Critical Care Final Questions Flashcards
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease?
A) Asterixis
B) Constructional apraxia
C) Fetor hepaticus
D) Palmar erythema
Brunner 49 #9
A) Asterixis
The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fetor hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.
Lactulose is considered the first-line treatment for hepatic encephalopathy and works by:
A) causing ammonia to enter the bloodstream via the colon
B) trapping ammonia in the bowel for excretion.
C) causing constipation and inhibiting the excretion of ammonia.
D) creating an alkaline environment in the bowel.
Sole 17 #45
B) trapping ammonia in the bowel for excretion.
Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient’s current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
A) Two to 3 soft bowel movements daily
B) Significant increase in appetite and food intake
C) Absence of nausea and vomiting
D) Absence of blood or mucus in stool
Brunner 49 #17
A) Two to 3 soft bowel movements daily
Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient’s appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse:
A) evaluate renal function studies daily.
B) give the medication every 12 hours.
C) evaluate liver studies for signs of neomycin-induced damage.
D) obtain stool guaiac tests to ensure that pathogens are being destroyed.
Sole 17 #46
A) evaluate renal function studies daily.
Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.
The patient is diagnosed with hepatitis. In caring for this patient, the nurse should:
A) administer anti-inflammatory medications.
B) provide rest, nutrition, and antiemetics if needed.
C) provide anti-anxiety medications freely to decrease agitation.
D) instruct the patient to take over-the- counter anti-inflammatory medications at home.
Sole 17 #42
B) provide rest, nutrition, and antiemetics if needed.
No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.
The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.)
A. Hypoglycemia B. Malnutrition C. Ascites D. Hypercoagulation E. Disseminated intravascular coagulation
Sole 17 Select All #5
B. Malnutrition
C. Ascites
E. Disseminated intravascular coagulation
Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response.
Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.
EKG strip- What is the cardiac dysrhythmia know as a SAW TOOTH pattern that is extremely rapid, but regular rate of 250 – 350 BPM?
atrial flutter
EKG strip- irregular ventricular rate with no discernible P wave
a. Atrial Fibrillation
b. Atrial Flutter
c. Atrial flutter with RVR
d. Junctional escape rhythm
Sole 7 #35
a. Atrial Fibrillation
EKG strip- atria and ventricles beat independently of each other; P wave is not associated with QRS complex
a. First-degree AV block
b. Second-degree AV block Mobitz I (Wenckebach phenomenon)
c. Second-degree AV block Mobitz II
d. Third-degree AV block (complete heart block)
Sole 7 #48
d. Third-degree AV block (complete heart block)
Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.
The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical ventilation. The patient’s calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and:
a) places the patient on seizure precautions.
b) expects that the provider will come and remove the endotracheal tube.
c) withhold any further calcium treatments.
d) place an oral airway at the bedside.
Sole 17 #37
a) places the patient on seizure precautions.
Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low and replacement of calcium is expected.
EKG strip- regular rhythm but extremely fast of 150-250 beat per minute P waves (if present) may merge in T waves, also called paroxysmal atrial tachycardia
SVT
EKG strip- The patient is alert and talking when the nurse notices the following rhythm (tachycardic, 3+ PVC’s in a row). The patient’s blood pressure is 90/44 mm Hg. The nurse should:
a. defibrillate immediately.
b. begin basic life support.
c. begin advanced life support.
d. treat with intravenous amiodarone or lidocaine.
Sole 7 #42
d. treat with intravenous amiodarone or lidocaine.
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The patient may or may not have a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine.
EKG strip- The nurse notes the following rhythm on the heart monitor (chaotic pattern). The patient is unresponsive and not breathing. The nurse should
a. treat with intravenous amiodarone or lidocaine
b. provide emergent basic and advanced life support
c. provide electrical cardioversion.
d. ignore the rhythm because it is benign.
Sole 7 #43
b. provide emergent basic and advanced life support
Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation.
EKG strip- chaotic pattern
a. Atrial flutter with variable conduction
b. Ventricular fibrillation
c. Atrial fibrillation
d. Atrial flutter with RVR (rapid ventricular response)
Sole 7 #34
b. Ventricular fibrillation
A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient:
A) “I’m going to contact the pharmacist to see if you can take this medication by mouth.”
B) “This injection is being given to prevent blood clots from forming.”
C) “This medication will dissolve any blood clots you might get.”
D) “You should not be receiving this medication. I will contact the physician to get it stopped.”
B) “This injection is being given to prevent blood clots from forming.”
This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them. Heparin’s antithrombin activity prevents further clot formation, but will not dissolve a clot. It prevents the conversion of fibrinogen to fibrin thereby blocking the clotting process.
The most common cause of acute kidney injury in critically ill patients is:
A) sepsis.
B) fluid overload.
C) medications.
D) hemodynamic instability.
A) sepsis
The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI.
- A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential complications? (Select all that apply.)
a. Cardiac dysrhythmias
b. Heart failure
c. Pericarditis
d. Ventricular rupture
Sole 12 #5
a. Cardiac dysrhythmias
b. Heart failure
c. Pericarditis
d. Ventricular rupture
All are potential complications of AMI.
Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the ED. (Select all that apply).
a. Administration of morphine
b. Administration of nitroglycerin (NTG)
c. Dopamine infusion
d. Oxygen therapy
Sole 12 SA #2
a. Administration of morphine
b. Administration of nitroglycerin (NTG)
d. Oxygen therapy
The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct.
Which of the following statements is true regarding oral care for the prevention of ventilator- associated pneumonia (VAP)? (Select all that apply.)
a. Tooth brushing is performed every 2 hours for the greatest effect
b. Implementing a comprehensive oral care program is an intervention for preventing VAP
c. Oral care protocols should include oral suctioning and brushing teeth.
d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP
b. Implementing a comprehensive oral care program is an intervention for preventing VAP
c. Oral care protocols should include oral suctioning and brushing teeth.
d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP
A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery.
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)
a. Drain condensate from the ventilator tubing away from the patient
b. Elevate the head of the bed 30 to 45 degrees
c. Instill normal saline as part of the suctioning procedure
d. Perform regular oral care with chlorhexidine.
a. Drain condensate from the ventilator tubing away from the patient
b. Elevate the head of the bed 30 to 45 degrees
d. Perform regular oral care with chlorhexidine.
Condensate should be drained away from the patient to avoid drainage back into the patient’s airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.
Asthma is a chronic inflammatory disease of the airways. Ultimately it leads to recurrent episodes of asthma symptoms. What are the symptoms of asthma? (Mark all that apply.)
A) Chest tightness B) Crackles C) Hypopnea D) Wheezing E) Cough
Brunner 24 SA #34
A) Chest tightness
D) Wheezing
E) Cough
Acute kidney injury from post renal etiology is caused by:
A) obstruction of the flow of urine.
B) conditions that interfere with renal perfusion.
C) hypovolemia or decreased cardiac output.
D) conditions that act directly on functioning kidney tissue.
A) obstruction of the flow of urine.
Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal.
Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who:
A) has been on aminoglycosides for the past 6 days.
B) has a history of controlled hypertension with a blood pressure of 138/88 mm Hg.
C) was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks.
D) has a history of fluid overload as a result of heart failure.
C) was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks.
Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure. Because of this delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed. The blood pressure of 138/88 mm Hg controlled by medication would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure.
A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has ordered a chest radiograph. How should the nurse most safely facilitate the test?
a. Arrange for a portable x-ray machine to be used.
b. Have the patient wear a mask to the x-ray department.
c. Ensure that the radiology department has been disinfected prior to the test.
d. Send the patient to the x-ray department, and have the staff in the department wear masks.
a. Arrange for a portable x-ray machine to be used.
A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patient’s room. This confers more protection than disinfecting the radiology department or using masks.
Critical to caring for the immunocompromised patient is the understanding that:
A) the immunocompromised patient has normal white blood cell (WBC) physiology.
B) the immunosuppression involves a single element or process.
C) infection is the leading cause of death in these patients.
D) immune incompetence is symptomatic even without pathogen exposure.
C) infection is the leading cause of death in these patients.
Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection.
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection?
A) Salmonella infection
B) Mycobacterium tuberculosis
C) Clostridium difficile
D) Pneumocystis pneumonia
D) Pneumocystis pneumonia
There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other opportunistic infections may involve Salmonella, Mycobacterium tuberculosis, and
Clostridium difficile.
A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the nurse about the risk of contracting HIV when visiting the patient. What is the nurse’s best response?
a. “Do you think that you might already have HIV?”
b. “Don’t worry. Your immune system is likely very healthy.”
c. “AIDS isn’t transmitted by casual contact.”
d. “You can’t contract AIDS in a hospital setting.”
c. “AIDS isn’t transmitted by casual contact.”
AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital setting does not necessarily preclude HIV infection.
During a shift assessment, the nurse is identifying the client’s point of maximum impulse (PMI). Where will the nurse best palpate the PMI?
a. Left midclavicular line of the chest at the level of the nipple
b. Left midclavicular line of the chest at the fifth intercostal space
c. Midline between the xiphoid process and the left nipple
d. Two to three centimeters to the left of the sternum
b. Left midclavicular line of the chest at the fifth intercostal space
The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.
A patient is brought into the ED by family members who tell the nurse the patient grabbed his chest and complained of substernal chest pain. The care team recognizes the need to monitor the patient’s cardiac function closely while interventions are performed. What form of monitoring should the nurse anticipate?
a. Left-sided heart catheterization
b. Cardiac telemetry
c. Transesophageal echocardiography
d. Hardwire continuous ECG monitoring
d. Hardwire continuous ECG monitoring
Two types of continuous ECG monitoring techniques are used in health care settings: hardwire cardiac monitoring, found in EDs, critical care units, and progressive care units; and telemetry, found in general nursing care units or outpatient cardiac rehabilitation programs. Cardiac catheterization and transesophageal echocardiography would not be used in emergent situations to monitor cardiac function.
The nurse is working on the night shift when she notices sinus bradycardia on the patient’s cardiac monitor. The nurse should:
A) give atropine to increase heart rate.
B) begin transcutaneous pacing of the patient.
C) start a dopamine infusion to stimulate heart function.
D) assess for hemodynamic instability.
D) assess for hemodynamic instability.
Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic, interventions include administration of atropine. If atropine is not effective in increasing heart rate, then transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided for treatment of bradycardia associated with hypothermia.
A resident of a long-term care facility has complained to the nurse of chest pain. What aspect of the resident’s pain would be most suggestive of angina as the cause?
a. The pain is worse when the resident inhales deeply.
b. The pain occurs immediately following physical exertion.
c. The pain is worse when the resident coughs.
d. The pain is most severe when the resident moves his upper body.
b. The pain occurs immediately following physical exertion.
Chest pain associated with angina is often precipitated by physical exertion. The other listed aspects of chest pain are more closely associated with noncardiac etiologies.
The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction(MI)?
a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels
b. Depressed ST-segment on ECG and elevated total CPK
c. Depressed ST-segment on ECG and normal cardiac enzymes
d. Q wave on ECG with normal enzymes and troponin levels
a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels
ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.
Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject?
A) Symptoms of hypovolemia
B) Symptoms of low blood pressure
C) Complications requiring graft removal
D) Intubation and mechanical ventilation
D) Intubation and mechanical ventilation
