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Complex Final Exam

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The nurse fails to record a set of vital signs on a blood transfusion report, which is against hospital policy. The patient does not sustain any damage as a result. Can the nurse be charged with malpractice in this case?

A. Yes. Even though there were no damages, the nurse failed to follow hospital protocol.
B. No. There were no damages associated with failure to document.
C. Yes. Failure to document always results in negligence.
D. No. Documentation is not part of the duty of nurse.
B.
To establish negligence, there must be a duty to the patient, the nurse must have breached that duty, the breach must cause harm to the patient, and the patient should therefore be compensated. Without damage, there is no charge. The nurse did violate hospital policy and could be subject to disciplinary actions. Failure to document on its own does not meet all the criteria to establish negligence, and documentation is part of the duty of the nurse.
A patient in the critical care unit has an order to be transported off the unit for a diagnostic procedure. The nurse fails to ensure that the patient is properly monitored during transport, and the patient experiences a cardiac arrest. Which of the following actions did the nurse fail to adequately perform?

A. Assess and analyze the level of care needed by the patient.
B. Make the proper nursing diagnosis.
C. Communicate findings in a timely manner.
D. Act as a patient advocate to postpone the examination.
A.
The nurse failed to properly assess and analyze the patient's need to be transported with a cardiac monitor and professional staff. Misdiagnosis and lack of communication were not the issues. There is not enough evidence to determine whether postponing the examination would have prevented the event.
On the morning laboratory report, the patient's potassium is noted to be 2.5 mEq/L. The nurse does not want to bother the physician this early. During the change-of-shift report, the patient develops ventricular tachycardia and has to be resuscitated. What part of the nursing process did the nurse fail to perform?

A. Assessment
B. Planning
C. Implementation
D. Evaluation
C.
The nurse failed to communicate critical laboratory values to the physician in a timely manner. Because the laboratory report was available, this was not an issue with assessment, planning, or evaluation.
Which action would be considered a breach of the standard of care for the RN, thus exposing the nurse to malpractice? (Select all that apply.)

A. Failure to administer a medication to a patient, resulting in injury to the patient
B. Failure to administer medication, resulting in no injury
C. Administration of the wrong medication to a patient due to misidentification of the patient, resulting in injury
D. Failure to administer a medication to a coworkers patient, resulting in injury
A, C
Failure to administer a medication to a patient and administration of the wrong medication to a patient caused by misidentification of the patient, both resulting in injury, demonstrate a duty to the patient and a failure to act as a prudent practitioner would in a similar situation; damages were incurred by the patient. In failure to administer medication with no resulting injury, although the nurse failed to follow hospital policy and would be subject to disciplinary action, no harm occurred. In failure to administer a medication to a coworker's patient, resulting in injury, the nurse does not have a duty to provide care in the place of another practitioner (unless the nurse was officially covering for the other nurse).
A postoperative patient with a history of intractable pain is receiving fentanyl IV. The nurse is preparing to suction the patient's endotracheal tube and notes that the high-pressure alarm is sounding. When the nurse attempts to ventilate with a bag-valve-mask, it suddenly requires a lot more effort to ventilate the patient. The nurse suspects that this is:

A. A normal side effect of fentanyl
B. An expected postoperative finding
C. Due to chest wall muscle rigidity from the fentanyl
D. A sign of pain relief from the fentanyl
C.
This is a life-threatening complication of fentanyl administration. It is not normal. It could be an expected complication of fentanyl, but it is not caused by surgery. It is not an indication of pain relief.
The nurse is explaining to the student nurse why pain assessment is known as the fifth vital sign. Which statements indicate an understanding of this concept? (Select all that apply.)

A. Pain assessment needs to be performed by the nursing assistant.
B. Pain assessment needs to be performed following pharmacological treatments.
C. Pain assessments need to be completed at specific time intervals.
D. The nurse can assume that the only patients in pain are those who put on the call light.
E. Pain is only manifested by physiological parameters.
B., C.
The patient should be assessed before and after medications are administered for pain, and pain assessments must be performed and documented at specified time intervals. Nursing assistants cannot assess pain; they can ask if the patient is in pain, but this should be reported to the nurse. Some patients in pain may not want to bother the staff and may still be in pain. Pain has physiological, cognitive, and emotional components.
The nurse is assessing a patient with a patient-controlled analgesic device (PCA) who is receiving morphine. The nurse notes that the patient has made 20 attempts but has only received four doses from the drug. This could indicate that: (Select all that apply.)

A. The patient is not using the device.
B. The patient is having unrelieved pain.
C. The patient requires a lower dose of morphine in the device.
D. The patient is an addict.
E. The patient needs reinforcement of education on the device.
B., E.
The patient is attempting to administer more doses of the drug than the lockout period will allow. This could be a sign of unrelieved pain, or the patient could require more education on the device. The patient is pushing the button and so is using the device. If the patient wants more of the drug than allowed, a higher dose might be necessary. It should not be automatically assumed that the patient is a drug addict in the acute care setting.
The nurse notes that the patient complaining of pain (8 of 10 on the pain scale) has an increased heart rate, blood pressure, and respiratory rate along with dilated pupils. The nurse remembers that these signs indicate: (Select all that apply.)

A. Sympathetic nervous system stimulation
B. Parasympathetic nervous system stimulation
C. Acute pain
D. Chronic pain
E. Corticotropin factor release from the hypothalamus
A., C., E.
Corticotropin factor release in acute pain stimulates the sympathetic nervous system. Parasympathetic nervous system stimulation and chronic pain would be indicated by a lowered heart rate and decreasing blood pressure.
A patient woke up from a sound sleep in a cold sweat with nausea and light-headedness and now has chest pain (8 of 10 on the pain scale) that is unrelieved by nitroglycerin (NTG) after 5 minutes. The patient is experiencing:

A. stable angina.
B. unstable angina.
C. variant angina.
D. silent ischemia.
B.
The patient is showing signs of unstable angina. Stable angina occurs with predictable precipitating factors and improves with rest or NTG within 5 minutes. Variant angina is caused by spasm of a coronary artery, usually occurs at the same time every day, and is relieved by NTG. Silent ischemia is painless.
A patient is admitted with syncope, exertional dyspnea, and a systolic murmur. Cardiac catheterization reveals significantly increased left ventricular end-diastolic pressure (LVEDP) and:

A. aortic stenosis.
B. mitral stenosis.
C. tricuspid stenosis.
D. pulmonary regurgitation
A
Symptoms of aortic stenosis include syncope, exertional dyspnea, increased LVEDP, and systolic murmur. Mitral and tricuspid stenoses are associated with a diastolic murmur as is pulmonary regurgitation.
A patient is admitted with fever, hematuria, and new onset of a cardiac murmur. The patient has a history of intravenous drug abuse and complains of tender spots on the pads of her fingers. She has a low-grade fever, and the nurse notes an enlarged spleen on physical examination. What is the priority nursing diagnosis?

A. Risk for infection related to invasive procedures
B. Risk for anxiety related to lack of availability of narcotics
C. Decreased cardiac output related to alteration in contractility
D. Knowledge deficit related to discharge plans
C
Because the patient is experiencing endocarditis, the most important nursing diagnosis is decreased cardiac output related to alteration in contractility.Infection and anxiety are only potential problems, and although knowledge deficit is important, it is not the priority on admission.
A patient with a family history of coronary artery disease (CAD) has the following laboratory results: total cholesterol, 250 mg/dL; high-density lipoprotein, 35 mg/dL; low-density lipoprotein, 160 mg/dL; and triglycerides, 240 mg/dL. Which interventions should the nurse anticipate? (Select all that apply.)

A. Document the normal findings.
B. Instruct the patient to increase exercise to 30 minutes a day, 5 days a week.
C. Educate on increasing saturated fat and decreasing fiber in the diet
D. Monitor and control blood pressure.
E. Enroll in smoking cessation classes.
B, D, E
The patient with elevated lipids and a history of CAD should be instructed to increase exercise, monitor blood pressure, and stop smoking. Documenting the findings as normal would be inappropriate because the laboratory test results are not normal. The patient should be educated to decrease saturated fats and increase fiber.
A patient in the acute phase of systolic heart failure is admitted to the intensive care unit. Which interventions would the nurse anticipate? (Select all that apply.)

A. Diuretics to lower systemic vascular resistance (SVR)
B. Morphine for peripheral dilation and to decrease anxiety
C. Nitroglycerin to decrease preload and afterload
D. Dopamine to decrease contractility of the heart
E. Nesiritide to decrease pulmonary artery occlusion pressure and dyspnea
B, C, E

Morphine, nitroglycerine, and nesiritide are all used to treat patients in systolic heart failure. Diuretics will decrease preload, not SVR. Dopamine will increase myocardial contractility.
The nurse caring for a patient with a temporary transvenous pacemaker notes on the monitor a pacing spike (artifact) that is not followed by a QRS. Which action should the nurse take first?

A. Notify the physician.
B. Decrease the mA.
C. Reposition the patient on the left side.
D. Evaluate the sensitivity threshold.
C
The patient has developed failure to capture, and the nurse should place the patient on the left side and increase the mA. Failure to capture occurs as a result of displacement of the pacing electrode or an increase in pacing threshold. Decreasing the mA will make the problem worse. Adjusting the sensitivity will not affect the pacemaker's ability to capture. Notifying the physician is important but should occur after repositioning and assessing the patient.
The charge nurse has just received report on the patients in the cardiac intervention recovery unit. Which patient should be seen first?

A. Patient 3 hours after percutaneous coronary angioplasty (PTCA) with an ACT of 180 seconds
B. Patient with an arterial and venous sheath intact via the left leg with no pedal pulse
C. Patient who had sheath removed 6 hours ago and is asking for a urinal
D. Patient who denies chest pain after a PTCA
B
The patient with the sheaths in place is experiencing circulatory compromise as evidenced by the loss of pedal pulse in the extremity. This patient would be considered top priority because of the potential loss of blood flow to the patient's leg. The patient with the ACT of 180 seconds will need the sheath removed, but this can wait for a few more minutes. The patient who needs a urinal can also wait a few more minutes. The patient who denies chest pain is stable.
After a coronary artery bypass graft (CABG), the nurse notes the patient has muffled heart tones, jugular vein distention, and decreased blood pressure. There is no drainage from the chest tube for the last 2 hours. The nurse suspects the patient is having:

A. coronary vasospasm.
B. cardiac tamponade.
C. postoperative infection
D. postoperative hemorrhage
B
These are the signs of cardiac tamponade. Symptoms of coronary vasospasm include chest pain. Symptoms of postoperative infection include fever, drainage, and tachycardia. Symptoms of postoperative hemorrhage include flattened neck veins, tachycardia, and increased chest tube drainage.
Which patients are candidates for fibrinolytic therapy? (Select all that apply.)

A. A 38-year-old patient with chest pain for 8 hours and ST elevation in leads V1 to V4
B. A 47-year-old patient with bundle branch block (BBB) and ST elevation in leads II, III, and aVF and new onset left BBB
C. A 54-year-old patient who had a surgical repair of gastric ulcer 1 week ago, with chest pain for 10 hours
D. A 64-year-old patient with chest pain for 6 hours after a motor vehicle crash in which the airbag was deployed
E. A 49-year-old patient with chest pain for 14 hours and a history of BBB
A, B
Patients with a history of trauma, surgery, or stroke are not candidates for fibrinolytics, nor are patients with chest pain for longer than 12 hours. A 38-year-old patient with chest pain for 8 hours and ST elevation in leads V1 to V4 and a 47-year-old patient with BBB and ST elevation in leads II, III, and aVF and new onset left BBB are both candidates for fibrinolytics.
A patient has a history of respiratory problems. The nurse is assessing the patient's chest and notes that the sternum and lower ribs are displaced posteriorly, creating a pit-shaped depression in the chest. The nurse recognizes this as:

A. barrel chest.
B. kyphosis.
C. pectus excavatum.
D. pectus carinatum
C
The patient has pectus excavatum or funnel chest. Barrel chest has an increased anteroposterior diameter with the sternum forward and the ribs outward. Kyphosis is a rearward curvature of the spine. In pectus carinatum, or pigeon chest, the sternum projects forward.
A nurse is performing an assessment on a patient's lungs. While performing percussion on the left lung, the nurse notes a low-pitched resonant sound. This is compatible with what disease process?

A. Asthma
B. Bronchitis
C. Emphysema
D. Pneumothorax
B
Bronchitis produces a low-pitched resonant tone. Asthma, emphysema, and pneumothorax produce very low-pitched hyperresonant tones.
A postoperative patient has a respiratory rate of 10 breaths/min with an SpO2 of 95%. Arterial blood gas (ABG) values are PaO2 85, pH 7.32, PaCO2 51, and HCO3 24. The patient is experiencing:

A. respiratory alkalosis.
B. respiratory acidosis.
C. metabolic alkalosis.
D. metabolic acidosis.
B
The patient is experiencing respiratory acidosis as evidenced by a pH below 7.35, a PaCO2 above 35, and a normal HCO3. Respiratory alkalosis would have a pH above 7.45, a PaCO2 below 35, and a normal HCO3. Metabolic alkalosis would have a pH above 7.45, an HCO3 above 26, and a normal PaCO2. Metabolic acidosis would have a pH below 7.35, an HCO3 below 22, and a normal PaCO2.
Which ABG is considered compensated?

A. pH 7.22, PaCO255, HCO325
B. pH 7.33, PaCO2 62, HCO335
C. pH 7.35, PaCO2 48, HCO328
D. pH 7.50, PaCO2 42, HCO333
C
The ABG of pH 7.35, PaCO2 of 48, and HCO3 of 28 is a compensated respiratory acidosis. The pH has come back within normal range as a result of the retaining HCO3 to buffer for the excess PaCO2. The ABG of pH 7.22, PaCO2 of 55, and HCO3 of 25 is an uncompensated respiratory acidosis. The ABG of pH 7.33, PaCO2 of 62, and HCO3 of 35 is a partially compensated respiratory acidosis. The ABG of pH 7.50, PaCO2 of 42, and HCO3 of 33 is an uncompensated metabolic alkalosis.
A patient in metabolic acidosis has the following laboratory results: Na+ 146; Cl2- 106; HCO3 15. What kind of acidosis would this be?

A. Non-anion gap metabolic acidosis
B. High anion gap metabolic acidosis
C. Low anion gap metabolic acidosis
D. Normal anion gap metabolic acidosis
Anion gap is calculated by [Na+] ([Cl2-] + [HCO3]). This patient has a high anion gap (>16).
A nurse notes that a patient's trachea is deviated to the left side. What condition could cause this to occur? (Select all that apply.)

A. Atelectasis in the left lung
B. Pneumothorax in the right lung
C. Bilateral pneumonia
D. Pleural effusion on the left side
E. Bronchiectasis in the left lung
A, B, E
Atelectasis and bronchiectasis cause a tracheal shift to the same side as the problem. Pneumothorax and pleural effusion cause the trachea to deviate toward the normal side (opposite the problem). Bilateral pneumonia does not cause a tracheal shift.
A patient has bronchial breath sounds over the peripheral lung fields. What condition could cause this? (Select all that apply.)

A. Asthma
B. Lung mass with exudate
C. Bronchitis
D. Pulmonary edema
E. Bronchospasms
B, E
Lung mass with exudates and pulmonary edema cause displaced bronchial breath sounds. Rhonchi and wheezes are heard in asthma. Bronchitis produces rhonchi, and bronchospasm produces wheezes.
In normal respiration, inspiration is longer than expiration. In which disorders will inspiration be equal to expiration? (Select all that apply.)

A. Pneumothorax
B. Pneumonia with consolidation
C. Pulmonary fibrosis
D. Atelectasis
E. Effusion
B, C
In pneumonia with consolidation and pulmonary fibrosis, inspiration and expiration are equal. In pneumothorax, atelectasis, and pleural effusions, inspiration is longer than expiration.
A mechanically ventilated patient has a fever, P/F ratio of 230, and a pulmonary artery occlusive pressure of 15 mm Hg. The patient is coughing and triggering the high-pressure alarm on the ventilator. The radiologist has notified the nurse that the patients? feeding tube is in the right lung, and the patient has developed bilateral infiltrates on the radiograph. The nurse is concerned that the patient is developing:

A. acute pulmonary embolism.
B. acute lung injury.
C. pneumothorax.
D. inadequate nutrition.
B
C
The patient is showing signs of acute lung injury brought on by the direct lung injury from the misplaced feeding tube. There is no evidence of a pulmonary embolism. A pneumothorax would have shown up on the radiograph as a unilateral problem, not a diffuse infiltrate. Nutrition is not the immediate concern at this moment.
The nurse is discussing the pharmacologic treatment of a pulmonary embolism (PE) with a nursing student. Which statement made by the nursing student indicates that the education was effective?

A. Heparin is administered to break down the existing clots.
B. Heparin is titrated to achieve a prothrombin time of two to three times the control value.
C. Heparin should be continued until the warfarin is started.
D. Streptokinase can be used to treat patients with massive pulmonary embolism and hemodynamic instability.
D
Streptokinase is a fibrinolytic reserved for severe PE. Heparin is administered to prevent further clots from forming and has no effect on the existing clot. The heparin should be adjusted to maintain the activated partial thromboplastin time (aPTT) in the range of two to three times of upper normal. Warfarin should be started at the same time, and when the international normalized ratio (INR) reaches 3.0, the heparin should be discontinued. The INR should be maintained between 2.0 and 3.0.
The nurse is admitting a patient with severe community-acquired pneumonia. Select all interventions that are appropriate for this patient.

A. Start intravenous (IV) antibiotics.
B. Place the patient on the monitor and obtain vital signs.
C. Obtain sputum cultures and laboratory work.
D. Inquire about allergies and current medications.
E. Start a peripheral IV.
A, B, C, D, E
Assess the patient and establish any allergies (to Betadine or ChloraPrep for IV insertion and antibiotics) and current medications. (Is the patient already on antibiotics?) Start the peripheral IV and obtain the laboratory work and sputum culture before starting the antibiotics.