Nursing Considerations in Acute Respiratory Failure and Renal Replacement Therapy | Exams Nursing | Docsity (2025)

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TEST BANK INTRODUCTION TO

CRITICAL CARE NURSING 7TH

EDITION 2024

Chapter06: Nutritional Therapy - Correct answer

ApatientishavingcomplicationsfromabdominalsurgeryandremainsNPO.Becauseenteraltu befeedingsarenotpossible, thedecisionistoinitiateparenteralfeedings.Whatarethemajorcomplicationsforthistherapy - Correct answer b. Fluidandelectrolyteimbalancesandsepsis .Apatientisbeingventilatedandhasbeenstartedonenteralfeedingswithanasogastricsmall- borefeedingtube.Whatistheprimaryreasonthenursemustfrequentlyassesstubeplacement ? - Correct answer d. Topreventaspirationofthefeedings

Thepatientistostartparenteralnutrition.Thenurseknowstopreparewhichsiteforcatheterinser tion? - Correct answer d. Subclavianvein

4. Apatienthasbeenadmittedtothecriticalcareunitafterastroke.Afterfailingaswallowstudy, thepatientisplacedonenteralfeedings.Followingplacementofanasogastrictubefortubefeedi ng, whatisthenextcriticalstep? - Correct answer c. Obtainachestradiograph.

Apatientsfeedingtubehasbeensuccessfullyplacedinthesmallintestinewithcontinuousflowt ubefeeding.Thenurseknowsthatthisapproachwaschosenbecause: - Correct answer c. theintestinalmucosanormallyreceivesnutrientsfromthestomachinperistalticwaves

Apatientisbeingfedthroughanasogastrictubeplacedinhisstomach.Thenursewouldcarryout whichinterventiontominimizeaspirationrisk? - Correct answer Elevatetheheadofthebed30degrees.

Apatientwhoisreceivingcontinuousenteralfeedingshasjustvomited250mLofmilkygreenflui d.Thisisaconcernbecausethismostlikelydemonstratesthatthepatienthas: - Correct answer d. tube feeding intolerance.

Apatientisreceivingenteralfeedingsandhasjustvomited250mLofmilkygreenliquid.Thenurs eholdsthetubefeeding,

whichhadbeeninfusingat100mL/hr.Thenurseknowsthatthenextactionshouldbe: - Correct answer d. recheck the residual in 2hours

9. Inadditiontoresidualstomachvolume, whatotherevidencesuggestsfeedingintolerance?

• Correct answer a. abdominal distention

10. Approximately5daysafterstartingtubefeedings, apatientdevelopsextremediarrhea.Astoolspecimeniscollectedtocheckforwhichpossibleca use? - Correct answer a. Clostridium difficult

Apatientwithacutepancreatitisisstartedonparenteralnutrition.Thestudentnurselistedpossib leinterventionsforthispatient.Whichinterventionneedscorrectionbeforefinalizingtheplanofc are? - Correct answer b. Infuseantibioticsthroughtheintravenousline.

12. Inevaluatingapatientsnutrition, thenursewouldmonitorwhichbloodtestasthemostsensitiveindicatorofproteinsynthesisandc atabolism? - Correct answer c. Prealbumin
13. Apatientisreceivingenteraltubefeedingsandhasdevelopeddrug- nutrientinteractions.Thenurserecognizeswhichdrugashavingthepotentialforcausingdrug- nutrientreactions? - Correct answer d. Phenytoin
14. Whichstatementistrueaboutnormalfunctionofthegastrointestinal (GI) tract? - Correct answer d. Without nutritional stimulation, mucosal villi atrophy.
15. An important nutritional consideration in the elderly population is: - Correct answer c. potential for drug-nutrient interaction related to polypharmacy.
16. Objectivedatadesignatingthatthenutritiongoalsarenotbeingmetinclude: - Correct answer d. weight loss, elevated glucose, and dehydration
17. In trauma patients, enteral nutrition via nasogastric tube feedings into the small bowel is best initiated within what time frame following the injury? - Correct answer a. 24hours 18.Apatientwithahistoryofemphysema,diabetes,andhyperlipidemiaisinthecriticalcareunito naventilator.Thenutritionassessmentnotesthatthepatienthasaproteinandvitamindeficienc yandisunderweight.Whichformulafornutritionalassessmentismostappropriate? - Correct answer b. Fiber-added formula

Selectthephysiologicalreasoningbehindenteraltherapyasthepreferredsourceofnutritionalt herapy - Correct answer d. Gut mucosa is preserved.

Apatienthascoronaryarterybypassgraftsurgeryandistransportedtothesurgicalintensivecar eunitatnoon.Heisplacedonmechanicalventilation.Interprethisinitialarterialbloodgaslevels: pH7. PaCO248mmHg Bicarbonate22mEq/L PaO2115mmHg O2saturation99% - Correct answer d. Uncompensated Respiratory Acidosis; Hyper oxygenated 2.Thephysicianordersthefollowingmechanicalventilationsettingsforapatientwhoweighs kg.Thepatientsspontaneousrespiratoryrateis22breaths/ min.Whatarterialbloodgasabnormalitymayoccurifthepatientcontinuestobetachypneicatthe seventilatorsettings? Settings: Tidal volume: 600mL (8mLperkg) FiO2:0. Respiratory rate: 14breaths/min Mode assist/ control - Correct answer d. Respiratory alkalosis 3.Apatientsventilatorsettingsareadjustedtotreathypoxemia.Thefractionofinspiredoxygenis increasedfrom.60to.70,andthepositiveend- expiratorypressureisincreasedfrom10to15cmH2O.Shortlyaftertheseadjustments,thenurs enotesthatthepatientsbloodpressuredropsfrom120/76mmHgto90/60mmHg.Whatisthemo stlikelycauseofthisdecreaseinbloodpressure? - Correct answer a. Decrease in cardiac output

Thenurseiscaringforapatientwithanendotrachealtube.Thenurseunderstandsthatendotrac healsuctioningisneededtofacilitateremovalofsecretionsandthattheprocedure: - Correct answer c. is done as indicated by patient assessment. 5.A65-year-oldpatientisadmittedtotheprogressivecareunitwithadiagnosisofcommunity- acquiredpneumonia.Thepatienthasahistoryofchronicobstructivepulmonarydiseaseanddia betes.Asetofarterialbloodgasesobtainedonadmissionwithoutsupplementaloxygenshowsp H7.35;PaCO255mmHg;bicarbonate30mEq/L;PaO265mmHg.Thesebloodgasesreflect: - Correct answer hypoxemia and compensated respiratory acidosis 6.Apatientsstatusworsensandneedsmechanicalventilation.Thepulmonologistwantsthepat ienttoreceive10breaths/ minfromtheventilatorbutwantstoencouragethepatienttobreathespontaneouslyinbetweent hemechanicalbreathsathisowntidalvolume.Thismodeofventilationiscalled: - Correct answer c. intermittent mandatory ventilation

7.Apatientsendotrachealtubeisnotsecuredtightly.Therespiratorycarepractitionerassiststh enurseintapingthetube.Afterthetubeisretaped,thenurseauscultatesthepatientslungsandn otesthatthebreathsoundsovertheleftlungfieldsareabsent.Thenursesuspectsthat: - Correct answer a. the endotracheal tube is in the right main stem bronchus.

8. Amodeofpressure- targetedventilationthatprovidespositivepressuretodecreasetheworkloadofspontaneousbr eathingthroughtheendotrachealtubeis: - Correct answer c. pressure support ventilation.

Neuromuscularblockingagentsareusedinthemanagementofsomeventilatedpatients.Their primarymodeofactionis: - Correct answer c. paralysis

10. Oneoftheearlysignsoftheeffectofhypoxemiaonthenervoussystemis: - Correct answer restlessness.
11. Theamountofeffortneededtomaintainagivenlevelofventilationistermed: - Correct answer work of breathing.

Whichofthefollowingdevicesisbestsuitedtodeliver65%oxygentoapatientwhoisspontaneou slybreathing? - Correct answer a. Face mask with non-rebreathing reservoir 13.Apatientisbeingmechanicallyventilatedinthesynchronizedintermittentmandatoryventila tionmodeatarateof4breaths/min.Hisspontaneousrespirationsare12breaths/ min.Hereceivesadoseofmorphinesulfate,andhisrespirationsdecreaseto4breaths/ min.Whichacid-basedisturbancewilllikelyoccur? - Correct answer Respiratory acidosis 14.Apatientisbeingmechanicallyventilatedinthesynchronizedintermittentmandatoryventila tionmodeatarateof4breaths/min.Hisspontaneousrespirationsare12breaths/ min.Hereceivesadoseofmorphinesulfate,andhisrespirationsdecreaseto4breaths/ min.Whatadjustmentsmayneedtobemadetothepatientsventilatorsettings? - Correct answer Increasethesynchronizedintermittentmandatoryventilationrespiratoryrate 15.Currentguidelinesrecommendtheoralrouteforendotrachealintubation.Therationaleforth isrecommendationisthatnasotrachealintubationisassociatedwithagreaterriskfor: - Correct answer d. sinusitisandinfection.

16. Oxygen saturation (SaO2) represents: - Correct answer b. oxygen that is chemically combined with hemoglobin.
17. Pulseoximetrymeasures: - Correct answer d. oxygen saturation.
18. APaCO2of48mmHgisassociatedwith: - Correct answer .b. hypoventilation.

26. A53-year-old, 80- kgpatientisadmittedtothecardiacsurgicalintensivecareunitaftercardiacsurgery. Fourhoursafteradmissiontothesurgicalintensivecareunitat4PM,thepatienthasstablevitalsi gnsand normalarterialbloodgases(ABGs)andisplacedonaT- pieceforventilatoryweaning.Duringthenurses7PM (1900)assessment,thepatientisrestless,heartratehasincreasedto110beats/ min,respirationsare breaths/min,andbloodpressureis156/98mmHg.Thecardiacmonitorshowssinustachycardi awith prematureventricularcontractions(PVCs)perminute.Pulmonaryarterypressuresareelevate d.Thenurse suctionsthepatientandobtainspink,frothysecretions.Loudcracklesareaudiblethroughoutlu ngfields.The nursenotifiesthephysician,whoordersanABGanalysis,electrolytelevels,andaportablechest x-raystudy. Incommunicatingwiththephysician, whichstatementindicatesthenurseunderstandswhatislikelyoccurring withthepatient? - Correct answer my assessment indicates potential fluid overload

Thenurseiscaringforamechanicallyventilatedpatientandnotesthehighpressurealarmsound ing.The nursecannotquicklyidentifythecauseofthealarmandnotesthepatientsoxygensaturationisde creasing andheartrateandrespiratoryrateareincreasing.Thenursespriorityactionisto - Correct answer d. manually ventilate the patient while calling for a respiratory therapist

28. Thenurseiscaringforapatientwhoseventilatorsettingsinclude15cmH2Oofpositiveend- expiratory pressure (PEEP).Thenurseunderstandsthatalthoughbeneficial, PEEPmayresultin: - Correct answer d. low cardiac output secondary to increased intrathoracic pressure
29. Whenassessingthepatientforhypoxemia, thenurserecognizesthatanearlysignoftheeffect ofhypoxemiaonthecardiovascularsystemis

• Correct answer tachycardia

Thenurseiscaringforamechanicallyventilatedpatient.Thephysiciansareconsideringperfor minga tracheostomybecausethepatientishavingdifficultyweaningfrommechanicalventilation.Rel atedto tracheostomy, thenurseunderstandswhichofthefollowing - Correct answer the greatest risk after a percutaneous tracheostomy is accidental Dec annulation

31. Thenurseisassessingtheexhaledtidalvolume (EVT) inamechanicallyventilatedpatient.The rationaleforthisassessmentisto: - Correct answer compare the tidal volume delivered with the tidal volume prescribed

Thenurseiscaringforamechanicallyventilatedpatientandrespondstoahighinspiratorypress urealarm. Recognizingpossiblecausesforthealarm, thenurseassessesforwhichofthefollowing - Correct answer Coughing or attempting to talk/ c. Kinks in the ventilator Need for suctioning Selectallofthefactorsthatmaypredisposethepatienttorespiratoryacidosi - Correct answer Central nervous system depression Overdose of sedative

3. Thenurseisassistingwithendotrachealintubationandunderstandscorrectplacementofthe endotrachealtubeinthetracheawouldbeidentifiedbywhichofthefollowing? (Selectallthatapply. - Correct answer Equal bilateral breath sounds upon auscultation Position above the carina verified by chest x-ray Positive detection of carbon dioxide (CO2) through CO2 detector devices

Thenurseiscaringforamechanicallyventilatedpatientandischartingoutsidethepatientsroom whenthe ventilatoralarmsounds.Whatisthepriorityorderforthenursetocompletetheseactions:_____ __________, _______________, _______________, _______________? (Putacommaandspacebetweeneachanswerchoice - Correct answer Go to patient’s bedside. After troubleshooting, connect back to mechanical ventilator and reassess patient. Manually ventilate the patient while getting respiratory therapist Barter troubleshooting, connect back to mechanical ventilator and reassess patient

Thenurseisassistingwithendotrachealintubationofthepatientandrecognizesthattheproced urewill bed one in what order - Correct answer Assess balloon on endotracheal tube for symmetry and leaks Suction oropharynx. Insert endotracheal tube with laryngoscope and blade .Inflate balloon of endotracheal tube. Assess lung fields for bilateral expansion

Thenurseisworkingforahospitalthatholdsanagreementwithalocalorganprocurementorgani zation (OPO).ThepatienthasaGlasgowComaScale (GCS) scoreof3anddiscussionshavebeenheldwiththe familyaboutwithdrawinglifesupport.Whichstatementbythenursebestdescribesrequirement sthatmust bemettosustainCentersforMedicareandMedicaidServices (CMS) ConditionsofParticipation? - Correct answer a. I need to notify Trans Life (OPO) of my patients impending death

Thechargenurseofatransplantunitisreviewingtheclinicalcourseofseveraltransplantpatients beingcaredforintheunit.Whichpatientassessedbythechargenurserequiresimmediateactio n? - Correct answer d. Liver transplant recipient, 12 hours post op with a serum glucose of 58mg/LD. 11.Thenurseiscaringforarenaltransplantrecipientinthepost- anesthesiacareunit.Bloodpressureis125/ mmHg;heartrateis115beats/min;respiratoryrateis24breaths/min;oxygensaturation(SpO2) is95%on L/minofoxygenvianasalcannula,temperatureis97.8F,andthecentralvenouspressure(CVP/ RAP)is2mm Hg.Whatisthebestactionbythenurse? - Correct answer a. Administer fluid replacement therapy; monitor intake and output closely.

Thenurseiscaringforapostoperativerenaltransplantrecipientinthecriticalcareunit.Afterseei ng minimalurineoutputinthecatheterformostoftheday, thepatientexpressesconcerntothenurse.Whatis thebestresponsebythenurse? - Correct answer it can take a few days for your kidney to start working

Thenurseisprovidingdischargeinstructionstoarenaltransplantrecipient.Thepatienthasafoll ow-up appointmentthenextdayforroutinepost-transplantlaboratorybloodwork, includingtroughlevelsofantirejectionmedications.Whichinstructiondescribeswhatthepatie ntshoulddoregardingtheanti-rejection medicationsthenextday - Correct answer b. Take your morning dose of medications after labs have been drawn

Thenurseiscaringforapatientfollowingabilaterallungtransplant.Whenplanningpostoperativ ecareof thepatient, priorityisplacedonpulmonaryhygiene.Whichstatementprovidesthebestexplanationforthis priority? - Correct answer d. Loss of cough reflex results in decreased ability to remove secretions effectively

15. Whilefollowinguponapostoperativerenaltransplantrecipient, thenursediscoversthatthedonor testedpositiveforcytomegalovirus (CMV).Whatisthepriorityactionbythenurse - Correct answer a. Notify the OPO transplant coordinator
16. Thetransplantclinicnurseisconductingpatienteducationontheimportanceoffollow- uphealth screeningactivitiesimportantindetectingcomplicationsassociatedwithlong- termimmunosuppressant therapy.Whichstatementismostimportantforthenursetoincludeinthediscussion - Correct answer Avoid sun exposure during peak hours of the day

Thenurseobtainsinitialvitalsignsonapatient2weeksposttransplantwhopresentsforfollow- up monitoringtotheoutpatienttransplantclinic.Whichassessmentfindingbythenurserequires immediate action? - Correct answer d. Tenderness over graft site

18. Thetransplantclinicsocialworkeriscompletingasocialhistoryonapatientwithend- stagerenal diseasewhoisbeingevaluatedfortransplant.Whichstatementbythepatientwarrantsfurthera ction - Correct answer a. I only smoke marijuana on an occasional basis

Thetransplantclinicnurseiseducatingapatientabouttherenalcriteriathatmustbemetinordert obe placedonthetransplantwaitinglist.Whichstatementbythepatientbestindicatesanunderstan dingof The criteria - Correct answer I qualify if my glomerular filtration rate is less than 20 mL per minute

Thenurseiseducatingarenaltransplantpatientabouthisimmunosuppressantmedicationther apy. Whichstatementbythepatientbestindicatesanappropriateunderstanding - Correct answer c. My doctors may try to stop my steroids soon after my transplant

ThenurseispreparingtoadmitapatientwithheartfailurewhohasbeenlistedontheUNOStransp lantlis - Correct answer b. Hospitalization is required with mechanical support and vasoactive infusions

Thenurseisprovidingpostoperativeeducationtoatransplantpatientsfamily.Whenaskedabo ut detectingrejection, whichanswerbythenurseismostappropriate - Correct answer a. End myocardial biopsies will be performed weekly for the first six weeks after surgery

Thetransplantclinicnurseisconductingapretransplanteducationsessionforpatientsbeingev aluatedfor livertransplantation.Whichstatementbythenurseprovidesthebestexplanationofthenumeric systemusedto classifytheseverityofapatientsliverdisease - Correct answer a score is calculated based upon kidney function, clotting time, and bilirubin level

24. Whichstatementbestrepresentsappropriatedonor-to- recipientcriteriaforlivertransplantation? - Correct answer Body type and body size

Thenurseassessesmorninglabresultsforapostoperativeday1livertransplantrecipient.Labr

theRNnotesnourine output.Whichphysicianordershouldthenurseimplementfirst? - Correct answer Irrigate the indwelling urinary catheter gently with 30 mL0.9% normal saline

Thenurseiscaringforarenaltransplantpatientadmittedwithanacuterejectionepisode.Thepat ientasks thenursehowthedoctorswillknowifthekidneyhasbeenrejected.Whatisthebestresponsebyth enurse? - Correct answer b. A procedure called a renal biopsy will be the best way to confirm rejection

Thefamilyofacriticallyillpatienthasaskedtodiscussorgandonationwiththepatientsnurse.Wh en preparingtoanswerthefamilysquestions, thenurseunderstandswhichconcern(s) afamilysdecisiontodonate? - Correct answer a. Donordisfigurementinfluencesonfuneralcare, b. Fearofinferiormedicalcareprovidedtodonor e. Fearthatthepotentialdonormaynotbedeceased f. Concernoverfinancialcostsassociatedwithdonatio

Thenurseadmitsapatienttothecriticalcareunitfollowingamotorcyclecrash.Assessmentfindi ngsby thenurseincludebloodpressure100/50mmHg, heartrate58beats/min, respiratoryrate30breaths/min, and temperatureof100.5.Thepatientislethargic, respondstovoicebutfallsasleepreadilywhennotstimulated. Whichnursingactionismostimportanttoincludeinthispatientsplanofcare? - Correct answer frequent neurological assessment

2. Apatientwithaheadinjuryhasanintracranialpressure (ICP) of18mmHg.Herbloodpressureis144/90mm Hg, andhermeanarterialpressure (MAP) is108mmHg.Whatisthecerebralperfusionpressure (CPP) - Correct answer c. 90mmH
3. Whilecaringforapatientwithatraumaticbraininjury, thenurseassessesanICPof20mmHgandaCPP of85mmHg.Whatisthebestinterpretationbythenurse? - Correct answer c. ICP is high; CPP is normal.

ThenurseiscaringforamechanicallyventilatedpatientwithasustainedICPof18mmHg.Thenu rse needstoperformanhourlyneurologicalassessment, suctiontheendotrachealtube, performoralhygienecare, andrepositionthepatienttotheleftside.Whatisthebestactionbythenurse? - Correct answer Provide rest periods between nursing interventions

5. Whilecaringforapatientwithabasilarskullfracture, thenurseassessescleardrainagefromthe patientsleftnaris.Whatisthebestnursingaction - Correct answer c. Place a nasal drip pad under the nose

Thenurseiscaringforapatientwhowashitontheheadwithahammer.Thepatientwasunconsci ousat thescenebrieflybutisnowconsciousuponarrivalattheemergencydepartment(ED) withaGCSscoreof15. Onehourlater, thenurseassessesaGCSscoreof3.Whatistheprioritynursingaction - Correct answer d. Notify the physician immediate

7. ThenurseiscaringforapatientwithanICPof18mmHgandaGCSscoreof3.Followingthe administrationofmannitol (Osmitrol), whichassessmentfindingbythenurserequiresfurtheraction? - Correct answer d. CVP of 2mm Hg

Thenurseiscaringforamechanicallyventilatedpatientwithabraininjury.Arterialbloodgasvalu esindicatea PaCO2of60mmHg.Thenurseunderstandsthisvaluetohavewhicheffectoncerebralbloodflo w - Correct answer increased cerebral blood volume due to vessel dilation

ThenurseassessesapatientwithaskullfracturetohaveaGlasgowComaScalescoreof3.Additi onal vitalsignsassessedbythenurseincludebloodpressure100/70mmHg, heartrate55beats/min, respiratory rate10breaths/min, oxygensaturation (SpO2)94%onoxygenat3Lpernasalcannula.Whatisthepriority nursing action? - Correct answer Monitor the patients airway patency

Thenurseiscaringforapatientwhohasadiminishedlevelofconsciousnessandwhoismechani cally ventilated.Whileperformingendotrachealsuctioning, thepatientreachesupinanattempttograbthe suctioncatheter.Whatisthebestinterpretationbythenurse? - Correct answer the patient is exhibiting purposeful movement

11. ThenurseiscaringforapatientadmittedtotheEDfollowingafallfroma10- footladder.Uponadmission, the nurseassessesthepatienttobeawake, alert, andmovingallfourextremities.Thenursealsonotesbruisingbehind theleftearandstraw- coloreddrainagefromtheleftnare.Whatisthemostappropriatenursingaction - Correct answer Apply a small nasal drip pad 12.Whilecaringforapatientwithaclosedheadinjury,thenurseassessesthepatienttobealertwi tha bloodpressure130/90mmHg,heartrate60beats/min,respirations18breaths/ min,andatemperatureof 102F.Toreducetheriskofincreasedintracranialpressure(ICP)inthispatient,whatis(are)thepr

21.Thenursereceivesapatientfromtheemergencydepartmentfollowingaclosedheadinjury. Afterinsertionof anventriculostomy,thenurseassessesthefollowingvitalsigns:bloodpressure100/60mmHg, heartrate beats/min,respiratoryrate24breaths/min,oxygensaturation(SpO2)97%onsupplementalox ygenat45%via Venturimask,GlasgowComaScalescoreof4,andintracranialpressure(ICP)of18mmHg.Whi chphysician ordershouldthenurseinstitutefirst? - Correct answer a. Manito 1g intravenous

Thenurseiscaringforapatient5daysfollowingclippingofananteriorcommunicatingarteryane urysm forasubarachnoidhemorrhage.Thenurseassessesthepatienttobemorelethargicthanthepre vioushour withabloodpressure95/50mmHg, heartrate110beats/min, respiratoryrate20breaths/min, oxygen saturation (SpO2)95%on3L/minoxygenvianasalcannula, andatemperatureof101.5F.Whichphysician ordershouldthenurseinstitutefirst? - Correct answer 500 mL albumin in fusion intravenously

23. Thenurse, caringforapatientfollowingasubarachnoidhemorrhage, beginsanicardipine (Cardene) infusion.Baselinebloodpressureassessedbythenurseis170/100mmHg.Fiveminutesafterb eginningthe infusionat5mg/hr,thenurseassessesthepatientsbloodpressuretobe160/90mmHg.Whatist hebest actionbythenurse - Correct answer Increasethedoseby2.5mg/hr.
24. Thenurseispreparingtoadministeraroutinedoseofphenytoin (Dilantin).Thephysicianordersphenytoin (Dilantin) 500mgintravenousevery6hours.Whatisthebestactionbythenurse - Correct answer c. Contact the physician

Thenurseiscaringforapatientadmittedtotheemergencydepartmentinstatusepilepticus.Vital signs assessedbythenurseincludebloodpressure160/100mmHg, heartrate145beats/min, respiratoryrate Breaths/min, oxygensaturation (SpO2)96%on100%supplementaloxygenbynon- rebreathermask.After establishinganintravenous (IV) line, whichorderbythephysicianshouldthenurseimplementfirst? - Correct answer Administer clonazepam (Ativan)

26. Thephysicianordersfosphenytoin (Cerebyx), 1.5gintravenous (IV) loadingdosefora75-kgpatientin statusepilepticus.Whatisthemostimportantactionbythenurse - Correct answer Administer drug over 10 minutes

27. Thenurseistoadminister100mgphenytoin (Dilantin) intravenous (IV).Vitalsignsassessedbythenurse includebloodpressure90/60mmHg, heartrate52beats/min, respiratoryrate18breaths/min, andoxygen saturation (SpO2)99%onsupplementaloxygenat3L/minbycannula.Topreventcomplications, whatisthe bestactionbythenurse - Correct answer Administer over 5 minutes
28. Thenurseispreparingtoadminister100mgofphenytoin (Dilantin) toapatientinstatusepilepticus.To preventpatientcomplications, whatisthebestactionbythenurse - Correct answer Ensure patency of intravenous (IV) line
29. ThenurseiscaringforapaDownloaded by: jaylincoxwilliams | [emailprotected] tientadmittedwithasubarachnoidhemorrhagefollowingsurgicalrepairofthe aneurysm.Assessmentbythenursenotesbloodpressure90/60mmHg,heartrate115beats/ min,respiratoryrate 28breaths/min,oxygensaturation(SpO2)99%onsupplementaloxygenat3L/minbycannula,a Glasgow ComaScoreof4,andacentralvenouspressure(CVP)of2mmHg.Afterreviewingthephysician orders, whichorderisofthehighestpriority - Correct answer 500 mL albumin intravenous infusion Afterreceivingthehand-offreportfromthedayshiftchargenurse, whichpatientshouldtheevening chargenurseassessfirst? - Correct answer a patient with an intracranial pressure ICP of 20mmHg and an oral temperature of 104

Thenursehasjustreceivedapatientfromtheemergencydepartmentwithanadmittingdiagnosi sof bacterialmeningitis.Topreventthespreadofnosocomialinfectionstootherpatients, whatisthebestaction bythenurse? - Correct answer Implement droplet precautions upon admission

32. Thenurseiscaringforapatientadmittedwithbacterialmeningitis.Vitalsigns assessedbythenurseincludebloodpressure110/70mmHg, heartrate110beats/min, respiratoryrate30 breaths/min, oxygensaturation (SpO2)95%onsupplementaloxygenat3L/min, andatemperature103.5F. Whatistheprioritynursingaction - Correct answer Implement seizure precautions
33. Thenurseispreparingtomonitorintracranialpressure (ICP) withafluid- filledmonitoringsystem.The nurseunderstandswhichprinciplesand/orcomponentstobeessentialwhenimplementingICP monitoring? (Selectallthatapply.) - Correct answer Recording ICP as a mean value, Zero referencing the transducer system

enurse informsthephysicianofthisassessmentandanticipatesanorderfor - Correct answer c. neuromuscular blockade. 9.Apatientpresentstotheemergencydepartmentinacuterespiratoryfailuresecondarytocom munityacquiredpneumonia.Thepatienthasahistoryofchronicobstructivepulmonarydisease .Thenurse anticipateswhichtreatmenttofacilitateventilation? - Correct answer c. Non- invasive positive-pressure ventilation (NPPV) 10.Whichofthefollowingacid- basedisturbancescommonlyoccurswiththehyperventilationandimpaired gasexchangeseeninsevereexacerbationofasthma - Correct answer Respiratory acidosis 11.Anacuteexacerbationofasthmaistreatedwithwhichofthefollowing? - Correct answer Inhaled bronchodilators and intravenous corticosteroids 12.Thenurseisdischargingapatienthomefollowingtreatmentforcommunity- acquiredpneumonia.Aspart ofthedischargeteaching,thenurseinstructs: - Correct answer It is important for you to get an annual influenza shot to reduce your risk of pneumonia 13.Thenurseisdischargingapatientwithasthma.Aspartofthedischargeinstruction,thenursei nstructs thepatienttopreventexacerbationby: - Correct answer taking all asthma medications as prescribed. 14.Thenurseiscaringforapostoperativepatientwithchronicobstructivepulmonarydisease(C OPD).Which assessmentwouldbeacuetothepatientdevelopingpostoperativepneumonia - Correct answer Change in sputum characteristics 15.Thenurseiscaringforapatientwithadiagnosisofpulmonaryembolism.Thenurseundersta ndsthat themostcommoncauseofapulmonaryembolusis: - Correct answer deep vein thrombosis from lower extremities 16.Thenurseisconcernedthatapatientisatincreasedriskofdevelopingapulmonaryembolusa nd developsaplanofcareforpreventiontoincludewhichofthefollowing - Correct answer Mobility 17.Whichofthefollowingstatementsistrueregardingvenousthromboembolism(VTE)andpul monary embolus(PE)? - Correct answer PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE 18.ApatientathighriskforpulmonaryembolismisreceivingLovenox.Thenurseexplainstothep atient: - Correct answer This injection is being given to prevent blood clots from forming. 19.Adefinitivediagnosisofpulmonaryembolismcanbemadeby: - Correct answer pulmonary angiogram

20.Astrategyforpreventingthromboembolisminpatientsatriskwhocannottakeanticoagulant sis - Correct answer insertionofavenacavafilter. 21.Whichofthefollowingtreatmentsmaybeusedtodissolveathrombusthatislodgedinthepul monary artery? - Correct answer Thrombolytics 22.Thenurseisassessingapatient.Whichassessmentwouldcuethenursetothepotentialofac ute respiratorydistresssyndrome(ARDS)? - Correct answer Increased peak inspiratory pressure on the ventilator 23.ThenursecalculatesthePaO2/ FiO2ratioforthefollowingvalues:PaO2is78mmHg;FiO2is0.6(60%). - Correct answer 130; meets criteria for ARDs 24.Thenurseisassessingapatientwithacuterespiratorydistresssyndrome.Anexpectedasse ssmentis: - Correct answer PAOP of 10mmHg and Pa O2 of 55. 25.Thenurseiscaringforapatientwhoisbeingturnedproneaspartoftreatmentforacuterespirat orydistress syndrome.Thenurseunderstandsthattheprioritynursingconcernforthispatientiswhichofthef ollowing - Correct answer Management and protection of the airway 26.Duringrounds,thephysicianalertstheteamthatproningisbeingconsideredforapatientwith acuterespiratorydistresssyndrome.Thenurseunderstandsthatproningis: - Correct answer an optional treatment if the PaO2/FiO2 ratio is less 100 27.Theetiologyofnoncardiogenicpulmonaryedemainacuterespiratorydistresssyndrome(A RDS)isrelated todamagetothe - Correct answer alveolar-capillary membrane 1.IdentifydiagnosticcriteriaforARDS.(Selectallthatapply. - Correct answer a.Bilateralinfiltratesonchestx-raystudy / PaO2/FiO2 ratio of less than 20 2.Whichofthefollowingstatementsistrueregardingoralcareforthepreventionofventilatorass ociatedpneumonia(VAP)?(Selectallthatapply.) - Correct answer b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine glucometer have been effective in preventing VAP 3.Whichofthefollowingarephysiologicaleffectsofpositiveend- expiratorypressure(PEEP)usedinthe treatmentofARDS?(Selectallthatapply. - Correct answer a. Increase functional residual capacity b. Prevent collapse of unstable alveoli c. Improve arterial oxygenation