Test 2

Question 1

ICU nurse is monitoring a patient with a traumatic brain injury for signs of increased intracranial pressure which would indicate an early sign of deterioration?

Answer 1

Bradycardia and increased blood pressure

Question 2

Which dietary modification is a priority for a patient on amlodipine for blood pressure issues?

Answer 2

Eliminate grapefruit

Question 3

The nurse is reviewing the diagnostic test of a client admitted with a thoracic aneurysm. The client asks the nurse how the doctor knows there is an aneurysm. The nurse knows which diagnostic test is best to confirm the diagnosis.

Answer 3

CT angiogram

Question 4

A client was diagnosed with cardiac tamponade. Which collaborative intervention should the nurse anticipate?

Answer 4

Pericardiocentesis

Question 5

A patient with a chronic spinal cord injury at C3 level is admitted to the ER with complaints of a severe headache. Blood pressure is 210/104 which action by the nurse would be appropriate initially?

Answer 5

Assess for bladder distention

Question 6

The ICU nurse is caring for a patient diagnosed with head injury who is intubated and becomes agitated and combative. The nurse prepares to administer which medication to help calm him down?

Answer 6

Propofol

Question 7

The nurse is reviewing the healthcare providers orders for a patient with DIC. Which of the following or should the nurse question?

Answer 7

Vitamin K IM

Question 8

The nurse is teaching a new licensed nurse about DIC. Which of the following clients with the nurse identified to the healthcare provider as having the highest risk of having this disorder?

Answer 8

77 yr old with sepsis

Question 9

A client with a spinal cord injury is having difficulty with muscle spasms and spasticity, and the healthcare provider orders dantrolene to manage the symptoms. Which of the following instructions are important for the nurse to inform the client about?

Answer 9

Liver function test should be performed regularly

Question 10

The PR progressively gets longer, and you drop a QRS.

Answer 10

Second Degree heartblock- Wenckebach

Question 11

Which of the following signs would cause the nurse to suspect that a critically ill patient is developing DIC?

Answer 11

Nosebleed

Question 12

The nurse is caring for a patient with an open AAA repair who is four hours postop. Which action by the tech would require the nurse to intervene?

Answer 12

Preparing to help the patient to the bathroom

Question 13

The nurse is reviewing the health history of a patient who has been prescribed sotalol to control V-tach. Which of the following is a contraindication of this medication?

Answer 13

Asthma

Question 14

The patient has a heart rate of 44, history of glaucoma, and we need to know how to treat the heart rate of 44. How would you manage this?

Answer 14

Transcutaneous pacing

Question 15

Before we give digoxin to someone with A-fib, what do we need to do first?

Answer 15

Check pulse

Question 16

Which one is the fixed pacemaker?

Answer 16

The pacemaker fires at a constant rate, not on demand

Question 17

The nurse is teaching a client who has been on phenytoin to prevent seizures related to brain injury. Which of the following statements by the client would indicate understanding?

Answer 17

Need back up contraceptive for my birth control pills

Question 18

The nurse is teaching a client with a spinal cord injury who has a new prescription for baclofen to treat muscle spasms. Which statement by the client indicates and understanding of teaching?

Answer 18

Avoid alcohol while on this medication

Question 19

The nurse is assisting a tech during the morning care of a client with a spinal cord S1 at T5. Which of the following actions by the Would require correction by the nurse?

Answer 19

Raising the knees to make the patient more comfortable

Question 20

Client with 8cm enlarging AAA is scheduled for surgery in the morning. Which of the following pre-op orders by the HCP should the nurse question?

Answer 20

Sedative at bedtime

Question 21

Client with 8cm enlarging AAA is scheduled for surgery in the morning. Which of the following pre-op orders by the HCP should the nurse question?

Answer 21

Sedative at bedtime

Question 22

A patient is in A-fib and a cardio version is wanted. What part of the ECG should the electrical pulse discharge?

Answer 22

QRS wave

Question 23

Patient is in V-fib. Defibrillation unsuccessful. Which medication should be first to give?

Answer 23

Epinephrine

Question 24

Which posturing is flexion?

Answer 24

Decorticate

Question 25

Someone in A-Fib is going to be cardioverted. TEE ordered prior to procedure. Why?

Answer 25

To make sure there are no clots before fibrillation. Eval for atrial thrombi.

Question 26

The patient is being discharged from the ER after suffering a mild concussion, which set of instructions with the nurse gives a clients family?

Answer 26

Return to the ER if patient has vomiting and slurred speech

Question 27

The patient has pericarditis and is having difficulty breathing and chest pain heart rate 108 respiratory rate 28 blood pressure 106/94 oxygen 92%. The client has jugular venous distention heart rate sounds are faint and has crackles. Which condition do they have?

Answer 27

Cardiac tamponade

Question 28

The nurse is caring for a client with a closed head injury, who is emerging from a coma, which of the following science would prompt the nurse to notify the healthcare provider immediately?

Answer 28

Unequal pupils

Question 29

The nurse is caring for a client following a traumatic brain injury five days ago. Which of the following interventions with the nurse implement to prevent complications?

Answer 29

Anticipate anti-convulsant
Monitor for hyponatremia
Stool softeners
Ensure nutritional support

Question 30

The nurse is assisting in the clinical evaluation of a patient who is a potential organ donor due to irreversible brain injury. Which of the following signs would indicate brain death in a patient?

Answer 30

Apnea
Coma
Absence of brainstem reflexes

Question 31

The nurse is providing education to a client with a small thoracic aneurysm. Which information should the nurse include in the teaching session?

Answer 31

Dyspnea may develop if the aneurysm dilates

Question 32

A pregnant client is experiencing gestational hypertension, and will need an anti-hypertensive medication. The client states my grandmother takes losartan and her blood pressure is good. Do you think the doctor can prescribe me that? How should the nurse respond?

Answer 32

This medication can cause birth defects or fetal death

Question 33

The nurse is caring for a client who is experiencing increased intracranial pressure. The nurse observes that the clients body becomes stiff with flexion of the upper extremities with extension and internal rotation of the lower extremities. How will the nurse document?

Answer 33

Decorticate posturing

Question 34

The physician prescribes amlodipine for a patient with hypertension and a family history of aneurysms. The patient asked the nurse how the medication works. How should they respond?

Answer 34

It relaxes the heart and dilates the blood vessels

Question 35

The nurse is provided education to a client who has hypertension and has a new prescription for captopril. Which statement by the client would indicate that reinforcement is needed?

Answer 35

I won’t worry if I have a little swelling around my lips or face

Question 36

The nurse is performing a Glasgow coma scale assessment on a client who is unconscious. Which total score would indicate to the nurse that the patient probably has a severe brain injury?

Answer 36

Five

Question 37

Which assessment finding with the nurse expect to find in a patient diagnosed with it AAA.

Answer 37

Ripping abdominal pain

Question 38

Which of the following nursing interventions are appropriate and immediate post care of the client with an endovascular repair of a AAA?

Answer 38

Check pedal pulses

Question 39

The ICU is caring for a client with a spinal cord injury who is incontinent. Which order from the healthcare provider to manage the incontinent patient should the nurse question?

Answer 39

Maintain bedrest with bedpan use

Question 40

The nurse is preparing to give the first dose of Zosyn to a patient who is postop from an aneurysm repair. The nurse is aware that the ideal time to give this medicine to prevent adverse effects is, which of the following?

Answer 40

At bedtime

Question 41

The nurse is caring for a patient diagnosed with DIC. The nurse checks stat labs to see the status of the patient which lab values with the nurse expect to be abnormal?

Answer 41

D dimer
Platelet
PTT

Question 42

The charge nurse is observing a new nurse providing discharge teaching for a client with hypertension who is being prescribed analapril. Which of the following comments by the new nurse would prompt the charge nurse to intervene?

Answer 42

You will need to increase your diet high in potassium foods

Question 43

After a patient receives a pacemaker, the patient asked the nurse for the wires from the implanted transfers, pacing lead, and pacemaker are located. The nurse explains based on the lead being in which of the following anatomical positions?

Answer 43

Enters the external jugular vein ends at right ventricle

Question 44

Which of the following should the nurse review with the client who is being discharged with a permanent pacemaker?

Answer 44

Avoid MRI
Wear a medic alert ID
Keeps cell phones on opposite sides
Do not raise arms above the head for two weeks

Question 45

The ICU is caring for a patient with a traumatic brain injury who develops cerebral edema. Which drug will the nurse expect to administer to the patient to decrease the swelling.

Answer 45

Mannitol