Sole for unit 5
Ch 3, 13, 15, 21
Terms in this set (76)
What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intra-cranial pressure (ICP)?
Lowering ICP by allowing for elevations in CO2 to dilate cerebral arteries
Lowering ICP by facilitating venous drainage and decreasing venous obstruction
Lowering ICP by maintaining an open airway
Lowering ICP by reducing the risk of snoring
Under normal circumstances the cerebral vasculature exhibits pressure and chemical autoregulation. What happens when autoregulation is lost?
Central venous engorgement occurs.
Cerebral blood flow is not affected.
Hypertension increases cerebral blood flow.
Shunting of cerebrospinal fluid (CSF) is blocked.
The nurse is monitoring a patient's intracranial pressure (ICP). While the nurse is providing hygiene measures, she observes that the ICP reading is sustained at 18 mm Hg. What is the priority nursing action?
Cease stimulating the patient
Continue with hygiene measures.
Lower the head of the bed to 10 degrees.
Open the ICP monitor to continuous drainage.
Herniation syndromes can be life-threatening situations. Which syndrome causes the supratentorial contents to shift downward and compress vital centers of the brainstem?
In a patient with increased intracranial pressure (ICP), which of the following cranial nerves would be assessed for consensual light response, elevation of the eyelids, and eye movement?
I, IX, X
II, V, VII
II, VI, X
III, IV, VI
The nurse is managing the blood pressure of a patient with a traumatic brain injury. When planning the care of this patient, which statement best represents appropriate blood pressure management?
Cerebral perfusion pressure (CPP) should be sustained at least 70 mm Hg.
Hypertension greater than 160 mm Hg is necessary to achieve adequate perfusion.
Nimodipine reduces blood pressure through its effect on cerebral vessels.
Nitrates are the vasopressors of choice with increased ICP.
The nurse is caring for a patient with a ruptured cerebral aneurysm. During initial assessment, the nurse notes that the cerebrospinal fluid draining into a ventriculostomy system is blood tinged. What is the best interpretation of this finding by the nurse?
Cerebral aneurysms commonly rupture in the subarachnoid space.
This assessment finding is indicative of developing cerebral meningitis.
Patient movement has resulted in dislodgement of the catheter.
Normal cerebral spinal fluid contains a small amount of visible blood.
The nurse is caring for a patient admitted with a spinal cord injury. Upon assessment, the nurse notes a complete loss of motor and sensory function below the patient's nipple line. What is the best understanding of this assessment finding by the nurse?
Anterior cord lesion
Central cord lesion.
Complete cord lesion.
The nurse is preparing to admit a patient from the ED who has sustained a complete spinal cord lesion at the C5 level. When planning the patient's care, which nursing intervention is most important?
Perform hourly incentive spirometry.
Apply warming devices as needed.
Give small, frequent feedings.
Assist with passive range of motion.
The nurse is caring for a patient with an assessed Glasgow Coma Scale score of 3. What is the best understanding of this finding?
Coma scale score is a direct
Coma scale score is a direct result of dysfunction of the cerebellum.
Damage to the patient's corpus callosum has led to a comatose state.
A Glasgow Coma Scale score of less than 3 indicates a semi-comatose state.
There is impairment of the reticular activating system (RAS), resulting in coma.
Autonomic dysreflexia is characterized by an exaggerated response of the sympathetic nervous system to a variety of stimuli. Common causes of autonomic dysreflexia include: (Select all that apply.)
urinary tract infection.
Which statements best represent optimal fluid administration for the management of increased intracranial pressure? (Select all that apply.)
Normal saline (0.9%) is recommended for fluid volume resuscitation.
The goal is to keep serum osmolality greater than 320 mOsm/L.
0.45% saline solution is acceptable for fluid volume resuscitation.
Hypotonic solutions are avoided to prevent an increase in cerebral edema.
The nurse is examining the patient's urinalysis and notices the presence of red blood cells and albumin as well as nitrogenous waste products and sodium. The nurse realizes that:
red blood cells are normally found in urine.
albumin is an abnormal finding in urine.
urinary sodium levels should be higher than serum levels.
nitrogenous waste products in urine indicate kidney disease.
The nurse is caring for a patient who is 90 years old. The patient's creatinine level is within normal limits. The nurse understands that the reason for the normal value is:
renal blood flow remains constant throughout life.
the number of glomeruli increases with collateral circulation.
serum creatinine levels may remain the same in the elderly.
peritubular density increases as glomeruli decrease in number.
A 53-year-old patient has kidney and ureteral stones and is hospitalized for urinary retention and severe flank pain. What classification of acute kidney injury is the patient in danger of developing?
Acute tubular necrosis
Decreased blood flow through the kidney results in:
decreased systolic blood pressure.
increased excretion of sodium and water.
release of renin from the kidney
The nurse is caring for a patient who weighs 70 kg. For this patient, oliguria is defined as urine output that is _____ mL per hour.
greater than 35
less than 50
less than 100
less than 35
During the maintenance phase of intrinsic renal failure, which of the following abnormalities are likely?
Infection, hypokalemia, hyponatremia
Oliguria, azotemia, hyperkalemia
Oliguria, hypokalemia, hypernatremia
Uremia, hyperkalemia, infection
Hyperventilation is often seen in patients with renal failure as a compensatory mechanism for:
The patient is admitted for general malaise and low urine output. The patient is alert and oriented and states that he has lost 5 pounds over the past few days. His heart rate is 124 beats per minute. His blood pressure is 88/40 mm Hg. His mouth is dry and he has flat neck veins and poor skin turgor. The nurse assesses that his low urine output is due to:
The patient is admitted with generalized edema and hypertension. The patient states that his urine output has been less than normal. An indwelling urinary catheter is inserted, but very little urine is obtained. The patient has distended neck veins and his blood pressure is 210/110 mm Hg. The nurse assesses that the patient's fluid retention is due to:
The patient's creatinine level is 1.1 mg/dL. The nurse would expect the patient's blood urea nitrogen (BUN) level to be
0.5 to 0.1 mg/dL.
0.11 to 0.22 mg/dL.
5 to 10 mg/dL
11 to 22 mg/dL.
The patient has an elevated blood urea nitrogen (BUN) level and an elevated creatinine level but a normal BUN/creatinine ratio. This indicates:
normal kidney function.
acute tubular necrosis (ATN)
problems other than kidney failure.
Which of the following nursing actions is most important for a patient with acute kidney injury?
Maintain accurate intake, output, and daily weight measurements.
Obtain a drug trough level immediately after an antibiotic is administered.
Insert an indwelling urinary catheter.
Restrict fluids to 200 mL per day.
Intrarenal causes of acute kidney injury from prerenal conditions can be prevented by:
administering diuretics before procedures.
inserting an indwelling urinary catheter.
maintaining adequate hydration
administering low-dose dopamine.
The patient has a potassium level of 7 mEq/L but is not scheduled for a dialysis treatment for the next 3 days. To reduce plasma and body potassium levels, the nurse prepares to administer:
regular insulin to be given IV.
sodium polystyrene sulfonate (Kayexalate) and sorbitol rectally.
sodium polystyrene sulfonate (Kayexalate)
calcium gluconate by mouth.
The patient is receiving continuous renal replacement therapy (CRRT). The nurse should become concerned when:
the blood tubing becomes warm to touch.
the ultrafiltrate is showing a pink tinge
there are no dark fibers in the hemofilter after 2 hours.
the patient's temperature drops by one degree.
The nurse is caring for a patient getting peritoneal dialysis. The patient complains of abdominal pain, chills, and nausea. The dialysate return is cloudy. The nurse notifies the provider that the patient is exhibiting symptoms of:
mechanical dysfunction of the dialysate.
intolerance of peritoneal fluid volume.
The kidneys help to maintain acid-base equilibrium by: (Select all that apply.)
reabsorbing filtered bicarbonate in response to acidosis.
producing new bicarbonate in response to acidosis.
excreting hydrogen ions in response to alkalosis
excreting bicarbonate in response to acidosis
producing ammonia when the patient is acidotic
The nurse is caring for a patient who has an elevated blood urea nitrogen level (BUN). Factors that can elevate BUN include: (Select all that apply.)
blood in the gastrointestinal tract.
Which statement best describes the role of the acute care nurse in the organ donation process?
Approach the family for consent for organ donation once brain death has been determined.
Implement donor management procedures once brain death has been determined.
Obtain consent from the next-of-kin for withdrawal of life support.
Notify the organ procurement organization (OPO) in cases of impending death.
Which transplant patient being cared for by the nurse requires immediate intervention?
A third post-op day renal transplant recipient with an activity pain level of 3/10
A second post-op day lung transplant recipient with a semi-productive cough
A 12-hour post-op heart transplant recipient with premature atrial contractions
A 2-hour post-op liver transplant recipient with a central venous pressure of 1 mm Hg
The nurse is caring for a patient in acute liver failure caused by an overdose of acetaminophen. The patient is not expected to survive the night. Which statement best reflects appropriate application of the MELD score in this situation?
The patient's present situation reflects a MELD score of 22.
Patient status indicates the patient is ineligible for transplant.
The MELD score indicates survival beyond 24 hours is not likely.
Use of the MELD score is not applicable in this situation.
Which statement best represents immunosuppressant therapy in organ transplant recipients?
Immunosuppressive therapy in renal transplant patients requires steroids.
Effective immunosuppressant therapy requires a minimum of four medications.
The use of an mTOR inhibitor is contraindicated in early postoperative lung transplants.
Medication trough levels provide information on immune system suppression.
The transplant clinic nurse is reviewing the medical history of a lung transplant patient who is 3 months posttransplant. The patient states he has been feeling "tired" all the time. The nurse notes an oral temperature of 99.2° F and identifies the patient's white count to be 2500/mm3. What is the interpretation of these findings by the nurse?
Findings may indicate cytomegalovirus (CMV) infection.
Assessment findings indicate hyperacute graft rejection.
These are normal findings in a posttransplant lung recipient.
Immunosuppressant medications need to be adjusted.
Which laboratory test best predicts the potential for organ rejection in transplant recipients?
ABO blood group typing
Complete blood count
The nurse is caring for a renal transplant patient who is 3 days postoperative with a Jackson-Pratt drain. Output from the drain has been 75 mL serous color for the past 24 hours. What is the best interpretation of this finding by the nurse?
Drainage is excessive for 24 hours; notify the physician.
Drainage is normal; anticipate removal of the drain.
Drainage color indicates infection; notify the physician.
Drainage is minimal; the drain should be irrigated.
The nurse is preparing an organ transplant recipient for discharge from the hospital. Which statement by the nurse is most important to include as part of discharge education?
"Be sure to wash your raw fruits and vegetables before eating them."
"Be careful to wear protective gloves when working in the garden."
"Talk with your doctor before getting any preventative immunizations."
"You must take all your medication as prescribed, on time, every day."
Which statements best describe functions of an organ procurement organization? (Select all that apply.)
Declaration of brain death
Consent for organ donation
Management of organ donor
Evaluation of transplant candidate
Surgical retrieval of organs
To qualify as a living organ donor, several characteristics are required. Which statement(s) best reflect characteristics of living organ donors? (Select all that apply.)
Between the ages of 18 and 60
Similar ethnicity as recipient
No history of heart disease
Blood type of recipient
No history of diabetes
The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Handoff communication from the OR included a reported output of 500 mL following anastomosis of the renal vessels and reperfusion. One hour after admission to the PACU, the RN notes no urine output. Which physician orders are appropriate to treat this situation? (Select all that apply.)
Administer 20 mL Lasix IV q 4 hours prn urine output < 30 mL/hr.
Administer 500 mL bolus of 0.9% normal saline over 2 hours.
Irrigate the urinary catheter using 30 mL 0.9% normal saline.
Provide maintenance IV fluids of D5 ½ NS to infuse at 100 mL/hr.
Your patient was a passenger in a motor vehicle crash yesterday and suffered an open fracture of the femur. His condition was stable until an hour ago, when he began to complain of shortness of breath. His heart rate is 104 beats/min, respiratory rate is 30 breaths/min, BP is 90/60 mm Hg, and temperature is now 38.4° C. You suspect that he:
has a fat embolism
has developed metabolic acidosis.
is developing systemic inflammatory response syndrome (SIRS).
is experiencing early multiple organ dysfunction syndrome (MODS).
Poor patient outcomes after a traumatic injury are associated with:
chest tube placement for treatment of a hemothorax.
immediate decompression of a tension pneumothorax.
massive transfusions of blood products.
intraosseous cannulation for intravenous fluid administration.
Which condition is a common cause of death after chest trauma?
A trauma patient with a fractured forearm complains of extreme, throbbing pain at the fracture site and paresthesia in the fingers. Upon further assessment, you note that the forearm is extremely edematous and you are now having difficulty palpating a radial pulse. You notify the physician immediately because you suspect:
The trauma patient presenting with left lower rib fractures develops left upper quadrant tenderness, hypotension, and referred pain to the left shoulder. You suspect:
Spinal cord injury causes a loss of sympathetic output, resulting in distributive shock with hypotension and bradycardia. Although blood pressure may respond to fluid resuscitation, what other therapy may be required to compensate for loss of sympathetic innervation?
Proton pump inhibitors
A restrained patient's status after a motor vehicle crash includes dyspnea, dysphagia, hoarseness, and complaints of severe chest pain. Upon assessment you note that the patient has weak femoral pulses. Which of the following complications and related diagnostic test should be considered?
Aortic dissection and aortogram
Cardiac tamponade and pericardiocentesis
Liver laceration and focused assessment with sonography for trauma (FAST)
Pulmonary contusion and chest x-ray
The primary priority for the critical care nurse with regard to the trauma patient is which of the following?
Decrease the patient's risk for multiple organ dysfunction syndrome.
Ensure adequate fluid resuscitation.
Increase the physiological reserve of the trauma patient.
Provide adequate oxygenation and tissue perfusion.
A 72-year-old patient fractured his pelvis in a motor vehicle crash 2 days ago. He suddenly becomes anxious and short of breath. His respiratory rate is 34 breaths per minute, and he is complaining of midsternal chest pain. His oxygen saturation drops to 75%. You suspect:
A 55-year-old trauma patient hit the steering wheel and has a cardiac contusion. Which are potential complications of the injury? (Select all that apply.)
The nurse is assessing a patient for suspected alcohol withdrawal and identifies which signs and symptoms as suspicious? (Select all that apply.)
Irritable, confused, hallucinations
Nausea, vomiting, diarrhea
Hypotension and tachycardia
Low body temperature
Somnolent, difficult to arouse
When obtaining report on a trauma patient, which question would be helpful in determining potential injuries associated with the mechanism of injury? (Select all that apply.)
Was the patient wearing a seat belt?
Where was the patient in the car?
Where are the family members?
Was fluid resuscitation initiated?
To maintain the patient's airway, which interventions are appropriate to implement with a trauma patient who sustained a spinal cord injury? (Select all that apply.)
Avoid hyperextension of the neck.
Observe respiratory pattern.
Insert an oral airway if patient is alert.
Elevate the head of bed 30 degrees .
Observe depth of ventilation.
Maintain complete spinal immobilization.
Which interventions are appropriate to consider in the management of the geriatric trauma patient? (Select all that apply.)
Ask the patient if he or she has fallen recently
Obtain a detailed medical history
Administer intravenous fluids rapidly to maintain blood pressure
Frequently assess for signs of acute delirium
Observe for signs of infection, primarily elevated temperature
Obtain a detailed list of current medications
Prevention of hypothermia is crucial in caring for trauma patients. Which treatments are appropriate for preventing hypothermia? (Select all that apply.)
Administer cool humidified oxygen.
Cover the patient with an external warming device
Leave the patient's clothing on, even if wet
Warm fluids and blood products before or during administration
Warm the room in the emergency department and critical care unit.
An adult patient suffered an anterior wall myocardial infarction (MI) 4 days ago. Today the patient is experiencing dyspnea and sitting straight up in bed. The nurse's assessment includes bibasilar crackles, an S3 heart sound with a heart rate of 125 beats/min. What condition are these signs and symptoms consistent with?
Papillary muscle rupture
The patient, who is being treated for hypercholesterolemia, complains of hot flashes and a metallic taste in the mouth. These are common side effects of:
bile acid resins.
A patient is complaining of midsternal chest discomfort radiating down the right arm. The discomfort has been present for about 5 minutes. The patient is also asthmatic and allergic to calcium channel blockers. The medication of choice for this patient at this time is:
The patient presents to the emergency department with severe substernal chest discomfort. Cardiac enzymes are elevated and his ECG shows ST-segment depression in V2 and V3. This patient is most likely experiencing:
non-Q-wave myocardial infarction (MI)
Q-wave myocardial infarction (MI).
right ventricular infarction.
A 67-year-old female is admitted to the emergency department complaining of mid-back pain and shortness of breath for the preceding 2 hours. She also complains of nausea and states that she vomited twice before coming to the hospital. She denies any chest discomfort or arm pain. The presenting symptoms suggest that this patient may be:
exhibiting flu symptoms.
having an anxiety attack.
having a myocardial infarction (MI)
suffering from osteoporosis.
Angiotensin-converting enzymes inhibitors (ACE inhibitors) should be started within 24 hours of acute myocardial infarction (AMI) to reduce the incidence of:
The initial drug recommended at the onset of acute myocardial infarction (AMI) to reduce platelet aggregation is:
The most sensitive cardiac enzyme to assess myocardial necrosis is:
Which statements related to the management of unstable angina are true? (Select all that apply.)
Aspirin is given at the onset of each chest pain episode
Calcium channel blockers help to reduce symptoms
Early revascularization (e.g., angioplasty) may be helpful
It is best treated with rest and nitroglycerin
The patient presents to the emergency department after having crushing chest pain for the past 5 hours. The ECG and laboratory work confirm suspicions of an acute myocardial infarction (AMI). Which findings would be the most conclusive that the patient is having an AMI? (Select all that apply.)
ECG changes with ST-elevation
Elevated CK-MB isoenzymes
Elevated serum troponin levels
Elevated urinary myoglobin level
The family of a critically ill patient whose care has been deemed futile has decided not to administer antibiotics or blood products. This decision is termed:
do not resuscitate.
The nurse is caring for a patient who is unresponsive, unable to communicate, and has no voluntary action or cognition. The condition is considered permanent. The term for this condition is:
non-heart beating donor
persistent vegetative state
A 33-year-old patient is admitted with closed head trauma following a motor vehicle crash. She has a signed organ donor card expressing her wish to become an organ donor. Brain death is established; however, her spouse refuses to sign consent for organ donation. Which ethical principle is being violated by her spouse?
The nurse understands which statement regarding ethical care is true?
A nurse should request a change in assignment if care of the assigned patient violates his/her ethical principles
A spouse is always the designated healthcare surrogate for a patient who is married.
It would be unlawful to discontinue a vasopressor drip once a patient has been given a DNR order.
Morphine should not be given to an end-stage cancer patient with extreme pain, respirations of 10 breaths per minute, and a DNR order.
The hospital has an ethics committee. The nurse knows that which statement about ethics committees is true?
Its members consist only of physicians and nurses.
It deals with generalities instead of specific issues.
Its goal is to protect the hospital's interests.
It serves to educate and to develop guidelines
An example of extraordinary care is:
The critical care nurse must demonstrate characteristics of ethical nursing practice, which include: (Select all that apply)
Withdrawal or withholding of life support includes: (Select all that apply.)
continuous renal replacement therapy.
discontinuing comfort measures.
do not resuscitate orders
stopping tube feedings
weaning from mechanical ventilation
The nurse understands that elements of informed consent are: (Select all that apply.)
Adequate instruction of the patient
Patient family understanding of what is to be done (competence)
Voluntary permission for what is to be done
Written on a standardized form
Ethical decisions should be based on: (Select all that apply.)
the patient's wishes and goals
burden versus benefit
relevant ethical principles
potential outcomes of options