Midterm Flashcards
A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?
a. Inspiratory crackles
b. Heart rate 45 beats/min
c. Cool, clammy extremities
d. Temperature 101.2°F (38.4°C)
ANS: B
Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.
An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?
a. Increase the rate for the dopamine infusion.
b. Decrease the rate for the nitroglycerin infusion.
c. Increase the rate for the sodium nitroprusside infusion.
d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
ANS: C
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which will improve cardiac output. Changes in the D5/.9 NS and nitroglycerin infusions will not directly decrease SVR. Increasing the dopamine will tend to increase SVR.
A nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which finding indicates that the drug is effective?
a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure of 92/40 mm Hg
ANS: C
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Because nitroprusside is a vasodilator, the blood pressure may be low even if the drug is effective. Absence of a heart murmur and a decrease in troponin level are not indicators of improvement in shock.
After receiving 2 L of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate an order for
a. furosemide
b. nitroglycerin
c. norepinephrine
d. sodium nitroprusside
ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are given to increase the systemic vascular resistance (SVR) and blood pressure and improve tissue perfusion. Furosemide would cause diuresis and further decrease the BP. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Nitroprusside is an arterial vasodilator and would further decrease SVR.
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?
a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Check stools for occult blood.
d. Palpate for abdominal tenderness.
ANS: C
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments will also be done, but these will not help in determining the effectiveness of the pantoprazole administration.
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?
a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.
ANS: B
Because pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently. The head of the bed is usually elevated to decrease dyspnea in patients with cardiogenic shock. Elevated temperature and flushing or itching of the skin are not typical of cardiogenic shock.
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which patient data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
a. The patient is receiving low dose dopamine.
b. The patient’s central venous pressure is 3 mm Hg.
c. The patient is in sinus tachycardia at 120 beats/min.
d. The patient has had no urine output since being admitted.
ANS: B
Adequate fluid administration is essential before giving vasopressors to patients with hypovolemic shock. The patient’s low central venous pressure indicates a need for more volume replacement. The other patient data are not contraindications to norepinephrine administration.
Which assessment information is most important for the nurse to obtain when evaluating whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the O2 saturation is the most critical assessment. Improvements in the other assessments will also be expected with effective treatment of anaphylactic shock.
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?
a. The patient’s serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient’s extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.
ANS: A
The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure. The crackles, chest pressure, and cool extremities are all symptoms consistent with the patient’s diagnosis of cardiogenic shock.
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104°F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?
a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine to keep systolic blood pressure above 90 mm Hg.
ANS: A
Because of the decreased preload associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.
The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
a. Skin cool and clammy
b. Heart rate of 118 beats/min
c. Blood pressure of 92/56 mm Hg
d. O2 saturation of 93% on room air
ANS: A
Because patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
a. Tell the client she will not be permitted to leave the facility until she has signed the against medical advice (AMA) form.
b. Tell the client if she leaves without a written prescription for discharge, her insurance will not pay for the facility visit.
c. Explain the risk the client faces if she leaves the facility.
d. Ask the security department to guard the room to the client’s door.
c. Explain the risk the client faces if she leaves the facility.
Rationale: The expected reference range for INR while a client is taking warfarin is 2 to 3. The nurse has an obligation to explain to the client that her INR is very high and she is at risk for bleeding.
A nurse is reviewing laboratory results of a client who has atrial fibrillation and is taking warfarin. For which of the following results should the nurse notify the provider?
A. Platelets 190,000/mm3
B. Hct 44%
C. PT 45 seconds
D. Hgb 16 g/dL
Answer: C
PT 45 seconds is above the normal range of 11 to 13.5 seconds. This result indicates that the blood is taking too long to clot, which increases the risk of bleeding. The nurse should notify the provider and expect a decrease in the warfarin dose.
A nurse is caring for an older adult client who has a terminal illness and is ventilator dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client’s wishes is a violation of which of the following ethical principles?
A. Justice
B. Veracity
C. Fidelity
D. Autonomy
Answer: D
Choice D reason: Autonomy. This answer is correct because autonomy is the ethical principle that respects the client’s right to make their own decisions about their health care, even if they are different from the provider’s or the nurse’s recommendations. Autonomy applies to this situation, as the client is expressing their preference to discontinue the ventilator, which is a life sustaining treatment.
A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?
A. Instructions on how to change ventilator settings
B. Instructions on mouth care
C. Instructions to suction the client’s tracheostomy every 2 hr
D. Instructions to place the client in a supine position
Answer: B
B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.
A nurse in a critical care unit is caring for a client who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?
A. Flattened neck veins.
B. Bradycardia.
C. Sudden lethargy.
D. Muffled heart sounds.
Answer: D
Choice D Reason: This choice is correct because muffled heart sounds are a sign of cardiac tamponade. Muffled heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through fluid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of fluid from pericardial sac).
A nurse is collecting data on a client who is experiencing hypovolemia. Which of the following findings should the nurse expect?
A. Hypertension
B. Peripheral edema
C. Oliguria
D. Bradycardia
Answer: C
This is the correct answer. Oliguria, or reduced urine output, is a common finding in hypovolemia. When the body is low on fluids, the kidneys try to conserve water by decreasing urine production.
A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis?
SELECT ALL THAT APPLY
A. Vomiting
B. Hypoglycemia
C. Hypertension
D. Altered mental status
E. Elevated WBC’s count
A, D, E
A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?
Semi-Fowlers
Four hours after mechanical ventilation is initiated, a patient’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23 mmol/L). The nurse will anticipate the need to
a. increase the FIO2.
b. increase the tidal volume.
c. increase the respiratory rate.
d. decrease the respiratory rate.
d. decrease the respiratory rate.
The patient’s PaCO2 and pH indicate respiratory alkalosis caused by too high a respiratory rate. The PaO2 is appropriate for a patient with COPD and increasing the respiratory rate and tidal volume would further lower the PaCO2.
Which of these nursing actions can the RN working in a long-term care facility delegate to an experienced LPN/LVN who is caring for a patient with a permanent tracheostomy?
a. Assessing the patient’s risk for aspiration
b. Suctioning the tracheostomy when needed
c. Educating the patient about self-care of the tracheostomy
d. Determining the need for replacement of the tracheostomy tube
ANS: B
Suctioning of a stable patient can be delegated to LPN/LVNs. Assessments and patient teaching should be done by the RN.
Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient’s endotracheal tube. Which action by the nurse is best?
A. Stop and ventilate the patient with 100% oxygen.
B. Check the patient’s potassium level
C. Give prescribed PRN antidysrhythmic medications.
D. Decrease the suction pressure to 80 mm Hg.
Answer: A
Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
Which assessment finding obtained by the nurse when caring for a patient receiving mechanical ventilation indicates a need for suctioning?
a. The patient’s oxygen saturation is 93%.
b. The patient was last suctioned 6 hours ago.
c. The patient’s respiratory rate is 32 breaths/minute.
d. The patient has occasional audible expiratory wheezes.
c. The patient’s respiratory rate is 32 breaths/minute.
-The increase in respiratory rate indicates that the patient may have decreased airway clearance and requires suctioning. Suctioning is done when patient assessment data indicate that is is needed, not on a scheduled basis. Occasional expiratory wheezes do not indicate poor airway clearance, and suctioning may induce bronchospasm and increase wheezing. An oxygen saturation of 93% is acceptable and does not suggest immediate suctioning is needed.
The nurse is weaning a patient who has COPD and Weighs 68 kilograms from mechanical ventilation which finding indicates that the weaning protocol should be stopped?
a. The patient’s heart rate is 97 beats/minute.
b. The patient’s oxygen saturation is 93%.
c. The patient’s respiratory rate is 32 breaths/minute.
d. The patient’s spontaneous tidal volume is 450 mL.
c. The patient’s respiratory rate is 32 breaths/minute.
The nurse provides discharge teaching for a client who has two fractured ribs from an automobile accident. Which statement, if made by the client, would indicate that teaching has been effective?
a. “I will use the incentive spirometer every hour or two during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I am going to buy a rib binder to wear during the day.”
d. “I should plan on taking the pain pills only at bedtime, so I can sleep.”
a. “I will use the incentive spirometer every hour or two during the day.”
During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
c. Use pulse oximetry to check the oxygen saturation.
For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately?
a) Blood pressure (BP) 192/102 mm Hg
b) Report of constipation
c) Anxiety
d) Heart rate 52 beats/min
a) Blood pressure (BP) 192/102 mm Hg
Which client who has just arrived in the emergency department does the nurse classify as emergent and needing an immediate medical evaluation?
a. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness
b. A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C)
c. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness
d. A 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic
d. A 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic
The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse?
a) Urine output of 20 mL over 2 hours
b) Blood pressure of 106/58 mm Hg
c) +3 pedal pulses
d) Absent bowel sounds
a) Urine output of 20 mL over 2 hours
A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
a. Assesses the client for back pain
b. Auscultates over abdominal bruit
c. Measures the abdominal girth
d. Palpates the abdomen in four quadrants
d. Palpates the abdomen in four quadrants
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this.
A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
b. Speech alterations
After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings:
Vital Signs Nursing Assessment
Time: 0800
Temperature: 98° F
Heart rate: 68 beats/min
Blood pressure: 135/60 mm Hg
Respiratory rate: 14 breaths/min
Oxygen saturation: 96%
Oxygen therapy: 2 L nasal cannula
Time: 1000
Temperature: 98.2° F
Heart rate: 50 beats/min
Blood pressure: 132/57 mm Hg
Respiratory rate: 16 breaths/min
Oxygen saturation: 95%
Oxygen therapy: 2 L nasal cannula Time: 0800
Client alert and oriented.
Cardiac rhythm: normal sinus rhythm.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlabored.
Client denies shortness of breath and chest pain.
Time: 1000
Client alert and oriented.
Cardiac rhythm: sinus bradycardia.
Skin: warm, dry, and appropriate for race.
Respirations equal and unlabored.
Client denies shortness of breath and chest pain.
Client voids 420 mL of clear yellow urine.
Based on the assessments, which action should the nurse take?
a. Stop the infusion and flush the IV.
b. Slow the amiodarone infusion rate.
c. Administer IV normal saline.
d. Ask the client to cough and deep breathe.
b. Slow the amiodarone infusion rate.
