Midterm Study Guide

Question 1

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)

Answer 1

b. Heart rate 45 beats/min

Neurogenic shock is characterized by hypotension and bradycardia. The other findings would be more consistent with other types of shock.

Question 2

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.

Answer 2

c. Increase the rate for the sodium nitroprusside infusion.

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.

Question 3

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

Answer 3

C. Warm, pink, and dry skin

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.

Question 4

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 .

Answer 4

c. norepinephrine .

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.

Question 5

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. Palpate for abdominal pain.
c. Ask the patient about nausea.
d. Check stools for occult blood.

Answer 5

d. Check stools for occult blood.

Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill patients. The other assessments also will be done, but these will not help in determining the effectiveness of the pantoprazole administration.

Question 6

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.

Answer 6

b. Monitor breath sounds frequently.

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.

Question 7

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.

Answer 7

b. The patient’s central venous pressure is 3 mm Hg.

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

Question 8

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

Answer 8

d. Oxygen saturation

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.

Question 9

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.

Answer 9

a. The patient’s serum creatinine level is elevated.

Question 10

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.

Answer 10

a. Give normal saline IV at 500 mL/hr.

Question 11

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

Answer 11

a. Skin cool and clammy

Question 12

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.

Answer 12

c. Explain the risk the client faces if she leaves the facility.

Question 13

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 13

C. PT 45 seconds

Question 14

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. Veracity
b. Autonomy
c. Fidelity
d. Justice

Answer 14

b. Autonomy

Question 15

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 15

B.
Instructions on mouth care

Question 16

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. Flatened neck veins.
B. Bradycardia.
C. Sudden lethargy.
D. Muffled heart sounds.

Answer 16

D. Muffled heart sounds.

Question 17

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 17

C. Oliguria

Question 18

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? (SATA)

a. Vomiting
b. Hypoglycemia
c. Hypertension
d. Altered mental status
e. Elevated WBC’s count

Answer 18

a. Vomiting
d. Altered mental status
e. Elevated WBC’s count

Question 19

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?

A. Prone
B. SemiFowler’s
C. Sims
D. On the nonoperative side

Answer 19

B. SemiFowler’s

Question 20

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 respiratory rate.
B) increase the FIO2.
C) decrease the respiratory rate.
D) increase the tidal volume.

Answer 20

C) decrease the respiratory rate.

Question 21

Which nursing action could the registered nurse (RN) working in a skilled care hospital unit delegate to an experienced licensed practical/vocational nurse (LPN/LVN) caring for a patient with a permanent tracheostomy?

a. Assess the patient’s risk for aspiration.
b. Suction the tracheostomy when needed.
c. Teach the patient about self-care of the tracheostomy.
d. Determine the need for replacement of the tracheostomy tube.

Answer 21

b. Suction the tracheostomy when needed.

Question 22

The nurse notes premature ventricular contractions (PVCs) while suctioning a patient’s endotracheal tube. Which next action by the nurse is indicated?

a. Plan to suction the patient more frequently.

b. Decrease the suction pressure to 80 mm Hg.

c. Give antidysrhythmic medications per protocol.

d. Stop and ventilate the patient with 100% oxygen.

Answer 22

d. Stop and ventilate the patient with 100% oxygen.

Question 23

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.

Answer 23

c. The patient’s respiratory rate is 32 breaths/minute.

Question 24

The nurse is weaning a patient who has chronic obstructive pulmonary disease (COPD) and weighs 68 kg fro mechanical ventilation. Which finding indicates that the weaning protocol should be stopped?

a. The patient’s heart rate is 97 beats/min.
b. The patient’s oxygen saturation is 93%.
c. The patient’s respiratory rate is 32 breaths/min.
d. The patient’s spontaneous tidal volume Is 450 mL.

Answer 24

c. The patient’s respiratory rate is 32 breaths/min.

Question 25

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective?
a. “I am going to buy a rib binder to wear during the day.”
b. “I can take shallow breaths to prevent my chest from hurting.”
c. “I should plan on taking the pain pills only at bedtime so I can sleep.”
d. “I will use the incentive spirometer every hour or two during the day.”

Answer 25

d. “I will use the incentive spirometer every hour or two during the day.”

Question 26

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?

A. Give the prescribed PRN sedative drug.

B. Offer reassurance and reorient the patient.

C. Use pulse oximetry to check the oxygen saturation.

D. Notify the health care provider about the patient’s status.

Answer 26

C. Use pulse oximetry to check the oxygen saturation.

Question 27

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

Answer 27

a) Blood pressure (BP) 192/102 mm Hg

Question 28

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation?
A) 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness
B) 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C)
C) 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness
D) 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic

Answer 28

D) 70-year-old with a history of diabetes who has “tearing” back pain and is diaphoretic

Question 29

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding?

A. Urine output of 20 mL over 2 hours
B. Blood pressure of 106/58
C. Absent bowel sounds
D. +3 pedal pulses

Answer 29

A. Urine output of 20 mL over 2 hours

Question 30

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

Answer 30

d. Palpates the abdomen in four quadrants

Question 31

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

Answer 31

b. Speech alterations

Question 32

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.

Answer 32

b. Slow the amiodarone infusion rate.

Question 33

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

A) Monitor the quality and presence of the pedal pulses

B) Teach the patient the sign of possible wound infection

C) Check the lower extremities for strength and movement

D) Help the patient to use a pillow to splint while coughing

Answer 33

D) Help the patient to use a pillow to splint while coughing

Question 34

A patient with aortic stenosis has acute pain due to decreased coronary blood flow. What would be an appropriate nursing intervention for this

a. Promote rest to decrease myocardial oxygen demand.
b. Teach the patient about the need for anticoagulant therapy.
c. Teach the patient to use sublingual nitroglycerin for chest pain.
d. Raise the head of the bed 60 degrees to decrease venous return.

Answer 34

a. Promote rest to decrease myocardial oxygen demand.

Question 35

A nurse is assessing a client who is receiving dopamine IV to treat left ventricular failure. Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect?

A. Systolic blood pressure is increased
B. Cardiac output is reduced
C. Apical heart rate is increased
D. Urine output is reduced

Answer 35

A. Systolic blood pressure is increased

Question 36

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

a. The patient’s PaO2 is 45 mm Hg.
b. The patient’s PaCO2 is 33 mm Hg.
c. The patient’s respirations are shallow.
d. The patient’s respiratory rate is 32 breaths/min.

Answer 36

a. The patient’s PaO2 is 45 mm Hg.

Question 37

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions

Answer 37

d. A patient with septicemia who has intercostal and suprasternal retractions

Question 38

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?

a. “PEEP will push more air into the lungs during inhalation.”
b. “PEEP prevents the lung air sacs from collapsing during exhalation.”
c. “PEEP will prevent lung damage while the patient is on the ventilator.”
d. “PEEP allows the breathing machine to deliver 100% O2 to the lungs.”

Answer 38

b. “PEEP prevents the lung air sacs from collapsing during exhalation.”

Question 39

Which finding by the nurse most specifically indicates that a patient is not able to effectively clear the airway?

a. Weak cough effort
b. Profuse green sputum
c. Respiratory rate of 28 breaths/min
d. Resting pulse oximetry (SpO2) of 85%

Answer 39

a. Weak cough effort

Question 40

A patient on a positive pressure ventilator is receiving a neuromuscular blocking agent (NMBA) to prevent asynchronous breathing. Which situation requires action by the nurse?

A. The patient’s oxygen saturation is 90% to 93%.
B. The patient has no cough reflex when suctioned.
C. The patient does not respond to voice.
D. No sedative is ordered for the patient.

Answer 40

D. No sedative is ordered for the patient.

Question 41

The nurse notes that a patients endotracheal tube, which was at the 22 cm mark, is now at the 25 cm mark, and that patient is anxious restless. Which action should the nurse take next?

a. Check the O2 saturation
b. Offer reassurance to the patient
c. Listen to the patients breath sounds
d. Notify the patients health care provider

Answer 41

c. Listen to the patients breath sounds

Question 42

A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider?

A. Hematocrit 45%
B. Partial thromboplastin time (PTT) 65 seconds
C. White blood cell count 8,000/mm3
D. Platelets 74,000/mm3

Answer 42

D. Platelets 74,000/mm3

Question 43

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

A. give morphine IV
B. administer oxygen therapy
C. start an iv infusion of LR
D. initiate cardiac monitoring

Answer 43

B. administer oxygen therapy

Question 44

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, which of the following findings should the nurse use to determine that the procedure was effective?

A. Decreased respiratory rate
B. Stable oxygen saturation
C. Clear breath sounds
D. Pink capillary refill

Answer 44

C. Clear breath sounds

Question 45

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

A. Prepare the client for reintubation.
B. Assess the client’s airway.
C. Suction the client’s mouth.
D. Elevate the client’s head of bed.

Answer 45

B. Assess the client’s airway.

Question 46

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

A.Progressive increase in platelet production
B.Increased clotting factors
C.Excessive thrombosis and bleeding
D. Immediate sodium and fluid retentioin

Answer 46

C.Excessive thrombosis and bleeding

Question 47

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

a. Increased BP
b. Dyspnea
c. Decreased HR
d. Weak pulse

Answer 47

d. Weak pulse

Question 48

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A. Sinus bradycardia
B. Sinus tachycardia
C. Atrial fibrillation
D. First-degree AV block

Answer 48

C. Atrial fibrillation

Question 49

A nurse is assessing a client who is receiving continuous IV infusion of dopamine which of the following findings should the nurse recognize as a therapeutic effect?

A. Increased pulse

B. Increased urine output

C. Decreased blood pressure

D. Decreased dysrhythmias

Answer 49

A. Increased pulse

OR

increased MAP of patient

Question 50

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective?

A. Increased urine output
B. Decreased blood glucose level
C. Decreased blood pressure
D. Increased heart rate

Answer 50

A. Increased urine output