees during feedings. Following intermittent feedings, keep the HOB elevated for 30-60 mins. Measuring gastric residuals is per institutional policy as there is a lot of disagreement about whether gastric residuals should be checked. Monitor for sensation of fullness, nausea, and vomiting. Promotility medications may be prescribed.
What 2 nursing interventions are indicated during parenteral nutrition to prevent the following complications of infection
-Refrigerate solutions until 30 minutes before use
-Aseptically change dressing to catheter site per institutional protocol and assess for signs of infection
-Label data and time started
-Change filter and tubing every 24 hours if lipids are being administered or every 72 hours if amino acids and dextrose are being administered
-Label tubing with date and time attached
-Do not infuse solution in 1 bottle more than 24 hours
-Do not add anything to the solution
The patient is to start total parenteral nutrition (TPN). The nurse knows to prepare which site for catheter insertion?
Subclavian vein, IJ, femoral
A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What is the most likely cause of the vomiting?
Tube feeding intolerance
The patient is to start total parenteral nutrition (TPN). The nurse knows to prepare which site for catheter insertion?
Subclavian vein, IJ, femoral
What are the risks of total parenteral nutrition?
Elevated blood sugar, infection at the catheter site, volume overload
What are the first 2 steps in a transfusion reaction?
- Stop transfusion
- Start normal saline
The nurse is preparing to administer a blood transfusion. What are the first four steps?
- Verify the order for the transfusion
- Verify that the physician has discussed risks, benefits, and alternatives with the patient
- Ensure that the patient has a patent 16- to 22-gauge IV
- Prime the transfusion tubing and filter with normal saline
Epinephrine may be used for severe _________ transfusion reactions, and the infusion may be restarted after treatment with antihistamines in mild cases
Allergic transfusion reactions
Which type of transfusion reaction occurs with leukocyte or plasma protein incompatibility and may be avoided with leukocyte reduction filters?
Febrile nonhemolytic reaction is the most common transfusion reaction
Which characteristics are related to an acute hemolytic transfusion reaction
ABO incompatibility, destruction of donor RBCs, acute kidney injury occurs
