|Cardiac output||The volume of blood pumped by the heart in 1 minute|
|Central venous pressure||Indirectly measures right ventricular end diastolic pressure. A measure of volume.|
|Systemic vascular resistance||Measures resistance to left ventricular ejection. Reflective of vasoconstriction or viscosity.|
|Pulmonary vascular resistance||Measures resistance to entry of blood into the heart. Reflective of volume.|
|Pulmonary artery wedge pressure||Reflects left ventricular end diastolic pressure.|
|complications of a radial arterial line?||Infection, Bleeding, Peripheral neurologic deficit, Thrombus formation|
|defines cardiac index||The amount of blood pumped through the heart per minute adjusted for an individual's BMI|
|indication for suctioning in a mechanically ventilated patient?||The patient's respiratory rate is 32|
|Complications of PEEP||Decreased blood pressure|
|A patient who has fibromyalgia tells the nurse, "My life feels very chaotic and out of my control. I will not be able to manage if anything else happens". Which response should the nurse make initially?|| Tell me more about how your life has been recently|
The nurse's initial strategy should be further assessment of the stressors in the patient's life.
|The nurse is providing stress management education to a group of elderly women. Which of the following statements, if made by the nurse, would be an accurate description of the effect of stress on the cardiovascular system?||Stress causes increased sympathetic nervous system stimulation, which causes the heart rate to increase and blood vessels to constrict . The result is an increase in blood pressure|
|A diabetic patient who is hospitalized tells the nurse, "I don't understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up". Which response by the nurse is appropriate?|| Stressors such as illness cause the release of hormones that increase blood sugar|
The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels.
|Determination of whether an event is a stressor is based upon a person's...||Perception|
|The nurse would expect the following findings in a patient as a result of the physiologic effect of stress on the reticular formation.||Inability to sleep the night before starting self-injections of insulin|
|A patient has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action will the nurse include in the plan of care?||Cluster nursing activities so that the patient has uninterrupted rest periods.|
|The family members of a patient who has just been admitted to the intensive care unit following an accident with multiple traumatic injuries have just arrived in the ICU waiting room. Which action should the nurse take first?||Describe the patient's injuries and the care that is being provided|
|To determine the effectiveness of medications that a patient has received to reduce afterload, which hemodynamic parameter will the nurse monitor?|| Systemic vascular resistance (SVR)|
Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload.
|Following surgery, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action will the nurse anticipate taking?|| Increase the IV fluid infusion rate|
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
|The ICU charge nurse will determine that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse...||positions the transducer line level with the phlebostatic axis|
|When monitoring the effectiveness of treatment for a patient with left ventricular failure, the most important information for the nurse to obtain is...||pulmonary artery wedge pressure (PAWP)|
PAWP reflects left ventricular end diastolic pressure (or left ventricular preload). Because the patient in left ventricular failure will have a high PAWP, a decrease in this value will be the best indicator of patient improvement. The other values would also provide useful information, but the most definitive measurement of improvement is a drop in PAWP.
|Which assessment data obtained by the nurse when caring for a patient with a left radial arterial line indicates a need for the nurse to take action?|| The left hand is cooler than the right|
The change in temperature of the left hand suggests that blood flow to the left hand is impaired
|Which of the following occurs as a result of "counterpulsation" during intraortic baloon pump (IABP) use?||Improved blood flow to the coronoary arteries|
|While waiting for cardiac transplantation, a patient with severe heart failure has a ventricular assist device implanted. When developing a plan of care, nursing actions should include which one of the following?||Monitoring the surgical incision for signs of infection|
|When caring for the patient with a pulmonary artery pressure catheter, the nurse notices that the waveform indicates that the catheter is in a wedged position. Which action should the nurse take?|| Notify the health care provider|
When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter.
|stroke volume?||Stroke volume (SV) + cardiac output / heart rate.|
|To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?||Elevate the head of the bed to 30-45 degrees|
|When the ventilator alarm sounds, the nurse finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take first?||Manually ventilate the patient with 100% oxygen|
The nurse should ensure maximal patient oxygenation by manually ventilating with a bag-valve-mask system. Offering reassurance to the patient, notifying the health care provider about the need to reinsert the tube, and activating the rapid response team also are appropriate after the nurse has stabilized the patient's oxygenation.
|A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10cm H2O. Which information indicates that a change in the ventilator settings may be required?|| The arterial line shows a blood pressure of 90/46|
The hypotension indicates that the high intrathoracic pressure caused by the PEEP may be decreasing venous return and cardiac output (CO).
|The nurse notes thick, white respiratory secretions from a patient who is receiving mechanical ventilation. Which intervention will be most effective is resolving this problem.|| Add additional water to the patient's enteral feedings|
Because the patient's secretions are thick, better hydration is indicated.
|Which assessment information obtained by the nurse when caring for a patient receiving mechanical ventilation indicates a need for suctioning?||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 it is needed, not on a scheduled basis.|
|Premature ventricular contractions (PVC's) occur while the nurse is suctioning the endotracheal tube. Which action by the nurse is best?|| Stop and ventilate the patient with 100% oxygen|
Dysrhythmias during suctioning may indicate hypoxemia or sympathetic nervous system stimulation, and the nurse should stop suctioning and ventilate the patient with 100% oxygen.
|To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to...||Use an end-tidal CO2 monitor to check for placement in the trachea|
End-tidal CO2 monitors are currently recommended for rapid verification of ET placement. Auscultation for bilateral breath sounds and checking chest expansion also are used, but they are not as accurate as end-tidal CO2 monitoring. A chest x-ray confirms the placement but is done after the tube is secured.
|Which assessment finding by the nurse caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicate that the PEEP may need to be decreased?|| The patient has subcutaneous emphysema |
The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP.
|purpose of positive end-expiratory pressure of a patient with ARDS|| PEEP prevents the lung air sacs from collapsing during exhalation|
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation.
|When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning has been effective?|| The patient's PaO2 is 90 mm Hg and the SaO2 is 92%|
The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2.
|The nurse obtains vital signs for a patient admitted 2 days ago with gram (-) sepsis. His temperature is 101.2 F, BP 90/56, pulse 92, and respiratory rate 32. Which priority action should the nurse take next?|| Obtain oxygen saturation using pulse oximetry|
The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS.
|A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse acticipate?|| Lower the positive end-expiratory pressure (PEEP)|
Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased.
|After receiving a change-of-shift report, which patient will the nurse assess first?|| septicemia who has intercostal and suprasternal retractions|
suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation.
|The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?|
Oxygen saturation has dropped to 89% even with the administration of 100% O2 per non-rebreather mask
blood-tinged sputum and scattered crackles
continued temperature elevation
|Oxygen saturation has dropped to 89% even with the administration of 100% O2 per non-rebreather mask|
|A patient with a possible pulmonary embolism complains of chest pain and upon assessment the nurse finds a heart rate of 142, BP 100/60, and respirations 42. The nurse's first action should be to...|| Elevate the head of the bed to 45-60 degrees|
The patient has symptoms consistent with a pulmonary embolism. Elevating the head of the bed will improve ventilation and gas exchange.
|After the nurse has received change-of-shift report about the following four patients, which shold be assessed first?||A 46-year old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath|
|A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, and coolness in the left leg. The nurse should notify the health care provider and follow-up with which of the following actions?|| Keep the patient on bedrest|
The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored.
|A patient at the clinic says, "I have always taken an evening walk but lately the leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking though". The nurse should proceed with a focused assessment by doing which of the following?|| Attempt to palpate the dorsalis pedis and posterior tibial pulses|
The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication.
|Changes in skin color that occur in response to cold||Raynaud's phenomenon|
|Tortuous veins on the legs||venous insufficiency|
|Unilateral leg swelling, redness, and tenderness||venous thromboembolism (VTE)|
|The nurse performing an assessment with a patient who has chronic peripheral artery disease of the legs and an ulcer on the left great toe would expect to find which of the following?|| Prolonged capillary refill in all the toes|
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery.
|After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?||The patient exercises indoors during the winter months|
Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynaud's phenomenon.
|A patient tells the health care provider about experiencing cold, numb fingers when running in the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about diagnostic test for which of the following?|| Autoimmune disorders|
Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders.
|While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be supportive of that information?|| My legs cramp whenever I walk more than a block|
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication.
|Finger pain associated with cold weather||Raynaud's phenomenon.|
|Swelling associated with prolonged standing||venous disease|
|When developing a teaching plan for a patient newly diagnosed with peripheral artery disease, which information should the nurse include?||It is important for you to stop smoking cigarettes|
Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.
|A patient is scheduled for an abdominal aortic aneurysm (AAA) repair. Which of the following events causes the nurse to suspect rupture of the aneurysm ?||The patient complains of sudden, severe back pain|
|Patients presenting to the Emergency department in hypertensive crisis will most likely experience|| Changes in vision|
Nausea / vomiting and chest pain
Numbness or weakness
|A patient arrives at the Emergency department after checking her BP on the HyVee automatic BP machine. The reading was 200/110 and this is confirmed by a similar reading at the ED. What further information is needed to differentiate between a hypertensive emergency and hypertensive urgency?||The presence of acute symptoms related to hypertension|
|When the nurse is caring for a patient on the first post-operative day after an abdominal aortic aneurysm (AAA) repair, which assessment finding is most important to communicate to the health care provider?|| Loose, bloody stools |
may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection.
|patient's presentation is consistent with dissecting thoracic aneurysm||complaining of "tearing" chest pain|
|Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?|| New onset shortness of breath|
New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider.
|In planning care and patient teaching for a patient with venous insufficiency, the nurse recognizes that the most important intervention in controlling this condition is...||Applying graduated compression stockings (TEDS)|
| Which of the following are probable clinical findings in a patient with an acute venous thromboembolism (VTE)?|
Mild to moderate calf pain and tenderness
Grossly diminished or absent pedal pulses
Unilateral edema and induration of the thigh
Palpable cord along a superficial varicose vein
| Mild to moderate calf pain and tenderness|
Unilateral edema and induration of the thigh
|A patient with venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why the two medications are necessary. Which of the following statements by the nurse is accurate?||The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation|
|The health care provider prescribes an infusion of heparin and daily PTT testing for a patient with a venours thromboembolism (VTE). Which of the following will nurse include in the plan of care?||Avoid giving any IM medications to prevent localized bleeding|
|A 46 year old is diagnosed with thromboangiitis obliterans (Buerger's disease). When planning expected outcomes for the patient, which outcome has the highest priority?||Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease.|
|A patient who has had severe chest pain for several hours is admitted with a diagnosis of acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI?|| Cardiac-specific troponin I or troponin T|
Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI).
|Three days after a myocardial infarction (MI), the patient develops chest pain that increases while taking a deep breath and is relieved by leaning forward. Which action should the nurse take next?|| Auscultate for a pericardial friction rub|
The patient's symptoms are consistent with the development of pericarditis, a possible complication of MI.
|When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient which of the following?|| About the purpose of outpatient Holter monitoring|
Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur.
|Which EKG change is most important for the nurse to convey to the health care provider when caring for a patient with chest pain?|| ST segment elevation|
The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or fibrinolytic medications is indicated to minimize the amount of myocardial damage.
|When caring for a patient with acute coronary syndrome who has returned to the ICU after having baloon angioplasty, the nurse obtains the following assessment information. Which one indicates the need for immediate intervention by the nurse?|| Chest pain rated at 8/10|
The patient's chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse.
|The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to convey to the health care provider?||Crackles are auscultated bilateraly in the mid-lower lobes|
The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient.
|A patient is admitted to the coronary care unit following a prolonged cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the health care provider's admission orders, which of the following orders is it most important for the nurse to question?|| Tissue plasminogen activator (t-PA) 100 mg IV infused over 3 hours|
Traumatic or prolonged (>10 minutes) cardiopulmonary resuscitation is a relative contraindication for the administration of fibrinolytic therapy.
|The nurse is caring for a patient who is receving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea . When evaluating the patient response to the medications, which of the following is the best indicator that the treatment has been effective?|| Decreased dyspnea with the HOB at 30 degrees|
Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees.
|IV sodium nitroprusside (Nipride) is ordered for a patient with acute decompensated heart failure (ADHF). Which of the following findings would require the nurse to adjust the nitroprusside?|| A systolic BP < 90|
Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension.
|After receving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first?|| A patient who is cool and clammy, with new-onset confusion and restlessness|
The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management.
| Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most rapid action by the nurse?|
Oxygen saturation of 88%
increase in apical pulse rate
1-kg weight gain
decreases in urine output
| Oxygen saturation of 88%|
A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient.
|A patient with ADHF presents with tachypnea, dyspnea, and an oxygen saturation of 88%. Which of the following is an appropriate priority nursing intervention for this patient?|| Place the patient in high Fowler's position with feet dangling|
A high fowler's position increases the lung capacity reducing the patient's work of breathing, while dangling promotes venous pooling in the extremities to reduce return to the heart.
|To determine whether there is a delay in impulse conduction through the atria, the nurse will measure||PR interval|
|The P wave represents||depolarization of the atria|
|P-R interval represents||depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches, and the Purkinje fibers.|
|QRS represents||ventricular depolarization|
|Q-T interval represents||depolarization and repolarization of the entire conduction system.|
|The nurse notes that a patient's cardiac monitor shows that every other beat has no P wave and has a QRS complex with a wide and bizarre shape. How will she document this rhythm?|| Bigeminal PVCs|
Bigeminal PVC's or ventricular bigeminy describes a rhythm in which every other QRS complex is wide and bizarre looking.
|Pairs of wide QRS complexes are described||couplets|
|Which laboratory result for a patient whose cardiac monitor shows multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?|| Serum potassium 2.8|
Hypokalemia increases the risk for ventricular dysrhythmias such as PVCs, ventricular tachycardia, and ventricular fibrillation; the health care provider will need to prescribe a potassium infusion to correct this abnormality.
|A diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made for a patient with type 2 diabetes who is brought to the emergency room in an unresponsive state. The nurse will anticipate the need to do which of the following priority actions?|| Insert a large-bore IV catheter|
HHS is initially treated with large volumes of IV fluids to correct hypovolemia.
| A patient is admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2.9. Which action prescribed by the health care provider should the nurse take first?|
|Place the patient on a cardiac monitor|
Hypokalemia can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Since potassium must be infused over at least 1 hour, the nurse should initiate cardiac monitoring before infusion of potassium.
|A diabetic patient is admitted with ketoacidosis and the health care provider writes the following orders. Which order should the nurse implement first?|| Infuse 1 liter normal saline per hour|
The most urgent patient problem is the hypovolemia associated with diabetic ketoacidosis (DKA), and the priority is to infuse IV fluids.
|When the nurse is assessing a patient who is recovering from an episode of DKA, the patient reports feeling anxious, nervous, and sweaty. Which action should the nurse take next?||Obtain a glucose reading using a finger stick|
| The nurse obtains a health history from a patient with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse is most appropriate?|
Myocardial infarction (MI)
family history of endocarditis
|Have you been to the dentist lately?"|
|While caring for a patient with aortic stenosis, the nurse establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. Which of the following is an appropriate intervention by the nurse related to this diagnosis?|| Promote rest to decrease myocardial oxygen demand|
Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain.
|During post-op teaching with a patient who had a mitral valve replacement with a mechanical valve, the nurse instructs the patient on which of the following?|| The need for frequent laboratory blood testing|
Anticoagulation with warfarin (Coumadin) is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing.
|When performing discharge teaching for the patient following a mechanical valve replacement, the nurse determines that further instruction is needed when the patients says...|| "The only risk I have during dental procedures is bleeding because of my anticoagulants"|
The greatest risk to a patient who has an artificial valve is the development of infective endocarditits with invasive medical or dental procedures.
|Which information obtained by the nurse when assessing a patient admitted with mitral valve regurgitation should be communicated to the health care provider immediately?|| The patient has crackles audible to the lung apices|
Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics.
|A systolic murmur and palpable thrill would be expected in a patient with||mitral regurgitation|
|most common form of valve disease in the United States?||Mitral valve prolapse|
|Which of the following are causes of increased ICP?||Stroke and head trauma|
|A patient has ICP monitoring with an intraventricular catheter. Which of the following is a priority nurisng intervention for this patient?||Aseptic technique to prevent infection|
|Which of the following is the earliest sign of increased ICP that the nurse can assess?||Decreased level of consciousness|
|Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is which of the following?||A 70 year-old African American male with hypertension|
|The warning signs of a stroke include all of the following except...||Respiratory distress|
| Which of the following types of strokes is not considered an ischemic stroke?|
|You and your classmates are studying for an Adult Health II exam, when Jena asks Katie "What do you think the answer is to number 16?" Katie does not answer, but stares blankly at Jena. What do you think is going on?|| Katie is having an atypical absence seizure|
An atypical absence seizure is characterized by a staring spell, peculiar behavior during the seizure, and confusion after the seizure.
|When teaching a patient with a seizure disorder about his medication regimen, which of the following priniciples is most important for the nurse to stress?||Stopping the medication abruptly may increase the frequency of seizures|
| Seizures may be precipitated in which of the following disturbances or imbalances?|
|Acidosis - not alkalosis, along with electrolyte imbalances, hypoxia, alcohol and barbiturate withdrawal, dehydration, and water intoxication can all precipitate seizure activity.|
|Which of the following menu choices is an appropriate choice for the client with acute renal failure (ARF)?|| Apple|
Citrus fruits, bananas, and baked potatoes are all high in potassium, which the patient with ARF is unable to clear.
|What is the leading cause of death in acute renal failure (ARF)?||Infection|
|Which of the following labs are important indicators of renal function to monitor in the client with acute renal failure (ARF)?||BUN & creatinine|
|A 60 year-old man arrives in the clinic complaining of shortness of breath, a pounding heartbeat, and dyspnea that is unrelieved even with rest. He complains of a persisten cough that gets worse when he lies down. Upon examination, you notice edema in his legs, ankles, and feet as well as pale skin. Which of the types of cardiomyopathy best fit the presentation of this patient?||Dilated cardiomyopathy|
|Which of the following is not considered a cauastive factor in the development of cardiomyopathy?||Chronic elevation in intracranial pressures|
|If not managed, cardiomyopathy may lead to all of the following complications except...||Diabetes mellitus|
|Which of the following is the mnemonic used to educate people about the warning signs of cancer?||CAUTION|
|basic pathophysiologic definition of cancer?||Cancer is an unchecked proliferation of cells|
|A client has been newly diagnosed with cancer and asks how severe the disease is. You correctly respond that the TNM staging test will be performed to give a more accurate prognosis. What does the TNM staging criteria evaluate?||Tumor size, nodal involvement, metastasis|
|Which of the following is the major difference between benign and malignant tumor cells?||Malignant tumors are capable of invasion and metastasis|
|Which of the following is characteristic of the cancer cell in the initiation phase?||Once initiated, mutation is irreversible|
|Tumor angiogenesis refers to||Formation of blood vessels within a tumor|
|events of metastasis|| Detach from the primary tumor and enter the circulation|
Survive the turbulent ciculation and adhere to the capillary basement membrane
Gain entrance into the organ parenchyma
Respond to a favorable growth environment
Undergo angiogenesis and proliferate
|true regarding a cancer cells susceptibility to chemotherapy?||Cells with a high mitotic rate respond well to chemotherapy|
|A client asks why the chemotherapeutic drugs he has read about online are classified as cell-cycle specific and cell-cycle non-specific. What is the best explanation of these types of chemotherapy?||They are used to describe the cycle of cell activity at which they will have the greatest impact|
|route by which chemotherapy is most frequently given?||IV|
|A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the family that|| full function of the patient's arms will be retained|
The patient with a T1 injury can expect to retain full motor and sensory function of the arms.
|Use of only the shoulders is associated with||cervical spine injury.|
|Loss of respiratory function occurs with||cervical spine injuries|
|Bradycardia is associated with||injuries above the T6 level.|
|A patient with paraplegia resulting from a t10 spinal cord injury has a neurogenic bladder. Which action will the nurse include in the plan of care?||Teach the patient how to self-catheterize at regular intervals|
Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization.
|The Credé method is more appropriate for a bladder that is||flaccid, such as occurs with a reflexic neurogenic bladder.|
|After a 25 year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing independently during rehab. Which of the following is the most appropriate action?||Develop a plan to increase the patient's independence in consultation with the patient and the spouse|
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important
|In caring for the patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority?|| Assessment of respiratory rate and depth|
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function.
|In caring for a patient who had a spinal cord injury 21 days ago and has a weak cough with loose-sounds secretions, the initial intervention by the nurse should be to|| place the hands on the epigastric area and push upward when the patient coughs|
Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions.
|To evaluate the effectiveness of IV methylprednisolone (Solu-medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain?|| Leg strength and sensation|
The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function.
|A patient with a hisotry of a T2 spinal cord innjury tells the nurse, "I feel awful today. My head is throbbing and I feel sick to my stomach". Which action should the nurse perform first?||The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring.|
|actions when caring for a trauma patient with a suspected spinal cord injury who is admitted to the emergency department?|| Immoblize the patient's head, neck, and spine|
Administer 02 using a non-rebreather mask
Monitor cardiac rhythm and blood pressure
Infuse normal saline at 150 ml / hr
Tranfer the patient to radiology for spinal CT
|A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most liely to occur is the ability to||Drive a vehicle with hand controls|
A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients);
|A 24 year-old patient is hospitalized with the onset of Guillain Barre syndrome. During the illness, the most essential assessment for the nurse to carry out is|| Observing respiratory rate and effort|
The most serious complication of Guillain-Barré syndrome is respiratory failure, and the nurse should monitor respiratory function continuously.
| Which of these nursing actions for a patient with Guillain-Barre' is appropriate for the nurse to delegate to an experinced nursing assistant?|
Administration of tube feedings
administration of ordered medications, assessment are skills
|Passive range of motion to the extremities q 8H|
|A 25 year old female is diagnosed with systemic lupus erythematosis (SLE). Which of the following statements regarding the need for family planning indicates further need for instruction?|| "Infertility rarely occurs"|
Infertility is a complication of SLE
|Which of the following skin conditions is a common finding in patients with systemic lupus erythematosis (SLE)?|| Discoid lesions|
Discoid lesions, vascular lesions, and a butterfly rash across the nose and cheeks are common skin manifestations.
|A patient is receiving intravesical bladder chemotherapy. For which of the following will the nurse monitor?|| Hematuria|
The adverse effects of intravesical chemotherapy are confined to the bladder.
|When reviewing the chart for a patient with cervical cancer, the nurse notes the cancer is stages as Tis (in-situ), N0, M0. The nurse will teach the patient that|| The cancer is localized to the cervix|
Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time.
|A patient with a large stomach tumor that is attached to the liver undergoes a debulking procedure. The nurse explains that the expected outcome of this surgery is|| Decrease in tumor size to improve the effects of other interventions|
A debulking surgery reduces the size of the tumor and makes radiation and chemotherapy more effective.
|A patient with Hodgkin's lymphoma who is undergoing external radiation tells the nurse "I am so tired I can haredly get out of bed in the morning." An appropriate intervention for the nurse to plan is to|| Establish a time to take a short walk almost every day|
Walking programs are used to keep the patient active without excessive fatigue.
|A patient undergoing external radiation has developed a dry desquamation in the treatment area. Which patient statement indicates that the nurse's teaching about management of this reaction has been effective?||"I can buy some aloe vera gel to use on the area"|
|When the nurse is administering a vesicant chemotherapeutic agent intravenously, an important consideration is to|| Stop the infusion if swelling is observed at the site|
Swelling at the site may indicate extravasation, and the IV should be stopped immediately.
|A patient who has severe pain associated with terminal liver cancer is being cared for at home by his family members. Which finding by the nurse indicates that teaching regarding pain management has been effective|| The patient takes opioids around the clock on a regular schedule with additional doses when breakthrough pain occurs|
For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional doses as needed for breakthrough pain.
|Which finding in a patient who is receiving interleukin-2 indicates a need for rapid action?|| Crackles heard at the lower scapular border|
Capillary leak syndrome and acute pulmonary edema are possible toxic effects of interleukin-2; the patient may need oxygen and the nurse should rapidly notify the health care provider.
|After receiving change-of-shift report, which of these patients should be seen first?|| 24 year-old who is receiving neck radiation and has blood oozing from the neck|
Since neck bleeding may indicate possible carotid artery rupture in a patient who is receiving radiation to the neck, this patient should be seen first.
|The nurse at the clinic is interviewing a 61 year-old woman who is 5 feet 3 inches tall and weighs 125 pounds (57 kg). The patient has not seen a health care provider for 20 years.She walks 5 miles on most days and has a glass of wine 2-3 times a week. Which topics will the nurse plan to include in patient teaching about cancer screening and decreasing cancer risk?|| Pap testing|
|A female client with a 30 pack year smoking history arives at the clinic for a physical. She admits a chronic cough over several years that has become more productive. You notice that her gait is unsteady, Which of the following diagnoses would you anticipate?|| Small cell CA|
Small cell CA quickly metastasizes to the bone and brain.
|Pathologic fractures may be indicative of||bone mets|
|The nurse obtains information about a hospitalized patient who is receiving chemotherapy for cancer of the colon. Which information about the patient is most indicative of the need for a change in therapy?|| Increase in CEA|
An increase in CEA indicates that the chemotherapy is not effective for the patient's cancer and may need to be modified.
|When preparing for an annual physical exam for a patient who is 50 years old, the nurse will plan to teach the patient about which of the following?|| Colonoscopy|
At age 50, individuals with an average risk for colorectal cancer (CRC) should begin screening for CRC. Colonoscopy is the gold standard for CRC screening.
|Chronic myelogenous leukemia (CML) is characterized by a proliferation of abnormal WBC's and the presence of which of the following fenetic markers?||Philadelphia chromosome|
|Reed-Sternberg cells are used in the identification of||Hodgkin's disease.|
|A 21 year-old female presents to the clinic with generalized fatigue and night sweats along with the presence of a painless, movable lump in the axillary area. What will the nurse anticipate testing for?|| Hodgkin's lymphoma|
cervical, axillary, and inguinal areas.
|Primary age groups for the development of Hodgkin's lymphoma are||young adults and adults over 60.|
|A 58 year-old woman calls the health clinic when she has a moderate amount of vaginal bleeding 6 years after menopause. The nurse will anticipate teaching the patient about which of the following?|| Endometrial biopsy|
A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis.
|Endometrial ablation and balloon therapy are used to treat||menorrhagia|
|Which assessment finding for a patient who is on the surgical unit after a radical abdominal hysterectomy related to ovarian CA is most important to report to the health care provider?|| Urine output of 80 ml in the first 8 hours after surgery|
decreased urine output indicates possible low blood volume and further assessment is needed to assess for possible internal bleeding.
|A 25 year-old woman arrives at the clinic for a physical. She has sought preventive care sporadically but has refused a pap smear in the past stating that nobody else in her family has ever had a cancer. The client asks what risk factors are associated with cervical cancer. Which of the following is a correct response?||Early-age onset of sexual activity, multiple sexual partners, multiparity, long-term 'pill' use, cervical trauma, HPV infection, smoking, and being of African descent are all risk factors.|
|Which statement by a patient who is scheduled for a needle biopsy or the prostate indicates the nurse's teaching about the purpose of the biopsy has been effective?|| The biopsy will help decide the treatment for my enlarged prostate"|
A biopsy is used to determine whether the prostate enlargement is benign or malignant and determines the type of treatment that will be needed.
|Which information will the nurse plan to include when teaching a 19 year-old to perform testicular self-examination||Testicular self-examination should be done in a warm area|
|In planning community education for prevention of spinal cord injuries, the nurse targets which of the following groups?|| Adolescent and young adult men|
Spinal cord injuries are highest in young adult men between the ages of 15 and 30 and those who are impulsive or risk takers in daily living.
|A patient with a spinal cord injury has spinal shock. The nurse plans care for the patient based on the knowledge that||Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder|
|In spinal shock, the entire cord below the level of the lesion fails to function, resulting in||flaccid paralysis and hypomotility of most processes without any reflex activity.|
|Return of reflex activity signals||the end of spinal shock.|
|An initial incomplete spinal cord injury often results in complete cord damage because of which of the following post-injury processes?||Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites|
|The pathophysiology of secondary injury is related to autodestruction of the||cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction to the cord.|
|Which surgical therapy used in the treatment of breast cancer involves removal of the entire tumor along with a margin of normal tissue?||Breast conservation surgery|
|A 57 year old woman comes to the clinic for her yearly mammogram. Upon the clinical breast exam, the nurse notes persistent lesions on the nipple and areola with a palpable mass. Upon questioning, the client admits that her nipples have been itching and burning with occasional bloody discharge. What type of malignant breast cancer will the nurse anticipate being identified?||Paget's disease|
|A 23 year old female comes into the clinic for a routine exam. She relates that she does monthly self-breast exam, but notes that each month there are different areas of tenderness on each breast. What questions are most appropriate for the nurse to ask?|| Are your periods regular or irregular?|
Do you check on the same date each month?
Have you noticed any consistent areas of tenderness?
Have you noticed any solid or immobile masses?
Have you had any dimpling of the breast or drainage from the nipples?
|The two main priorities in health promotion in the battle against HIV are||Early detection and disease prevention|
|A client who is HIV +, comes into the clinic with complaints of severe fatigue, drenching night sweats, diarrhea, and headache -- which she describes as worsening manifestations of earlier symptoms. The physician indicates that the client is in the Intermediate Chronic phase of infection. Which laboratory results would the nurse anticipate in this phase?||CD4 + T cell count of 300 cells/microliter and a increased viral load|
|A 35 year-old woman is diagnosed with HIV. The client asks about her chances for getting rid of the disease. Which of the following responses are accurate?||"Anti-viral combinations will help to manage the disease progression, but there is no cure for the disease"|
|Which ocular or facial signs/symptoms would the nurse expect to find when assessing the client diagnosed with myasthenia gravis?|| Ptosis and diplopia|
Ptosis is drooping of the eyelid, and diplopia is unilateral or bilateral blurred vision.
|The client is being evaluated to rule out myasthenia gravis and being administered the Tensilon (edrophonium chloride) test. Which response to the test indicates the client has myasthenia gravis?|| The client shows a marked improvement in muscle strength|
lasts approximately 5 minutes when Tensilon is injected.
|The client diagnosed with myasthenia gravis is prescribed the cholinesterase inhibitor, neostigmine (Prostigmin). Which data indicate the medication is effective?|| The client is able to feed self independently|
This medication promotes muscle contraction, which improves muscle strength, which, in turn, would allow the client to perform ADL's without assistance.
|Which of the following describes the triad of symptoms found in the patient with Parkinson's Disease?||Tremor, rigidity, bradykinesia|
|The pathophysiologic process of Parkinson's Disease involves the degeneration of which of the following?||Dopamine producing neurons in the substantia nigra|
|Which of the following is the benefit of yoga as an alternative therapy in the treatment of Parkinson's Disease?||Improves balance and flexibility|
|When educating a female client recently diagnosed with systemic lupus erythematosis (SLE) about the triggers of the disease, the nurse is correct in stating that the most significant environmental triggers are||Sun exposure and sunburn|
|As a nurse in a neuro clinic, you are aware that the most recognized organism associated with the development of Guillain-Barre' Syndrome (GBS) is||Campylobacter jejuni|
|Which of these findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?|| Urine output is 60 ml over the last hour|
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful.
|hemoglobin level, PAWP, and MAP are useful in determining the effects of||fluid administration|
|Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?|| Monitor breath sounds frequently|
Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the nurse should assess the breath sounds frequently.
|When the nurse is assessing a patient who is receiving nitroprusside (Nipride) infusion to treat cardiogenic shock, which finding indicates that the medication is effective?|| Skin is warm, pink, and dry|
Warm, pink, and dry skin indicates that perfusion to tissues is improved.
|Which assessment information is most important for the nurse to make in order to evaluate whether treatment for the patient with anaphylactic shock has been effective?|| Oxygen saturation|
Because the airway edema that is associated with anaphylaxis can affect airway and breathing, the oxygen saturation is the most critical assessment.
|Which information obtained by the nurse when caring for a patient who has cardiogenic shock is an indication that the patient may be developing multiple organ dysfunction syndrome (MODS)?|| The patient's serum creatinine level is elevated|
The elevated serum creatinine level indicates that the patient has renal failure as well as heart failure
|crackles, chest pressure, and cool extremities are all consistent with the patient's diagnosis of||cardiogenic shock|
|A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, and blood glucose of 246. Which of these prescribed interventions will the nurse implement first?|| Give normal saline IV @ 500 ml / hr|
Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy.
|When the charge nurse is evaluating the skills of a new RN, which action by the new nurse indicates the need for more education in the care of patients with shock?|| Decreasing the room temperature to 68 F for a patient with neurogenic shock|
Patients with neurogenic shock may have poikilothermia. The room temperature should be kept warm to avoid hypothermia.
|When caring for a patient who has septic shock, which assessment finding is most important for the nurse to report to the health care provider?|| Skin cool & clammy|
Since 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.
|A patient who has been involved in a motor vehicle crash is admitted to the emergency room with cool, clammy skin, tachycardia, and hypotension. Which of the following interventions should the nurse implement first?||Administer oxygen @ 100% per non-rebreather mask|
The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions also should be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.
|A patient with shock of unknown etiology whose hemodynamic monitoring reveals BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure (PAWP) has the following collaborative interventions prescribed. Which intervention will the nurse question?|| Infuse normal saline @ 250 ml / hr|
The patient's elevated pulmonary artery wedge pressure indicates volume excess. A normal saline infusion at 250 mL/hr will exacerbate this. The other actions are appropriate for the patient.
|In which of the following systems are the symptoms of early MODS most evident?|| Respiratory|
The respiratory system is the first to show signs because the direct effect on the pulmonary vasculature, fluid moves from the pulmonary
vasculature and into the pulmonary interstitial spaces
|When caring for a critically ill patient who is being mechanically ventilated, the nurse will monitor for which of the following clinical manifestations of MODS?|| Increased BUN / Cr levels|
Clinical manifestation of MODS include symptoms of respiratory distress, signs and symptoms of decreased renal perfusion, decreased serum albumin and prealbumin, decrased GI motility, acute neurologic changes, myocardial dysfunction, DIC, and changes in glucose metabolism.
|Anaphylactic shock||Maldistribution of blood|
|Cardiogenic shock||Low blood flow|
|Hypovolemic shock||Low blood flow|
|Neurogenic shock||Maldistribution of blood|
|Septic shock||Maldistribution of blood|
|Multiple Organ Dysfunction Syndrome (MODS) is diagnosed when an acutely ill patient is unable to maintain hemostasis without intervention. Which of the following must also be evident for this diagnosis to be made?||Failure of two or more organ systems|
|MODS is defined as||the failure of two or more organ systems in an acutely ill patient such that hemostasis cannot be maintained without intervention.|
|A patient has a spinal cord injury at T4. Vital signs reveal a falling BP with bradycardia. The nurse recognizes that this patient is experiencing which of the following?||Neurogenic shock r/t maldistribution of blood flow|
|Neurogenic shock is a type of||distributive shock and can result from a spinal cord injury at T5 or above.|
|Shock is best defined as...||Inadequate tissue perfusion|
|A 78 year-old man has confusion and a temperature of 104 F. He is diabetic with purulent drainage from his right great toe. His assessment findings are BP 84/40, HR 110, RR 42 and shallow. His skin has changed from hot and moist to cool and moist. This patient's symptoms are most likely indicative of which of the following?|| Septic shock|
The patient's blood pressure is low his heart rate is fast and his respirations are rapid. This indicates shock. He also has fever and known infection
|Sepsis with hypotension is characteristic of||septic shock|
|A patient with septic shock has a urine output of 20 ml / hr for the past 3 hours. The pulse rate is 120 bpm and the central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) are low. Which orders given by the health care provider will the nurse question?|| Give furosemide (Lasix) 40 mg IV|
Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock.
|A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock?||Apical heart rate 48 BPM|
|Neurogenic shock is characterized by||hypotension and bradycardia.|
|These four patients arrive in the emergency department after a motor vehicle crash. In which order should they be assessed?|
A 72 year old with palpitations and chest pain
A 30 year old with a misaligned right leg with intact pulses
A 22 year old with multiple fractures of the face and jaw
A 45 year old complaining of 6/10 abdominal pain
|The highest priority is to assess the 22-year-old patient for airway obstruction, which is the most life-threatening injury. The 72-year-old patient may have chest pain from cardiac ischemia and should be assessed and have diagnostic testing for this pain. The 45-year-old patient may have abdominal trauma or bleeding and should be seen next to assess circulatory status. The 30-year-old appears to have a possible fracture of the right leg and should be seen soon, but this patient has the least life-threatening injury.|
|The emergency department (ED) triage nurse is assessing four victimes of an automobile accident. Which patient has the highest priority for treatment?|| A patient with a sucking chest wound|
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with a sucking chest wound should be treated first.
|During the primary assessment of a trauma victim, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?|| Observe the patient's respiratory effort|
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing.
|A patient who is unconcious after a fall from a ladder is transported to the emergency room by family members. During the primary survey of the patient, the nurse should|| Obtain a Glasgow Coma Scale score|
The Glasgow Coma Scale is included when assessing for disability during the primary survey
|A patient with hypotension and temperature elevation after doing yard work on a hot day arrives in the emergency department (ED). After the nurse has completed discharge teaching, which statement indicates that treatment has been effective?|| "I should have sports drinks when exercising outside in the hot weather"|
Electrolyte solutions such as sports drinks help replace fluid and electrolytes lost when exercising in hot weather.
|An 88 year old female presents to the emergency department (ED) with nausea & vomiting. VS reveal BP 86/56; AP 118; T 102.2 F. A diagnosis of heat stroke is identified. You are aware that all forms of heat stress occur when thermoregulatory mechanisms are unable to compensate for exposure to increased ambient temperatures. Which of the following are 'thermoregulatory mechanisms' involved in the occurrence of heat stress.||Vasodilation, sweating, and increased respirations|
|Heat stress is an umbrella term for many heat-related emergencies including||heat syncope, heat edema, heat cramps, heat exhaustion, and heat stroke.|
|When preparing to rewarm a patient with hypothermia, the nurse will plan to|| Attach a cardiac monitor|
Rewarming can produce dysrhythmias, so the patient should be monitored and treated if necessary.
|A patient who experienced a near drowning accident ina local lake, but now is awake and breathing spontaneously, is admitted for observation. Which action will be most important for the nurse to make during this observation period?|| Auscultate breath sounds|
Since pulmonary edema is a common complication after near drowning, the nurse should assess the breath sounds frequently.
|When rewarming a patient who arived in the emergency department (ED) with a temprature of 87 F, which assessment indicates that the nurse should discontinue the rewarming?|| The core temperature is 94 F|
A core temperature of 89.6° F to 93.2° F (32° C to 34° C) indicates that sufficient rewarming has occurred.
|When assessing a patient's full-thickness burn injury during the emergent phase, the nurse would expect to find|| Leathery, dry, hard skin|
Dry, waxy, white, leathery, or hard skin is characteristic of full-thickness burns in the emergent phase
|Deep partial thickness burns in the emergent phase are||red, shiny, and have blisters|
|The initial intervention in the management of a burn of any type is to|| Remove the patient from the burn source and stop the burning process|
The first intervention is to remove the source and stop the burning process. Airway maintenance would be second, then establishing IV access, followed by assessing for other injuries.
|The initial cause of hypovolemia during the emergent phase of burn injury is|| Increased capillary permeability|
Although all the above selections could contribute to hypovolemia in the burn patient, the initial and most pronounced effect is caused by fluid shifts out of the blood vessels as a result of increased capillary permeability.
|The nurse positions the patient with ear, face, and neck burns|| Without pillows|
Patients with ear burns are not allowed to use pillows because of the danger of the burned ear sticking to the pillowcase, and patients with neck burns are not allowed to use pillows because contractures to the neck can occur.
|A burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion (ROM) secondary to pain. An appropriate nursing intervention for this person is to||Provide analgesic medications before physical activity and exercise|
The limited range of motion in this situation is related to the patient's inability or reluctance to exercise the joints because of pain, and the appropriate intervention is to help conrol the pain so that exercises can be performed. The patient is probably never without some pain, and although exercises and enlisting the help of the physical therapist are important, neither of these interventions addresses the cause.
|The emergency department (ED) nurse receives report about a patient with full-thickness burns to 24% of the body. Which IV fluid will the nurse anticipate infusing|| Lactated Ringers|
Fluid replacement is accomplished using crystalloid solutions such as Lactated Ringer's and colloids such as albumin. Albumin, however is usually reserved until after 12-24 hours post-burn when capillary permeability returns to normal or near normal.
|Burns caused by flame, flash, scald, or contact with a hot object are examples of which type of burn injury?||Thermal|
|The rule of nines is a guide for determining which of the following?|| Extent of burn calculated as total body surface area (TBSA)|
The rule of nines is an assessment tool used for estimating the extent of total body surface area that has been affected by the burn injury.
|Burns to which of the following areas poses a significant threat of infection?||Ears and nose|
|Burns to which of the following areas poses a significant threat for respiratory compromise?||Circumferential burns of chest & back|
|To maintain a positive nitrogen balance in a major burn, the patient must|| Eat a high protein, low-fat, high carbohydrate diet|
Increase normal caloric intake by about 3 times
|A patient has 25% TBSA burned from a car fire. His wounds have been debrided and convered with a silver-impregnated dressing (Silvadene). The nurse's priority intervention for wound care would be to||Observe the wound for signs of infection during dressing changes|
|Nursing priorities such as excision and grafting, pain management, and nutritional therapy are included in which phase of burn care?||Acute phase|
|Which of the following types of injury is least likely to result in a full-thickness burn?||Sunburn|
|During the rehabilitative phase of wound injury, the contour of scarring can be controlled with|| Pressure garments|
Pressure garments help keep scars flat and prevent elevation and enlargement above the original burn injury area.
|Lotions and splinting are used to prevent||contractures|
|Avoidance of sun is necessary for 1 year to prevent||hyperpigmentation and sunburn injury to healed burn areas|
|During the secondary survey of a trauma patient in the emergency deartment (ED), it is important that the nurse obtain details of the incident primarily because|| The mechanism of injury can indicate specific injuries|
Specific injuries are associated with specific types of accidents and events surrounding an incident, and details of the incident along with the trajectory of penetrating injuries are important in identifying and treating the injury.
|In assessing the emergency patient's health history during the secondary survey, the use a which of the following mnemonics can help guide the interview?|| A - allergies|
M - medication history
P - past history / pregnant
L - last meal
E - events os the illness or injury
|During the re-warming of a patient's toes that have suffered deep frostbite, the nurse|| Ensures that analgesics are administered|
Rewarming of frostbitten tissue is extremely painful, and analgesia should be administered throughout the process.
|The patient with septicemia develops a new onset of prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?|| Notify the patient's physician|
The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration
|A patient with a possible disseminated intravascular coagulation (DIC) arrives in the Energency Department (ED) with a blood pressure 82/40, temperature 102 F, and severe back pain. Which of these physician orders will the nurse implement first?|| Infuse normal saline 500 ml over 30 minutes|
The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs.
|Number in sequence the events that occur in disseminated intravascular coagulation (DIC).|
Activation of fibrinolytic system
Fibrinogen converted to fibrin
Release of fibrin split products
Widespread fibrin and platelet deposition in capillaries and arterioles
Inhibition of normal clotting
Production of intravascular thrombin
Depletion of platelets and coagulation factors
|Production of intravascular thrombin|
Fibrinogen converted to fibrin
Widespread fibrin and platelet deposition in capillaries and arterioles
Depletion of platelets and coagulation factors
Activation of fibrinolytic system
Release of fibrin split products
Inhibition of normal clotting
| Mr. Jones comes into the Emergency Room with a blood pressure of 189/124. What is the first priority of the health care team?|
a) Reduce blood pressure
b) Ensure adequate hydration
c) Reduce his pain
d) Admit him to the hospital
|a) Reduce blood pressure|
|Why is it pertinent to control blood pressure during a hypertensive emergency?|
a) To decrease possibility of intracranial hemorrhage caused by swelling of the brain
b) To decrease possibility of heart attack and heart failure
c) It decreases impaired blood flow to other important organs, like the kidneys
d) To prevent damage to the retina
e) All of the above
|e) All of the above|
| Patients presenting to the ED with hypertensive crisis will most likely experience:|
a) Severe anxiety and Respiratory failure
b) Changes in vision and Numbness or Weakness
c) Nausea/Vomiting and Chest Pain
d) B & C
e) All of the above
|Correct answer: D|
|A patient is getting ready to discharge after a hypertensive crisis. For the nursing staff, what is important for them to teach the patient?|
a) Educate on medications to control blood pressure
b) Educate on low sodium diet
c) Set up patient with resources
d) Explain about hypertensive crisis and warning signs
e) All of the above
|e) All of the above|
|The pathologic process of PD involves the degeneration of||dopamine producing neurons in the substantia nigra|
| How is PD diagnosed? Select all those that apply|
B. CT scan
C. history and clinical features
D. Positive response to antiparkinsonian drugs
| C. history and clinical features|
D. Positive response to antiparkinsonian drugs
|A patient is admitted to the hospital with a new diagnosis of Guillain Barre'. During the acute phase, the nurse recognizes that...|
The priority of care is to monitor the patient's vital capacity and ABG's
Early treatment with steroids can suppress the immune response and prevent ascending nerve damage
Voluntary motor neurons are damaged, but the autonomic nervous system is unaffected
The most serious complication is demyelination of the cranial nerves
|The priority of care is to monitor the patient's vital capacity and ABG's|
|A patient with GBS asks whether he is going to die as the paralysis ascends toward his chest. What is the most appropriate response?|
1. Patients who require ventilatory support almost always die
2. Death occurs when the nerve damage reaches the brain and meninges
3. Most patients with GBS make a complete recovery
4. Even if death can be prevented, residual paralysis is usually permanent
|3. Most patients with GBS make a complete recovery|
|Which of the following best describes the pathophysiology of SLE?|
1. Circulating immune complexes formed from IgG
2. T-cell reaction that leads to the destruction of the deep dermal layer
3. Immunologic dysfunction leading to chronic inflammation of cartilage and muscles
4. The production of a variety of antibodies directed against the compnents of the cell nucleus
|4. The production of a variety of antibodies directed against the compnents of the cell nucleus|
| During an acute exacerbation of SLE, the patient is treated with corticosteroids. The nurse should expect the steroids to be tapered when serum lab results reveal....|
| Which surgical therapy involves removal of the entire tumor along with a margin of normal tissue?|
Breast conservation surgery
Axillary node dissection
Modified radical mastectomy
|Breast conservation surgery|
|A young man comes into for a routine physical and mentions to his doctor that he has noticed his breasts have progressively become larger. After ruling out any malignancies, the best response of the doctor would be to tell the young man...|
This is the result of excess fibrous tissue
This is called Gynecomastia and is result of the disturbance of the normal ratio of active androgen to estrogen in plasma or within the breast itself. A common breast problem in men.
The enlarged breast may last years and will have a high risk for becoming malignant in the near future.
|This is called Gynecomastia and is result of the disturbance of the normal ratio of active androgen to estrogen in plasma or within the breast itself. A common breast problem in men.|
|Stacey is HIV positive and comes into the clinic with complaints of frequent drenching night sweats, diarrhea, headaches, and severe fatigue. Which laboratory finding do you expect to see?|
CD4+ T cell count of 800 cells/microliter and a decreased viral load.
CD4+ T cell count of 700 cells/microliter and an increased viral load
CD4+ T cell count of 300 cells/microliter and an increased viral load.
CD4+ T cell count of 1200 cells/microliter and a decreased viral load.
|CD4+ T cell count of 300 cells/microliter and an increased viral load.|
|The physician just informs you that Paige's enzyme immunoassay is positive for HIV and that you need to draw another blood sample. She looks confused and says, "I already had that done." What do you tell her?|
You have tested positive for HIV but we need to run another test to be certain.
We are unsure of the other blood sample so we need another to do the Western Blot blood test.
It is common to do more than one blood tests to confirm HIV.
|It is common to do more than one blood tests to confirm HIV.|
| Which of these infections, seen in the intermediate chronic infection phase, is an indicator of HIV disease progression?|
Oral hairy leukoplakia
|Oral hairy leukoplakia|
| Why might some tests be falsely positive or falsely negative?|
The tests were administered wrong
The tests were contaminated
The window period
All of the above
|The window period|
| The most effective health care strategies are?|
a) Health promotion and Detection
b) Detection and Prevention
c) Limit disability and Detection
d)) Health promotion and Prevention
|d)) Health promotion and Prevention|
|When planning a community education program related to prevention of the cancer with the highest death rates in both women and men, the nurse will stress the importance of: |
1. Smoking cessation.
2. Screening with colonoscopy.
3. Regular examination of reproductive organs.
4. Use of sunscreen and protection from ultraviolet light.
|1. Smoking cessation.|
|After 3 weeks of radiation therapy, a patient has lost 10 pounds and does not eat well because of mucositis. An appropriate nursing diagnosis for the patient is:|
1. Risk for infection related to poor nutrition.
2. Ineffective self-health management related to refusal to eat.
3. Imbalanced nutrition: Less than body requirements related to oral inflammation and ulceration.
4. Ineffective health maintenance related to lack of knowledge of nutritional requirements during radiation therapy.
|3. Imbalanced nutrition: Less than body requirements related to oral inflammation and ulceration.|
| Which of the following is the most common type of leukemia in older adults?|
1. Acute myelocytic leukemia
2. Acute lymphocytic leukemia
3. Chronic myelocytic leukemia
4. Chronic lymphocytic leukemia
|4. Chronic lymphocytic leukemia|
| The nurse is aware that a major difference between hodgkin's lymphoma and NHL is..|
1. Hodgkin's only occurs in young adults
2. Hodgkin's is characterized by the presence of Reed-Sternberg cells
3. NHL is characterized by the presence of Reed-Sternberg cells
4. NHL can only be treated with radiation
|2. Hodgkin's is characterized by the presence of Reed-Sternberg cells|
|A patient with metastatic CRC is scheduled for both chemotherapy and radiation. What patient teaching is appropriate for this patient?|
Chemotherapy can be used to cure CRC
Radiation is routinely used following surgery
Both chemotherapy and radiation can be used as palliative measures
The patient should expect few if any side effects from chemotherapeutic agents
|Both chemotherapy and radiation can be used as palliative measures|
| What is the first system to show signs of dysfunction?|
|The respiratory system is the first to show signs because the direct effect on the pulmonary vasculature, fluid moves from the pulmonary vasculature and into the pulmonary interstitial spaces|
| A patient has a spinal cord injury at T4. Vital signs include a falling BP with Bradycardia. The nurse recognizes that this patient is experiencing:|
a) Relative Hypervolemia
b) Absolute hypovolemia
c) Neurogenic shock from low blood flow
d) Neurogenic shock from a maldistribution of blood flow
| Answer: D|
Neurogenic shock is caused by a maldistribution of blood flow and can result from a spinal cord injury at T5 or above.
| Shock is best defined as|
A) cardiovascular collapse
B) loss of sympathetic tone
C) inadequate tissue perfusion
D) blood pressure less than 90 mm Hg systolic
| Answer: C|
Shock occurs when body tissues are inadequately perfused.
|A 78 year old man has confusion and temperature of 104 degrees. He is a diabetic with purulent drainage from his right great toe. His assessment findings are BP 84/40; heart rate 110; respiratory rate 42 and shallow. This patient's symptoms are most likely indicative of|
Systemic inflammatory response syndrome
| Answer: B|
The patient's blood pressure is low, his heart rate is fast, and his respirations are high. This indicates shock. He also has a fever and an infection. Sepsis with hypotension is characteristic of septic shock.
|The ED receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. In preparation for the patient's arrival, the nurse will obtain... |
5oo ml of 5% albumin
Lactated Ringer's solution
Two 14-guage IV catheters
Dopamine (Intropin) infusion
|Two 14-guage IV catheters|
|Assessment of the patient during the primary survey indicates that the patient has delayed capillary refill of the extremities and cannot explain the events prior to admission to the emergency department. The nurse should first:|
1. Insert one or two large-bore IV catheters to start intravenous fluid resuscitation.
2. Continue the primary survey to complete it with a brief neurologic examination.
3. Apply leads for electrocardiogram (ECG) monitoring.
4. Initiate pulse oximetry.
|Initiate pulse oximetry.|
| Heat stroke is characterized by which of the following?|
Temperature between 101 - 102.5
Hot, dry, ashen skin
| Altered mentation|
Hot, dry, ashen skin
|DIC is a disorder in which...|
1. the coagulation pathway is genetically altered leading to thrombus formation in all major blood vessels
2. an underlying disease depletes hemolytic factors leading to thrombotic episodes
3. a disease process stimulates the coagulation cascade resulting in microthrombi, as well as depletion of clotting factors
4. An inherited predisposition of clotting deficiencies
|3. a disease process stimulates the coagulation cascade resulting in microthrombi, as well as depletion of clotting factors|
| Supportive cares for DIC may include which of the following?|
Fresh Frozen Plasma (FFP)
|A pressure ulcer demonstrating full-thickness skin loss involving damage to subcutaneous tissue extending down to, but not through, the underlying fascia, would be classified as?||Stage 3|
|pressure ulcer involving extensive destruction of surrounding and supporting structures.||stage 4|
|Pressure ulcer in which are partial-thickness||stage 2|
|pressure ulcer defined as a change in skin temp. tissue consistency, and/or sensation.||stage 1|
|What would be most helpful for a patient that is experiencing chills because of an infection?|| provide a light blanket|
chills signify a rise in temp. For this reason the nurse should only use a light blanket to avoid overheating.
|When teaching a patient with HIV regarding transmission of the virus to others, what comment would indicate need for further education?|| I will isolate tissues that I use from my family.|
HIV is not spread casually
|The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome and will monitor the pt closely for what kind of electrolyte imbalance associated with this oncologic emergeny?|| hyokalemia|
TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemo. This can rapidly lead to acute renal failure.
|What are the hallmark signs of TLS||hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia.|
|The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. What would be a good way to increase the patient's nutritional intake?||adding items high in protein and/or calories like peanut butter, skim milk powder, cheese, honey, or brown sugar.|
|What would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for oral tissue injury secondary to chemotherapy?||a salt water rinse will not cause further irritation to oral tissue that is fragile because of mucositis from chemo.|
|When assessing a patient admitted with N&V what would support the diagnosis of fluid vlm deficit?|| restlessness|
This is an early sign that dehydration is left untreated, cerebral signs could progress to confusion and later coma.
|which of the following nursing interventions in most appropriate when caring for a patient with dehydration?||measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate restoration of fluid vlm.|
|1-kg of weight gain indicates a gain of what?||1000 ml of body water|
|When planning the care of a patient with dehydration, the nurse would instruct the unlicensed to report what?||an output of less than 20 ml per 2 hours|
|When planning care for adult patients, the nurse concludes that which of the following oral intakes is adequate to meet daily fluid needs of a stable patient?||2000-3000 ml|
|The nurse is caring for a patient with metastatic bone cancer. What are the clinical manifestations that would alert the nurse to the possibility of hypercalcemia?||lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, N&V|
|signs of hypocalcemia||paresthesia, facial spasms, and muscle tremors.|
|End of life care||the period of time during which an individual copes with declining health from a terminal illness or from the frailties associated with advanced age even if death is not clearly imminent.|
|Goals of End of Life Care|| 1) Provide comfort and supportive care during the dying process.|
2) Improve the quality of the remaining life.
3) Help ensure a dignified death.
|Physical Manifestations|| Sensory changes|
Circulatory and Respiratory Changes
Loss of Muscle Tone
|Psychosocial Manifestations|| Altered decision making|
|Grief||The lived experience in reaction to the loss.|
|Advance Directives|| Written statements of a person's wishes regarding medical care.|
Living wills, directives to physicians, durable power of attorney for health care, medical power of attorney
|Chemical code||use of drugs for resuscitation without use of CPR|
|Palliative Care|| the active total care of patients whose disease is not responsive to curative treatment.|
Focus on controlling pain and other symptoms
Reduce distress for patient and family
Can start earlier than 6 mo prior to death
|Hospice||exists to provide support and care for persons in the last phases of incurable diseases so that they might live as fully as comfortably as possible.|
|Uses for Common Transplants|| Skin grafts are frequently used with burn patients.|
Bone marrow donation is used with leukemias and other malignancies.
Corneas are used to prevent or correct blindness.
|Transplanting Partial Organs||Some organs such as the liver, lung lobes, or intestinal segments may be transplanted allowing a living donor and the recipient to both function using the organ.|
|the human leukocyte antigen||This is very important for kidney and bone marrow transplants and minimizing the HLA mismatch increases the survival rates for heart and lung transplants.|
|Crossmatching is done on donors to test for||cytotoxic antibodies, a panel of reactive antibodies (PRA) is done, high % indicates poor chance of finding a donor.|
|Transplant Rejection Occurs if the donor organ does not match the recipient's||HLA|
|Immunosuppressive therapy is used to prevent||organ rejection while at the same time maintaining sufficient immunity in the recipient.|
|Patients are at increased risk for infection and malignancies while on||immunosuppressive.|
|A 21-year-old is dying after an automobile accident. The family members want to donate the patient's organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when|
a. the patient is flaccid and unresponsive.
b. CPR is ineffective in restoring heartbeat.
c. the patient is apneic and without brainstem reflexes.
d. respiratory efforts cease and no apical pulse is audible.
The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes.
|The spouse of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, "I'm busy at work, but otherwise things are fine." An appropriate nursing diagnosis is|
a. ineffective coping related to lack of grieving.
b. anxiety related to complicated grieving process.
c. caregiver role strain related to feeling overwhelmed.
d. hopelessness related to knowledge deficit about cancer.
The wife's behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death.
|. As the nurse admits a patient with severe heart failure to the hospital, the patient tells the nurse, "If my heart or breathing stop, I do not want to be resuscitated." Which action is best for the nurse to take?|
a. Ask if these wishes have been discussed with the health care provider.
b. Place a "Do Not Resuscitate" (DNR) notation in the patient's care plan.
c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed.
d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.
A health care provider's order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient's request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient's wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient's current concern with possible resuscitation.
|A patient who is very close to death is very restless and keeps repeating, "I am not ready to die." Which action is best for the nurse to take?|
a. Remind the patient that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the patient needs.
c. Insist that family members remain at the bedside with the patient.
d. Tell the patient that everything possible is being done to delay death.
Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed.
|A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?|
a. Contact a grief counselor as soon as possible.
b. Cry along with the patient's family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since patient losses are common.
|It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic|
|Which of these patients is most appropriate for the nurse to refer to hospice care?|
a. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying
b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse
c. A 28-year-old with AIDS-related dementia who needs palliative care and pain management
d. A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home
Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life.
|A terminally ill patient is admitted to the hospital. Which action should the nurse include in the initial plan of care?|
a. Determine the patient's wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the patient and family.
d. Encourage the patient to talk about any fears or unresolved issues.
| A nurse is caring for a woman who has COPD and renal failure. She goes to dialysis three times a week and is thought to live for 1-2 more years. To which department would be best for the patient to be referred?|
| If the family of the deceased is unsure of the organ donation wishes of their family member, the nurse does not need to notify an organ donation team.|
|A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms|
a. will continue to increase until death finally occurs.
b. are a normal response before these functions decrease.
c. indicate a reflex response to the slowing of other body systems.
d. may be associated with an improvement in the patient's condition.
An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient.
|The contractile phase of the cardiac cycle is called||systole|
|Therelaxation phase of the cardiac cycle is called||diastole|
| The right heart delivers (oxygenated, deoxygenated) blood to the|
(pulmonary circulation, systemic circulation).
|deoxygenated, pulmonary circulation|
| An average cardiac output at rest is:|
a) 3 litres
b) 4 litres
c) 5 litres
d) 10 litres
| Heart valves ensure the forward flow of blood through the heart.|
True or False
| Cardiac output is the amount of blood ejected by the (atrium, ventricle) over|
(1 heart beat, 1 minute).
|types of burn injury||, smoke and inhalation, electrical, cold inhalation, and ... (chemical).|
|treatment of burns is related to the severity of the injury. Severity is measured by:||depth of burn, location of burn, percent of TBSA involved, and patient risk factors|
|A 46-year-old patient is told by his doctor that he has type 2 diabetes and will require treatment and lifelong changes in his lifestyle. The patient is very distressed but asks for information about the illness, visits the local office of the American Diabetes Association, and elicits help and suggestions from his family in planning lifestyle changes. The nurse recognizes that this patient's response to stress is mediated by the personal characteristic of: |
4. Sense of coherence.
|4. Sense of coherence.|
| Critical care nurses...|
A. Are formally trained to provide physical, emotional, and psychological care to patients and families
B. Are knowledgeable members of a multidisciplinary team
C. Must be certified to work independently at the bedside
D. Can insert central venous access devices in ICU only.
|B. Are knowledgeable members of a multidisciplinary team|
|The pulmonary artery waveform of a patient with a pulmonary artery catheter is blunted. The nurse notifies the health care provider, recognizing that:|
1. The balloon is overinflated.
2. The catheter may be occluded by a thrombus.
3. The catheter is wedged in a pulmonary capillary.
4. The catheter has migrated from the pulmonary artery to the right ventricle.
|2. The catheter may be occluded by a thrombus.|
|A patient's arterial blood gas (ABG) results include pH 7.31, PaCO2 50 mm Hg, PaO2 51 mm Hg, and HCO3 24 mEq/L. Oxygen is administered at 2 L/min, and the patient is placed in high-Fowler's position. An hour later, the ABGs are repeated with results of pH 7.36, PaCO2 40 mm Hg, PaO2 60 mm Hg, and HCO3 24 mEq/L. It is most important for the nurse to take which of the following actions?|
1. Increase the oxygen flow rate to 4 L/min.
2. Document the findings in the patient's record.
3. Reposition the patient in a semi-Fowler's position.
4. Prepare the patient for endotracheal intubation and mechanical ventilation.
|2. Document the findings in the patient's record.|
|When assessing a patient with sepsis, which of the following findings would alert the nurse to the early onset of acute respiratory distress syndrome (ARDS)?|
1. SpO2 of 80%
2. Use of accessory muscles of respiration
3. Fine, scattered crackles on auscultation of the chest
4. ABGs of pH 7.33, PaCO2 48 mm Hg, and PaO2 80 mm Hg
|3. Fine, scattered crackles on auscultation of the chest|
| A patient diagnosed with DVT develops hemoptysis, tachycardia, and hypoxemia. For which of the following diagnostic tests will the nurse prepare the patient?|
1. Chest radiograph
2. Venous doppler US
3. Pulmonary angiogram
4. Ventilation-perfusion scan
|1. Chest radiograph|
|Six P's|| Pallor|
Paralysis (late sign)
|A 60 year old man arrives in the clinic complaining of shortness of breath and a pounding heartbeat. Even when lying down he cannot seem to catch his breath. He also complains of a persistent cough that gets worse when he is lying down. Upon examination you notice edema in his legs ankles and feet as well as pale skin. You suspect the doctor will make a diagnosis of:|
| In this type of Cardiomyopathy the etiology of the disease is unknown. In this case the heart muscle is the only portion of the heart involved, and other cardiac structures are unaffected.|
| Causes of Cardiomyopathy include which of the following?|
Long term high blood pressure
Certain viral infections
All of the above
|All of the above|
| If not managed Cardiomyopathy may lead to all of the following complications except:|
Cardiac arrest and sudden death
| Which of the following are characteristics of Hypertrophic Cardiomyopathy?|
Massive ventricular hypertrophy
Rapid, forceful contraction of the left ventricle
Impaired relaxation (diastole)
Obstruction to aortic outflow (not present in all patients)
All of the above
|All of the above|
|A patient has been newly diagnosed with Restrictive Cardiomyopathy. The patient is very anxious and asks you what Restrictive Cardiomyopathy is exactly. Your best response would be:|
A disease where the heart muscle becomes rigid and less elastic, meaning the heart can't properly expand and fill with blood between heart beats.
A disease where the heart muscle becomes abnormally thick. This thickened heart muscle can make it harder for the heart to pump blood.
A condition where inflammation of the pericardial sac that is characterized by fibrin deposition and thickening of the pericardium occurs.
|A disease where the heart muscle becomes rigid and less elastic, meaning the heart can't properly expand and fill with blood between heart beats.|
|The most significant factor in long-term survival of a patient with sudden cardiac death is:|
1. Absence of underlying heart disease.
2. Rapid institution of emergency services and procedures.
3. Performance of perfect technique in resuscitation procedures.
4. Maintenance of 50% of normal cardiac output during resuscitation efforts.
|2. Rapid institution of emergency services and procedures.|
|A patient is admitted to the coronary care unit following a cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the health care provider's admission orders, which of the following orders is it most important for the nurse to question?|
1. Oxygen at 4 L/min per nasal cannula
2. Morphine sulfate 2 mg IV every 10 minutes until the pain is relieved
3. Tissue plasminogen activator (t-PA) 100 mg IV infused over 3 hours
4. IV nitroglycerin at 5 mcg/minute and increase 5 mcg/minute every 3 to 5 minutes
|3. Tissue plasminogen activator (t-PA) 100 mg IV infused over 3 hours|
| Angina occurs with myocardial ischemia as a result of which of the following?|
1. Death of myocardial tissue
2. Dysrhythmias caused by cellular irritability
3. Lactic acid accumulation during anaerobic metabolism
4. Elevated pressure in the ventricles and pulmonary vessels
|3. Lactic acid accumulation during anaerobic metabolism|
| Tachycardia that is a response of the SNS to the pain of ischemia is detrimental because not only does it increase oxygen demand, it also...|
1. Decreases CO
2. Causes reflex hypotension
3. May lead to ventricular dysrhythmias
4. Impairs perfusion of the coronary arteries
|4. Impairs perfusion of the coronary arteries|
| The nurse monitors the patient receiving treatment for ADHF with the knowledge that marked hypotension is most likely to occur with the IV administration of which of the following?|
| A patient with ADHF presents with tachypnea, dyspnea, and a sat of 88%. An appropriate priority nursing intervention for this patient is...|
Assist the patient to CT&DB
Assess intake and output
Encourage alternate periods of rest and activity
Place the patient in high Fowler's with feet dangling.
|Place the patient in high Fowler's with feet dangling.|
|A patient has a diagnosis of acute myocardial infarction, and his cardiac rhythm is sinus bradycardia with six to eight premature ventricular contractions (PVCs) per minute. The pattern that the nurse recognizes as the most characteristic of PVCs is:|
1. An irregular rhythm.
2. An inverted T wave.
3. A wide, distorted QRS complex.
4. An increasingly long PR interval.
|3. A wide, distorted QRS complex.|
| A patient's cardiac rhythm is sinus bradycardia with a heart rate of 34 beats/minute. If the bradycardia is symptomatic, the nurse would expect the patient to exhibit:|
3. Warm, flushed skin.
4. Shortness of breath.
|4. Shortness of breath.|
| What would be appropriate nursing interventions to include in the plan of care for a patient with acute renal failure?|
A. Monitor intake and output
B. Monitor for signs of infection
C. Provide for adequate intake of calcium and vitamin D
D. all of the above
|D. all of the above|
| The warning signs of a stroke include all of the following EXCEPT....|
A. Sudden respiratory distress
B. Sudden weakness
C. Sudden severe headache
D. Loss of vision
|A. Sudden respiratory distress|
| Of the following information provided by a patient, which would help differentiate a hemorrhagic stroke from a thrombotic stroke?|
A. Presence of motor weakness
B. Sudden onset of severe headache
C. History of hypertension
D. Sensory disturbance
|. Sudden onset of severe headache|
|Cardiac monitoring is initiated for a patient in diabetic ketoacidosis. The nurse recognizes that this measure is important to identify:|
1. Dysrhythmias resulting from hypokalemia.
2. Fluid overload resulting from aggressive fluid replacement.
3. The presence of hypovolemic shock related to osmotic diuresis.
4. Cardiovascular collapse resulting from the effects of excess glucose on cardiac cells.
|1. Dysrhythmias resulting from hypokalemia.|
|A patient is admitted with diabetic ketoacidosis (DKA) and has a serum potassium level of 2.9. Which action prescribed by the HCP should the nurse take first?|
Infuse regular insulin@ 20 units / hr
Place the patient on a cardiac monitor
Administer IV potassium supplements
Obtain urine glucose and ketone levels
|Place the patient on a cardiac monitor|
|Generalized seizures differ from partial seizures in that:|
a)Partial seizure are confined to one side of the brain and remain focal in nature
b)Generalized seizures result in loss of consciousness while partial seizures do not.
c)Generalized seizures result in temporary residual deficits during the postictal phase.
d)Generalized seizures have no warning because the entire brain is affected at the onset.
|d)Generalized seizures have no warning because the entire brain is affected at the onset.|
|A patient admitted to the hospital following a generalized tonic-clonic seizure asks the nurse what caused the seizure. The best response by the nurse is:|
a)"So many factors can cause epilepsy that it is impossible to say what caused your seizure."
b)"Epilepsy is an inherited disorder. Does anyone else in your family have a seizure disorder?"
c)"In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity."
d)"Scar tissue in the brain alters the chemical balance, creating uncontrolled electrical discharges."
|c)"In seizures, some type of trigger causes sudden, abnormal bursts of electrical brain activity."|
|When teaching a patient with a seizure disorder about the medication regimen, it is most important for the nurse to stress that:|
a) the patient should increase the dosage of the medication if stress is increased
b) if gingival hypertrophy occurs the drug should be stopped and the health care provider notified
c) stopping the medication abruptly may increase the intensity and frequency of seizures
d) most over-the-counter and prescription drugs are safe to take with anticonvulsant drugs
|c) stopping the medication abruptly may increase the intensity and frequency of seizures|
|The nurse finds a patient in bed having a generalized tonic-clonic seizure. During the seizure activity, the nurse should:|
a) turn the patient to the side
b) suction the patient and administer oxygen
c) insert an oral airway into the patient's mouth
d) restrain the patient's extremities to prevent soft tissue and bone injury
|a) turn the patient to the side|
|Following a generalized tonic-clonic seizure, the patient is tired and sleepy. The nurse should:|
a) suction the patient before allowing him to rest
b) allow the patient to sleep as long as he feels sleepy
c) stimulate the patient to increase his level of consciousness
d) check the patient's level of consciousness every 15 minutes for an hour
|b) allow the patient to sleep as long as he feels sleepy|
|During the diagnosis and long-term management of a seizure disorder, the nurse recognizes that one of the major needs of the patient is assistance to:|
Manage the complicated drug regimen of seizure control
Cope with the effects of negative social attitudes toward epilepsy
Adjust to the very restricted lifestyle required by a diagnosis of epilepsy
Learn to minimize the effect of the condition in order to obtain employment
|Cope with the effects of negative social attitudes toward epilepsy|
|A nurse monitoring a client who has sustained a head injury would determine that the intracranial pressure is rising if which of the following vital signs trends is notied during the course of the work shift?|
A. increased pulse, irregular respiration, increased BP
B. decreased pulse, irregular respiration, increased pulse pressure
C. increased pulse, decreased respiration, increased pulse pressure
D. increased temperature, decreased pulse, irregular respirations, increased bp
|D. increased temperature, decreased pulse, irregular respirations, increased bp|
| MODS starts as systemic inflammatory response syndrome which can occur as a result of what?|
Mechanical tissue trauma
Global perfusion deficits
All of the above
| Which of these factors affects the chances of a successful organ transplant? Select all that apply.|
Time and transport
Human leukocyte antigen
| Which of these transplants is least likely to have transplant rejection?|
| A patient with terminal cancer is at home with a morphine drip. He is showing signs of pain, however his respiration rate is 10. What should the hospice nurse do?|
A) Hold the morphine
B) Give the morphine
C) Call the doctor for a new pain medication since the morphine is not working
|B) Give the morphine|