Critical Care Nursing Diagnosis and Management 9th Edition by Linda Urden Test Bank

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Test Bank for Critical Care Nursing 9th Edition by Urden.

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Chapter 01: Critical Care Nursing Practice Urden: Critical Care Nursing, 9th MULTIPLE CHOICE 1. During World War II, what type of wards were developed to care for critically

injured patients?

Intensive care Triage Shock Postoperative

a. b. c. d.

ANS: C

During World War II, shock wards were established to care for critically injured patients.

Triage wards establish the order in which a patient is seen or treated upon arrival to a hospital. Postoperative wards were developed in 1900 and later evolved into intensive care units.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 1 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 2. What type of practitioner has a broad depth of specialty knowledge and expertise and

manages complex clinical and system issues?

Registered nurses Advanced practice nurses Clinical nurse leaders Intensivists

a. b. c. d.

ANS: B

Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Intensivists are medical practitioners who manage the critical ill patient. Registered nurses (RNs) are generally direct care providers. Clinical nurse leaders (CNLs) generally do not manage system issues.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 2 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 3. What type of practitioner is instrumental in ensuring care that is evidence based and

that safety programs are in place? a. Clinical nurse specialist b. Advanced practice nurse c.

Registered nurses d. Nurse practitioners ANS: A

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Clinical nurse specialists (CNSs) serve in specialty roles that use their clinical, teaching, research, leadership, and consultative abilities. They are instrumental in ensuring that care is evidence based and that safety programs are in place. Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems issues. Registered nurses are generally direct care providers. Nurse practitioners (NPs) manage direct clinical care of groups of patients.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 2 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 4. Which professional organization administers critical care certification exams for

registered nurses?

State Board of Registered Nurses National Association of Clinical Nurse Specialist Society of Critical Care Medicine American Association of Critical-Care Nurses

a. b. c. d.

ANS: D

American Association of Critical-Care Nurses (AACN) administers certification exams for registered nurses. The State Board of Registered Nurses (SBON) does not administer certification exams. National Association of Clinical Nurse Specialists (NACNS) does not administer certification exams. Society of Critical Care Medicine (SCCM) does not administer nursing certification exams for registered nurses.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 3 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 5. Emphasis is on human integrity and stresses the theory that the body, mind, and spirit

are interdependent and inseparable. This statement describes which methodology of care? a. Holistic care b. Individualized care c. Cultural care d. Interdisciplinary care ANS: A

Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status. Cultural diversity in health care is not a new topic, but it is gaining emphasis and importance as the world becomes more accessible to all as the result of increasing technologies and interfaces with places and peoples. Interdisciplinary care is care among a variety of health care professionals with the patient’s health as the common goal.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 4 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment qwessays.com Distribution of this document is illegal

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6. The American Association of Critical-Care Nurses (AACN) has developed short

directives that can be used as quick references for clinical use that are known as

a. b. c. d.

Critical Care Protocol.

Practice Policies.

Evidence-Based Research.

Practice Alerts.

ANS: D

The American Association of Critical-Care Nurses (AACN) has promulgated several evidence-based practice summaries in the form of “Practice Alerts.” Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. Critical care protocol and practice policies are established by individual institutions.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 3 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 7. What type of therapy is an option to conventional treatment? a. Alternative b. Holistic c. Complementary d. Individualized ANS: A

The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 4 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 8. Prayer, guided imagery, and massage are all examples of what type of treatment? a. Alternative therapy b. Holistic care c. Complementary care d. Individualized care ANS: C

The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments. Spirituality, prayer, guided imagery, massage, and animal- assisted therapy are all examples of complementary care. The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or state. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.

PTS: 1

DIF:

Cognitive Level: Understanding

REF: p. 4

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OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

9. What is the systematic decision-making model used by nurses termed? a. Nursing diagnosis b. Nursing interventions c. Nursing evaluations d. Nursing process ANS: D

The nursing process is a systematic decision-making model that is cyclic, not linear. An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria.

PTS: 1 DIF: Cognitive Level: Understanding REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 10. What is a health condition primarily resolved by nursing interventions or therapies called? a. Nursing diagnosis b. Nursing interventions c. Nursing outcomes d. Nursing process ANS: A

An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.

PTS: 1 DIF: Cognitive Level: Remembering REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 11. Designing therapeutic activities that move a patient from one state of health to another is

an example of which of the following?

Nursing diagnosis Nursing interventions Nursing outcomes Nursing process

a. b. c. d.

ANS: B

Nursing interventions constitute the treatment approach to an identified health alteration.

An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.

PTS: 1 DIF: Cognitive Level: Remembering REF: n/a OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

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12. A patient was admitted to a rural critical care unit in Montana. Critical care nurses are

assisting with monitoring and care of the patient from the closest major city. What is this type of practice termed? a. Tele-nursing b. Tele-ICU c. Tele-informatics d. Tele-hospital ANS: B

Tele-ICU is a form of telemedicine. Telemedicine was initially used in outpatient areas, remote rural geographic locations, and areas where there was a dearth of medical providers. Currently, there are tele-ICUs in areas where there are limited resources onsite. However, experts (critical care nurses, intensivists) are located in a central distant site.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 5 OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 13. Which core competency for interprofessional practice can be described as working with

individuals of other professions to maintain a climate of mutual respect and shared values? a. Interprofessional teamwork and team-based care b. Values and ethics for interprofessional practice c. Interprofessional communication d. Roles and responsibilities for collaborative practice ANS: B

Values and ethics for interprofessional practice mean working with individuals of other professions to maintain a climate of mutual respect and shared values. Roles and responsibilities for collaborative practice include using knowledge of one’s own role and the roles of other professions to appropriately assess and address the health care needs of the patients and populations served. Interprofessional communication includes communicating with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to maintaining health and treatment of disease. Interprofessional teamwork and team-based care means applying relationship- building values and principles of team dynamics to perform effectively in different team roles to plan and deliver patient population-centered care that is safe, timely, efficient, effective, and equitable.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 5|Box 1-5 OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 14. What is the stepwise decision-making flowchart for a specific care process

named? a. b. c. d.

Algorithm Practice guideline Protocol Order set

ANS: A

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An algorithm is a stepwise decision-making flowchart for a specific care process or processes. A practice guideline is usually created by an expert panel and developed by a professional organization. Protocols are more directive and rigid than guidelines, and providers are not supposed to vary from a protocol. An order set consists of preprinted provider orders that are used to expedite the order process after a standard has been validated through analytic review of practice and research.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 6 OBJ: Nursing Process Step: Intervention TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 15. Which nursing intervention continues to be one of the most error-prone for critical

care nurses?

Inappropriate care Intimidating and disruptive clinician behavior Injury to patients by falls Medication administration

a. b. c. d.

ANS: D

Medication administration continues to be one of the most error-prone nursing interventions for critical care nurses. Intimidating and disruptive clinician behaviors can lead to errors and preventable adverse patient outcomes. Patient safety has been described as an ethical imperative and one that is inherent in health care professionals’ actions and interpersonal processes; examples include inappropriate care and injury to patients by falls.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 7 OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 16. A practitioner and nurse are performing a dressing change on an unresponsive patient in

room 14. The practitioner asks the nurse for an update on the patient in room 13. Which action should the nurse take next? a. Give the update to the practitioner. b. Refuse to give the update because of Health Insurance Portability and Accountability Act (HIPAA) requirements. c. Give the update because the is patient’s unconscious. d. Refuse to give the update because of Occupational Safety and Health Administration (OSHA) requirements.

ANS: B

Most specific to critical care clinicians is the privacy and confidentiality related to protection of health care data. This has implications when interacting with family members and others and the often very close work environments, tight working spaces, and emergency situations. A patient’s unconscious state is not a reason for another patient’s care to be discussed in his or her presence. Research shows hearing is the last sense to deteriorate. Occupational Safety and Health Administration (OSHA) has to do with safety in the workplace, not privacy and confidentiality.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 8 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

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MULTIPLE RESPONSE 1. What considerations are taken into account in evidence-based nursing practice? (Select

all that apply.)

Clinical expertise of the nurse Availability of staff and facility equipment Research evidence on the topic Patient knowledge of the disease Patient preference regarding care

a. b. c. d. e.

ANS: A, C, E

Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse and patient preferences. For instance, when determining the frequency of vital sign measurement, the nurse would use available research and nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient). Availability of staff and facility equipment and the patient’s knowledge of the disease do not factor into evidence-based nursing practices.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 3 OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 2. The concept of diversity encompasses what thoughts and actions? (Select all that apply.) a.

Sensitivity to ethnic differences b. Openness to different lifestyles c. Openness to

different values d. Reticence to different beliefs e. Lack of concern regarding different opinions ANS: A, B, C

Diversity includes not only ethnic sensitivity but also sensitivity to openness to difference lifestyles, opinions, values, and beliefs. Reticence and lack of concern are not part of the concept of diversity.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 4 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 3. According to American Association of Critical-Care Nurses, what are the responsibilities of

a critical care nurse? (Select all that apply.)

Respecting the values, beliefs, and rights of the patient Intervening when the best interest of the patient is in question Helping the patient obtain necessary care Making decisions for the patient and patient’s family Monitoring and safeguarding the quality of care the patient receives Acting as a gatekeeper for the patient, the patient’s family, and other health care professionals

a. b. c. d. e. f.

ANS: A, B, C, E

American Association of Critical-Care Nurses (AACN) critical care nurse role responsibilities include respecting the values, beliefs, and rights of the patient; intervening Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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when the best interest of the patient is in question; helping the patient obtain necessary care; and monitoring and safeguarding the quality of care the patient receives. The nurse is not to make decisions for the patient or the patient’s family but should support their decisions. The nurse should act as a liaison, not a gatekeeper, for the patient and the patient’s family and other health care professionals.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 2|Box 1-1 OBJ: Nursing Process Step: N/A TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment 4. According to Kupperschmidt, what factors are needed to become a skilled

communicator? (Select all that apply.)

Becoming candid Becoming reflective Setting goals Surveying the team Becoming aware of self-deception

a. b. c. d. e.

ANS: A, B, E

Kupperschmidt and colleagues posed a five-factor model for becoming a skilled communicator: becoming aware of self-deception, becoming authentic, becoming candid, becoming mindful, and becoming reflective, all of which lead to being a skilled communicator. The HWE model was offered by Blake, who suggested five steps: rallying the team, surveying the team, establishing work groups, setting goals and developing action steps, and celebrating successes along the way.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 9 OBJ: Nursing Process Step: General TOP: Critical Care Nursing Practice MSC: NCLEX: Safe and Effective Care Environment

Chapter 02: Ethical Issues Urden: Critical Care Nursing, 9th EditionEdition Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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MULTIPLE CHOICE 1. What is the difference between ethics and morals? a. Ethics is more concerned with the “why” of behavior. b. Ethics provides a framework for evaluation of the behavior. c. Ethics is broader in scope than morals. d. Ethics concentrates on the right or wrong behavior based on religion and

culture values.

ANS: A

Ethics are concerned with the basis of the action rather than whether the action is right or wrong, good or bad.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 12

2. A patient’s wife has been informed by the practitioner that her spouse has permanent

quadriplegia. The wife states that she does not want anyone to tell the patient about his injury. The patient asks the nurse about what has happened. The nurse has conflicting emotions about how to handle the situation. What is the nurse experiencing? a. Autonomy b. Moral distress c. Moral doubt d. Moral courage ANS: B

The nurse has been placed in a situation initially causing moral distress and is struggling with determining the ethically appropriate action to take. Moral courage is the freedom to advocate for oneself, patients, and peers. Autonomy is an ethical principle. Moral doubt is not part of the American Association of Critical-Care Nurses (AACN) framework. The 4A’s to Rise Above Moral Distress.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 12

3. By what action can critical care nurses can best enhance the principle of autonomy? a. Presenting only the information to prevent relapse in a patient b. Assisting with only tasks that cannot be done by the patient c. Providing the patient with all of the information and facts d. Guiding the patient toward the best choices for care ANS: C

Patients and families must have all the information about a certain situation to make an autonomous decision that is best for them.

PTS: 1

DIF:

Cognitive Level: Applying

REF: pp. 15-16

OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment 4. Which ethical principle is most important when soliciting informed consent from a patient? a. Nonmaleficence Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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b. Fidelity c. Beneficence d. Veracity ANS: D

Veracity is important when soliciting informed consent because the patient needs to be aware of all potential risks of and benefits to be derived from specific treatments or their alternatives.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 15

5. The principle of respect for persons incorporates what additional a. b. c. d.

concepts?

Confidentiality and privacy Truth and reflection Autonomy and justice Beneficence and nonmaleficence

ANS: A

Confidentiality of patient information and privacy in patient interactions must be protected and honored by health care providers out of respect for persons. Confidentiality is a right involving the sharing of patient information with only those involved in the patient’s care. Privacy includes confidentiality but goes further to include the right to privacy of person and personal space, such as ensuring that a patient is adequately covered during a procedure.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 16

6. Which action best reflects the concept of beneficence within the critical care setting? a. Advocating for equitable health care b. Promoting for safe patient care c. Ensuring equal access for those with the same condition or diagnosis d. Confirming technologic advances are available to all in a given community ANS: B

Advocating for patient safety is an example of beneficence. The other actions are examples of justice.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 15|Box 2-2

7. Which statement best describes the concept of paternalism? a. Encouraging the patient to ambulate after surgery b. Demanding the patient get out of bed to sit in a chair c. Following the patient’s advance directive despite family objections

d. Administering antibiotics for a viral infection ANS: B

Encouraging the patient to ambulate after surgery is an example of beneficence. Demanding the patient get out of bed to sit in a chair is an example of paternalism. Following the Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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patient’s advance directive despite family objections is an example of autonomy.

Administering antibiotics for a viral infection is an example of physiologic futility.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 18

8. Which statement regarding the Code of Ethics for Nursing is

accurate? a. The Code of Ethics for Nurses is usurped by state or federal laws. b. It allows the nurse to focus on the good of society rather than the uniqueness of

the patient. c. The Code of Ethics for Nurses was recently adopted by the American Nurses

Association. d. It provides society with a set of expectations of the nursing profession.

ANS: D

The Code of Ethics for Nursing provides a framework for the nurse to follow in ethical decision making and provides society with a set of expectations of the profession.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 19

9. Ethical decisions are best made by performing which a. b. c. d.

action?

Following the guidelines of a framework or model Having the patient discuss alternatives with the practitioner or nurse Prioritizing the greatest good for the greatest number of persons Studying by the Ethics Committee after all diagnostic data are reviewed

ANS: A

To facilitate the ethical decision-making process, a model or framework must be used so that all involved will consistently and clearly examine the multiple ethical issues that arise in critical care.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 20

10. What is the first step of the ethical decision-making a. b. c. d.

process?

Consulting with an authority Identifying the health problem Delineating the ethical problem from other types of problems Identifying the patient as the primary decision maker

ANS: B

Step one involves identifying the major aspects of the patient’s medical and health problems. Consulting an authority is not always necessary in the process. Delineating the ethical problem from other types of problems may not be necessary. Identification of the patient as primary decision maker is not part of the process.

PTS: 1

DIF:

Cognitive Level: Remembering

REF: p. 20

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OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment 11. Truth-telling is an example of what ethical a. b. c. d.

principle?

Justice Beneficence Autonomy Nonmaleficence

ANS: C

Truth telling is an example of autonomy.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Psychosocial Integrity

REF: p. 15|Box 2-2

12. A practitioner is suggesting treatments to a patient that are contrary to the

patient’s preferences. What is this practice called?

Invaluable deficiency Physiologic uselessness Ethical futility Situational insufficiency

a. b. c. d.

ANS: C

Ethical futility is treatment that will not serve the underlying interests, values, and preferences of the patient such as when a practitioner’s idea of benefit is contrary to the values and preferences of the patient.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 18

13. Institutional ethics committees (IECs) review ethical cases that are problematic for

the practitioner. What is the major function of an IEC? Consultation with purely binding recommendations Support and education to health care providers Conflict resolution for moral dilemmas Recommendations that are binding in all cases

a. b. c. d.

ANS: B

The Institutional Ethics Committee (IEC) can function in a variety of ways, serving as consultants, providing education, and helping resolve ethical conflicts or dilemmas for health care providers. Recommendations from the formal IEC may or may not be binding and are relative to the situation at hand.

PTS: 1

DIF:

Cognitive Level: Remembering

REF: p. 22

OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment 14. Developing an organizational policy that supports unobstructed access to the ethics

committee by health care team members is one example of a proactive approach to dealing with what issue? a. Moral distress b. Surrogate decision-makers c. Paternalism Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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d. Patient advocacy ANS: A

Every organization must develop policies that support unobstructed access to resources such as the ethics committees to mitigate the harmful effects of moral distress in the pursuit of creating a healthy work environment.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: pp. 12-13|Box 2-1

15. A patient’s wife has been informed by the practitioner that her spouse has permanent

quadriplegia. The wife states that she does not want anyone to tell the patient about his injury. The patient asks the nurse about what has happened. Based on which ethical principles does the nurse answer the patient’s questions? a. Veracity b. Justice c. Autonomy d. Nonmaleficence ANS: C

Autonomy is a freedom of choice or a self-determination that is a basic human right. It can be experienced in all human life events.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: pp. 15-16

16. The nurse is using the SFNO approach to case analysis to facilitate ethical decision making.

What justification criteria may be used to help explain the reasons for selection of one option over another? a. Effectiveness b. Usefulness c. Legal ramifications d. Economics ANS: A

Justification criteria may be helpful in explaining the reasons for selecting one or two options as superior. These include necessity, effectiveness, proportionality, least infringement, and proper process. Usefulness, legal ramifications, and economics are not part of the criteria.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Ethics

REF: p. 21|Box 2-8

MSC: NCLEX: Safe and Effective Care Environment 17. The nurse is using the SFNO approach to case analysis to facilitate ethical decision making.

Which question is important to ask when considering stakeholders?

Are there reasons to give priority to one stakeholder over another?

Will the stakeholders abide by the decision?

Will the stakeholders want to be present during the ethics consultation?

Do the stakeholders understand how to use the SFNO model?

a. b. c. d.

ANS: A

In the SFNO model, questions about stakeholders include: Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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• Who has a stake in the decision being made?

Why? • Who will be significantly affected by the decision made? Why? Please be specific.

• Are there reasons to give priority to one stakeholder over another? The other questions are not relevant to this process.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: General TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 21|Box 2-8

MULTIPLE RESPONSE 1. Which of the following is/are criteria for defining an ethical dilemma? (Select all that

apply.) a. An awareness of different options b. An issue in which only one viable option exists c. The choice of one option compromises the option not chosen d. An issue that has different options ANS: A, C, D

The criteria for identifying an ethical dilemma are threefold: (1) an awareness of the different options, (2) an issue that has different options, and (3) the choice of one option over another compromises the option not chosen.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Ethics MSC: NCLEX: Safe and Effective Care Environment

REF: p. 21|Box 2-8

2. Which situations are early signs of an ethical dilemma? (Select all that apply.) a. Disagreements among health care team members b. Failure to discuss end-of-life issues with patient c. Aggressive pain management d. Belief that treatment is harmful e. Following the patient’s advance directive despite family objections f. Providing hope to the patient’s family ANS: A, B, D

Disagreements among health care team members, failure to discuss end-of-life issues with patient, and belief that treatment is harmful are early signs or indicators of an ethical dilemma.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: General TOP: Ethics

REF: p. 19|Box 2-5

MSC: NCLEX: Safe and Effective Care Environment

Chapter 03: Legal Issues Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. What is the legal standard of care for a nurse's

actions? a. Minimal competency under the state Nurse Practice Act Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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b. The ability to distinguish what is right or wrong for the patient c. The demonstration of satisfactory knowledge of policies and procedures d. The care that an ordinary prudent nurse would perform under the

same circumstances ANS: D

The legal standard of care for nurses is established by expert testimony and is generally “the care that an ordinarily prudent nurse would perform under the same circumstances.”

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 27

2. A patient is admitted with chest pain, and his electrocardiogram shows elevated ST

segments.

The nurse bases her plan of care on the nursing diagnosis of pneumonia. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: B

Basing nursing care on an erroneous diagnosis is a failure in planning. Standards of care include assessment, the collection of relevant data pertinent to the patient’s health or situation; diagnosis, analysis of the assessment data in determining diagnosis and care issues; implementation, coordinating care delivery and plan and using strategies to promote health and a safe environment; and evaluation, evaluation of the progress of the patient toward attaining outcomes.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 27|p. 30|Box 3-3

3. What is an injury resulting from the failure to meet an ordinary duty called? a.

Negligence b.

Malpractice c. Assault d. Battery ANS: A

Injury resulting from the failure to meet an ordinary duty or standard of care is negligence. Malpractice is a specialized form of negligence. Assault and battery are examples of intentional acts.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: pp. 27-28

4. A night nurse is notified by the laboratory that the patient has a critical magnesium level of

1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not notify the practitioner because of the patient’s code status. In doing so, the nurse is negligent for what? a. Failure to analyze the level of care needed by the patient b. Failure to respect the patient’s wishes c. Wrongful death d. Failure to take appropriate action Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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ANS: D

Nurses caring for acutely and critically ill patients must appropriately notify physicians of situations warranting treatment actions. Furthermore, the full no-code, do-not-resuscitate order does not exclude this patient from receiving treatment to correct the critical laboratory value. Failure to take appropriate action in cases involving acutely and critically ill patients has included not only physician-notification issues but also failure to follow physician orders, failure to properly treat, and failure to appropriately administer medication.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 28-29 OBJ: Nursing Process Step: Assessment | Nursing Process Step: Implementation TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 5. Two nurses are talking about a patient’s condition in the cafeteria. In doing so, these

nurses could be accused of what?

Failure to take appropriate action Failure to timely communicate patient findings Failure to preserve patient privacy Failure to document patient information

a. b. c. d.

ANS: C

Nurses have a duty to preserve patient privacy, and failure to do so is a breach of patient confidentiality and failure to preserve patient privacy. Nurses should also refrain from having discussions about specific patients with anyone except other health care professionals involved in the care of the patient. When discussing specific patients with other health care professionals, it is imperative that patient-specific discussions occur in non-public settings. Discussions about specific patients are never appropriate in public areas such as elevators, cafeterias, gift shops, and parking lots.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 31

6. What is negligence called when it applies to an individual who is a

professional? a. b. c. d.

Breach Malpractice Duty Harm

ANS: B

Whereas negligence claims may apply to anyone, malpractice requires the alleged wrongdoer to have special standing as a professional. If a nurse caring for acutely and critically ill patients is accused of failing to act in a manner consistent with the standard of care, that nurse is subject to liability for professional malpractice (negligence applied to a professional).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 28

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7.

A nurse fails to recognize an intubated patient’s need for suctioning. The endotracheal tube becomes clogged, and the patient has a respiratory arrest. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: A

Nurses have a duty to assess and analyze the care required by each patient they care for.

Failure to do so puts the nurse at risk for negligence related to failure to assess the patient’s needs.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 30

8. What element of malpractice is based on the existence of a nurse–patient relationship? a. Duty b. Breach c. Damages d. Harm caused by the breach ANS: A

Duty to the injured party is the first element of a malpractice case and is premised on the existence of a nurse–patient relationship. Breach is failure to act consistently within applicable standards of care. Harm caused by the breach occurs when the patient sustained injuries because of the breach of duty. Damages are derived from the harm or injury sustained by the acutely or critically ill patient and are calculated as a dollar amount.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 28

9. A patient is getting heparin by intravenous infusion. The nurse received an order to

increase the heparin infusion rate and obtain a partial thromboplastin time (PTT) in 1 hour.

The PTT was drawn correctly and revealed a critically elevated level. The nurse was busy with another patient and failed to report the critical result to the physician within 30 minutes according to the facility’s policy. Subsequently, the patient sustained a massive intracerebral bleed. What type of negligence may be present? a. Assessment failure b. Planning failure c. Implementation failure d. Evaluation failure ANS: C

Failure to communicate and document patient findings in a timely manner is a form of failure to implement appropriate action.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 30

10. On the way to surgery, a patient expresses doubt about proceeding with the planned

procedure. The patient states that the doctor did not explain it very well and she would like to talk to her again before starting the procedure. The nurse knows the surgery schedule is very tight, reassures the patient that everything will be all right, and administers the preoperative sedation. This scenario describes what possible type of negligence?

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a. b. c. d.

Assessment failure Planning failure Implementation failure Evaluation failure

ANS: D

The nurse has a duty to act as a patient advocate, in this case by holding the preoperative sedation until the doctor and the patient can speak and the patient is satisfied that she has the necessary information to make this decision.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 31

11. Which statement is accurate regarding a nurse’s job description? a. As long as the nurse follows the American Nurses Association Standards of

Care, the job description is irrelevant in a negligence allegation. b. Job descriptions must be reflective of the accepted standard of care. c. Institution-specific job descriptions are not legally acceptable. d. Job descriptions should be vague in describing nursing functions to avoid claims

of negligence.

ANS: B

Although job descriptions can be institution specific, they should be reflective of the national and community standards of care. Job descriptions are based on professional accountability as outlined by state boards of nursing and standards of practice.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 29

12. The ability to practice as a licensed professional nurse is a privilege granted by what entity? a. Employee contract b. State legislature c. State boards of nursing d. Congress

ANS: B

The very ability to practice as a licensed professional nurse is a privilege granted by the state and is a function of each state’s authority to promote and protect the health and welfare of its citizens. State boards of nursing (BON) are administrative bodies created by—and that operate under—state statutes, or more generally written state laws created by state legislatures and signed by the governor. In turn, the BONs develop more specific rules (or regulations) for obtaining and maintaining licensure.

PTS: 1 DIF: Cognitive Level: Understanding 24 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p.

13. Why is restraining a competent patient against his or her wishes considered an

intentional tort?

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a. The nurse did not document the patient’s need for restraints. b.

The nurse failed to get a physician’s order for

restraints. c.

The nurse touched the patient in an unauthorized manner. d. The nurse do not inform the patient that the restraints were needed.

ANS: C

Assault and battery are examples of intentional torts that are frequently brought against health care providers. Battery occurs if the health care professional actually touches the patient in an unauthorized manner. The act of restraining a patient without consent is battery.

PTS: 1 DIF: Cognitive Level: Understanding 32 OBJ: Nursing Process Step: Intervention TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p.

14. What is the best action a nurse could take to prevent allegations of malpractice? a.

Carrying malpractice

insurance b.

Clarifying orders with the nursing supervisor c.

Delegating care to nursing assistants d.

Providing care according to standards of practice ANS: D

Maintaining standards of practice is the best way to reduce risk. The hallmark of risk reduction is knowledge of the professional standards of care, delivery and documentation of that care, and consistent demonstration that the standards are met. Nurses caring for acutely and critically ill patients may be alleged to have acted in a manner that is inconsistent with standards of care or standards of professional practice and may find themselves involved in civil litigation that focuses in whole or in part on the alleged failure.

PTS: 1 DIF: Cognitive Level: Understanding 24 OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p.

15. While participating in rounds, a nurse is interrupted by the wife of a ventilated patient,

who informs the nurse that her husband is having difficulty breathing. The patient is found to be disconnected from the ventilator and unresponsive when the nurse enters the room after rounds. The alarm mode on the ventilator had been turned off. This situation an example of what legal situation?

a.

Assault b.

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c.

Injury d. Malpractice ANS: D

All four elements of negligence are present: duty and standard of care, breach of duty, causation, and injury. If a nurse caring for acutely and critically ill patients is accused of failing to act in a manner consistent with the standard of care, that nurse is subject to liability for professional malpractice (negligence applied to a professional). Assault occurs if the patient fears harmful or offensive touching. Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: pp. 27-28

16. After admission a patient shares with the nurse a concern that her adult children will not

be able to reach agreement on what to do if she is no longer able to make decisions for herself. The nurse informs the patient that it is possible to grant authority to one person to make decision through which mechanism? a. Court-appointed guardian b. Do-not-resuscitate order c. Durable power of attorney for health care d. Living will ANS: C

A durable power of attorney for health care includes legally binding documents that allow individuals to specify a variety of preferences, particular treatments he or she wants to avoid, and circumstances in which he or she wishes to avoid them. The durable power of attorney for health care is a directive through which a patient designates an “agent,” someone who will make decisions for the patient if the patient becomes unable to do so. A living will specifies that if certain circumstances occur, such as terminal illness, the patient will decline specific treatments, such as cardiopulmonary resuscitation and mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 36

17. In which situation did the nurse disregard the patient’s right to privacy? a. Informing the physician that the patient was verbalizing suicidal thoughts b. Notifying the health department of a patient’s tuberculosis diagnosis c. Reporting possible dependent-adult abuse to the police d. Warning a visitor to wear gloves when giving a back rub because the patient is HIV

positi ve ANS: D

Telling a visitor of the patient’s HIV status violated the patient’s right to privacy. The nurse could have ensured the visitor’s safety by providing gloves and explaining universal precautions.

PTS: 1

DIF:

Cognitive Level: Analyzing

REF: p. 31

OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment 18. Which statement best describes the definition of

assault?

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a. b. c. d.

An intentional act that causes the patient to believe that harm may have been done A statement that causes injury to the patient’s standing in the community Negligence that results in harm to a spousal relationship An intentional act that brings about harm or offensive contact with the patient

ANS: A

Assault occurs if the patient fears harmful or offensive touching. Battery is defined as an intentional act that brings about harm or offensive contact with the patient.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 32

19. During transport to the operating room for mitral valve replacement, a patient with a

signed consent form says that she does not want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse? a. “The operating room is prepared; let’s not keep the surgeon waiting.” b. “You have the right to cancel surgery, but it could be weeks before you are rescheduled.” c. “You sound frightened; tell me what you are thinking.” d. “Your preoperative medications will have you feeling more relaxed in a minute; it will be OK.” ANS: C

The patient has the right to withdraw consent at any time. The nurse must listen and then clarify whether that is really what the patient desires. If it is, the surgeon should then be notified.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 34

20. Which situation would be considered a failure of proper implementation? a. Not identifying and analyzing symptoms appropriately b. Not documenting the patient’s response to pain medication c. Not recognizing a malfunctioning chest tube d. Not asking the patient about code or no code wishes ANS: B

Nurses caring for acutely and critically ill patients are required not only to take appropriate action but also to accurately document their findings, interventions performed, and patients’ response to those interventions. Failure to thoroughly and accurately document any aspect of care gives rise to negligence causes of action.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 30

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21. Which agency is responsible for maintaining the expectations and limits of nursing practice? a. State Hospital Association b. Court system c. State Board of Nursing d. State Department of Health ANS: C

State Boards of Nursing (SBONs) maintain expectations for and limits of nursing practice in each state through the licensure of nurses and also through challenges to non-nurses engaged in professional activities that intrude upon the nursing scope of practice.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 24 OBJ: Nursing Process Step: N/A TOP: Nurse Practice Act MSC: NCLEX: Safe and Effective Care Environment 22. A nurse providing care for a patient with a recent tracheostomy notes the presence of an

ulceration or wound at the tracheotomy site. The nature of the ulceration or wound clearly indicates it has been present for at least several days. The nurse finds no documentation regarding the ulceration or wound since the insertion of the tracheostomy tube 12 days earlier. This situation an example of what legal situations? a. Assessment and implementation failure b. Failure to appropriately diagnose c. Failure to follow practitioners orders d. Planning and evaluation failure ANS: A

This situation is an example of the prior nurses’ failure to assess and implement appropriately. Assessment and implementation failures are related to a failure to assess and analyze a care need, communicate findings to a physician, take appropriate action, and document.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: N/A TOP: Legal MSC: NCLEX: Safe and Effective Care Environment

REF: p. 30

23. The patient received a blood transfusion based on test results of critically low hemoglobin.

The nurse records vital signs (VS) per hospital protocol. One hour after the transfusion was started, the nurse records VS as temperature (T) 102F, pulse (P) 110, respirations (R) 24, blood pressure (BP) 136/88. The nurse continues to administer the blood. This situation an example of what legal situation? a. Malpractice b.

Assault c.

Battery d. Libel ANS: A

To avoid liability associated with administration of blood and blood products, nurses must carefully follow organizational procedures and protocols that govern these interventions.

Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. Assault occurs if the patient fears harmful or offensive touching. Libel is defined as publishing false statements that are damaging to a person’s reputation.

PTS: 1

DIF:

Cognitive Level: Analyzing

REF: pp. 33-34

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OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. What elements or criteria must be present for negligence cases to go forward? (Select all

that apply.)

Duty to another person Acknowledgement of wrong doing Harm that would not have occurred in the absence of the breach Breach of duty Damages that have a monetary value

a. b. c. d. e.

ANS: A, C, D, E

There are four criteria or elements for all negligence cases: (1) duty to another person; (2) breach of that duty; (3) harm that would not have occurred in the absence of the breach (causation); and (4) damages that have a monetary value. All four elements must be satisfied for a case to go forward. Acknowledgement of wrong doing is not required.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment

REF: pp. 27-28

2. Which actions by a nurse demonstrate the act of battery? (Select all that

apply.) a. Performing cardiopulmonary resuscitation (CPR) on a patient with a dob. c. d. e.

not- resuscitate (DNR) order Threatening to punch someone Sexual misconduct with a patient Drawing blood without the patient’s consent Threatening to restrain a patient for not using his or her call light for mobility assistance

ANS: A, C, D

Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. Battery occurs if the health care professional actually touches the patient in an unauthorized manner. Assault occurs if the patient fears harmful or offensive touching.

Assault may be alleged if the patient was aware that he or she was going to be touched in a manner not authorized by informed consent. Threatening to punch someone and threatening to restrain a patient for not using his or her call light for mobility assistance are examples of assault.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: N/A TOP: Legal Issues MSC: NCLEX: Safe and Effective Care Environment

REF: p. 32

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Chapter 04: Genetic Issues Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. What is a genetic variant that exists in greater than 1% of the population termed? a. Genetic mutation b. Genetic polymorphism c. Genetic deletion d. Tandem repeat ANS: B

When a genetic variant occurs frequently and is present in 1% or more of the population, it is described as a genetic polymorphism. The term genetic mutation refers to a change in the DNA genetic sequence that can be inherited that occurs in less than 1% of the population.

Genetic material in the chromosome can also be deleted and new information from another chromosome can be inserted or can be a tandem repeat (multiple repeats of the same sequence).

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 43 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 2. Which type of genetic disorder occurs when there is an interaction between genetic

and environmental factors such as that which occurs with type 2 diabetes?

Chromosome Mitochondrial Multifactorial disorders Allele dysfunction

a. b. c. d.

ANS: C

In multifactorial disorders there is an interaction between vulnerable genes and the environment. Cardiovascular atherosclerotic diseases and type 2 diabetes are examples of multifactorial disorders that result from an interaction of genetic and environmental factors.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 46 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 3. Prader-Willi syndrome (PWS) is a rare genetic disorder in which genes on chromosome

15 (q11.2-13) are deleted. What type of disorder is PWS? a. Chromosome disorder b. Mitochondrial disorder c. Complex gene disorder d.

Multifactorial disorder ANS: A

Prader-Willi syndrome (PWS) is a chromosome disorder as a result of several missing genes on chromosome 15. In chromosome disorders, the entire chromosome or very large segments of the chromosome are damaged, missing, duplicated, or otherwise altered.

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PTS: 1 DIF: Cognitive Level: Applying REF: p. 45 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 4. A family pedigree is used to determine whether a disease has a genetic component. What

does a proband indicate in a family pedigree?

The disease being mother related or father related The first person in the family who was diagnosed with the disorder Who in the family is the xy band The disease genotype including locus

a. b. c. d.

ANS: B

For nurses, it is important to ask questions that elucidate which family members are affected versus those who are unaffected and then to identify the individuals who may carry the gene in question but who do not have symptoms (carriers). The proband is the name given to the first person diagnosed in the family pedigree. Homozygous versus heterozygous determines if the disorder is carried by a gene from one or both parents. The xy band determines if the disorder is carried through the sex genes. A disease locus is the genetic address of the disorder.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 46 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 5. Philadelphia translocation is a specific chromosomal abnormality that occurs

from a reciprocal translocation between chromosomes 9 and 22, where parts of these two chromosomes switch places. This abnormality is associated with which disease? a. Hemophilia A b. Chronic myelogenous leukemia c. Obesity d. Marfan syndrome ANS: B

Philadelphia chromosome or Philadelphia translocation is a specific chromosomal abnormality associated with chronic myelogenous leukemia. It occurs from a reciprocal translocation between chromosomes 9 and 22, where parts of these two chromosomes switch places. Hemophilia A is a sex-linked inheritance. Obesity is being studied with the FTO gene on chromosome 16. Marfan syndrome is classified as a single-gene disorder.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 42 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 6. What was the goal of the Human Genome a. b. c. d.

Project?

Identifying haplotype tags Exposing untaggable SNPs and recombination hot spots Producing a catalog of human genome variation Mapping all the human genes

ANS: D

The Human Genome Project was a huge international collaborative project that began in 1990 with the goal of making a map of all the human genes (the genome). The final genome sequence was published in 2003. The HapMap project was to identify haplotype tags. The Genome-Wide Association Studies was used to expose untaggable SNPs and recombination hot spots. The 1000 Genomes project was used to map all the human genes.

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PTS: 1 DIF: Cognitive Level: Remembering REF: p. 49 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 7. The patient is placed under general anesthesia for a carotid endarterectomy. During the

surgery, the patient develops muscle contracture with skeletal muscle rigidity, acidosis, and elevated temperature. What is a possible cause for malignant hyperthermia? a. Polymorphism in RYR1 at chromosome 19q13.1 b. Variant in the VKOR1 gene c. Variant in the cytochrome P450 enzyme CYP2C9 gene d. Halothane overdose ANS: A

Individuals with polymorphisms in the ryanodine receptor gene (RYR1) at chromosome 19q13.1 are at risk of a rare pharmacogenetic condition known as malignant hyperthermia.

In affected individuals, exposure to inhalation anesthetics and depolarizing muscle relaxants during general anesthesia induces life-threatening muscle contracture with skeletal muscle rigidity, acidosis, and elevated temperature. Warfarin is being researched as a variant in the VKOR1 gene and in the cytochrome P450 enzyme CYP2C9 gene.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 53|Box 4-3 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 8. What is the study of heredity particularly as it relates to the transfer heritable

physical characteristics called? a.

Chromatids b.

Karyotype c.

Genetics d. Histones ANS: C

Genetics refers to the study of heredity, particularly as it relates to the ability of individual genes to transfer heritable physical characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called chromatids, which are joined near the center.

A karyotype is the arrangement of human chromosomes from largest to smallest. A specialized class of proteins called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone cord.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 54 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 9. Each chromosome consists of an unbroken strand of DNA inside the nucleus of the cell.

What is the arrangement of human chromosomes termed?

a.

Chromatids b.

Karyotype c.

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ANS: B

A karyotype is the arrangement of human chromosomes from largest to smallest. Each somatic chromosome, also called an autosome, is made of two strands, called chromatids, which are joined near the center. Genomics refers to the study of all of the genetic material within cells and encompasses the environmental interaction and impact on biologic and physical characteristics. A specialized class of proteins called histones organizes the doublestranded DNA into what looks like a tightly coiled telephone cord.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 39 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 10. What is the study of all the genetic material within the cell and its impact on biologic

and physical characteristics called? a.

Chromatids b.

Karyotype c.

Genomics d. Histones ANS: C

Genomics refers to the study of all of the genetic material within cells and encompasses the environmental interaction and impact on biologic and physical characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called chromatids, which are joined near the center. A karyotype is the arrangement of human chromosomes from largest to smallest. A specialized class of proteins called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone cord.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 39 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 11. A specialized class of proteins that organizes the double-stranded DNA into what looks

like a tightly coiled telephone cord is known which of the following? a.

Chromatids b.

Karyotype c.

Genomics d. Histones ANS: D

A specialized class of proteins called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone cord. Genomics refers to the study of all of the genetic material within cells and encompasses the environmental interaction and impact on biologic and physical characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called chromatids, which are joined near the center. A karyotype is the arrangement of human chromosomes from largest to smallest.

PTS: 1

DIF:

Cognitive Level: Remembering

REF: p. 39

OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 12. To achieve a consistent distance across the width of the DNA strand, the nucleotide

base guanine (G) can only be paired with what other genetic material?

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Adenine b.

(A) Thymine (T) c.

Cytosine (C) d. Sex chromosome X a.

ANS: C

Four nucleotide bases—adenine (A), thymine (T), guanine (G), and cytosine (C)—comprise the “letters” in the genetic DNA “alphabet.” The bases in the double helix are paired T with A and G with C. The nucleotide bases are designed so that only G can pair with C and only T can pair with A to achieve a consistent distance across the width of the DNA strand. The TA and GC combinations are known as base pairs.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 40 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 13. Why are monozygotic twins separated at birth used to study the effects of genetics

versus environment?

They share an identical genome.

They have different sex chromosomes.

They have mirror chromosomes.

They have identical health issues.

a. b. c. d.

ANS: A

Studies of identical twins offer a unique opportunity to investigate the association of genetics, environment, and health. Identical twins are monozygotic and share an identical genome. Monozygotic twins are the same sex. Studies occur much less frequently today because tremendous efforts are made to keep siblings together when they are adopted.

Genetics can be stable in a study group, but the environment and health issues are dynamic even in a controlled study group.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 48 OBJ: Nursing Process Step: General TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 14. The process that is used to make polypeptide chains that constitute proteins can be written

as: a. RNA DNA protein. b.

DNA RNA protein. c. Protein RNA DNA. d.

Protein

DNA

RNA.

ANS: B

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The nucleotides A, T, C, and G can be thought of as “letters” of a genetic alphabet that are combined into three-letter “words” that are transcribed (written) by the intermediary of ribonucleic acid (RNA). The RNA translates the three-letter words into the amino acids used to make the polypeptide chains that constitute proteins. This process may be written as DNA RNA protein.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 41 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 15. What are the studies called that are done on large, extended families who have several

family members affected with a rare disease?

Genetic association Genetic epidemiology Kinships Phenotypes

a. b. c. d.

ANS: C

In genetic epidemiologic research of a rare disease, it can be a challenge to find enough people to study. One method is to work with large, extended families, known as kinships, which have several family members affected with the disease. Genetic association studies are usually conducted in large, unrelated groups based on demonstration of a phenotype (disease trait or symptoms) and associated genotype. Genetic epidemiology represents the fusion of epidemiologic studies and genetic and genomic research methods. Phenotypes are different at different stages of a disease and are influenced by medications, environmental factors, and gene–gene interaction.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 48 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 16. What is an example of direct-to-consumer genomic testing? a. Genetic testing through amniocentesis b. Paternity testing from buccal swabs of the child and father c. Biopsy of a lump for cancer d. Drug testing using hair follicles ANS: B

An example of direct-to-consumer testing is paternity testing from buccal swabs of the child and father. Genetic testing can be done through biopsies and amniocentesis, but they are performed in a facility by a medical professional. Drug testing and genomic testing are two different tests and are unrelated.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 53 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 17. What was the Genetic Information Nondiscrimination Act (GINA) of 2008 designed

to prevent from happening? a. Abuse of genetic information in employment and health insurance decisions b. Genetic counselors from reporting results to the health insurance companies

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d. Information sharing between biobanks that are studying the same genetic disorders ANS: A

The Genetic Information Nondiscrimination Act (GINA) of 2008 is an essential piece of legislation designed to prevent abuse of genetic information in employment and health insurance decisions in the United States. One of the paramount concerns in the genomic era is to protect the privacy of individuals’ unique genetic information. Many countries have established biobanks as repositories of genetic material, and many tissue samples are stored in medical center tissue banks. Some people who may be at risk for a disorder disease will not be tested because they fear that a positive result may affect their employability. GINA also mandates that genetic information about an individual and his or her family has the same protections as health information.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 53 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance MULTIPLE RESPONSE 1. Which patients would be candidates for genetic testing for long QT syndrome

(LQTS)? (Select all that apply.)

Patients with prolonged QT interval during a cardiac and genetic work-up Family history of positive genotype and negative phenotype Patients diagnosed with torsades de pointes Family history of sudden cardiac death Family history of bleeding disorders Family history of obesity

a. b. c. d. e. f.

ANS: A, B, C, D

Clinical genetic testing is available for long QT syndrome (LQTS). Genetic testing is very helpful within families of patients with LQTS. If the family member has a prolonged QTc interval, the reasonable assumption during the cardiac and genetic work-up is that the person has the mutation. It is also important to test family members with normal QTc intervals because up to 50% have “concealed” LQTS, meaning they have a positive genotype and negative phenotype (normal QT on the resting ECG). This is because of a genetic concept termed penetrance, in which the same gene does not have the same phenotypic effect on everyone who is affected. If a person carries the genetic mutation but has a normal QT interval at rest, he or she may still be vulnerable during exercise or physiologic stress.

Frequently patients are identified after a syncopal episode, a life-threatening dysrhythmia such as torsades de pointes, or sudden cardiac death. Hemophilia A and B are associated with bleeding disorders. The FTO gene is associated with obesity.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 51 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 2. Which disorders are classified as a single-gene disorder? (Select all that

apply.) a. Down syndrome b. Marfan syndrome

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f.

Cardiovascular atherosclerotic diseases

ANS: B, C, E

Cystic fibrosis, sickle cell disease, hemophilia A, and Marfan syndrome are examples of single-gene disorders. Down syndrome is a chromosome disorder (extra chromosome 21), and cardiovascular atherosclerotic disease and type 2 diabetes are examples of complex gene disorders that result from an interaction of genetic and environmental factors.

PTS: 1 DIF: Cognitive Level: Evaluating REF: pp. 45-46 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance 3. Hemophilia A is an inherited disease. Which statements would be determined by the

family pedigree regarding hemophilia A? (Select all that apply.) a. It is an X-linked disorder. b. Sons have a 50% chance of having hemophilia. c. It is a Y-linked disorder. d. Daughters have a 50% chance of being a carrier of the trait. e. Sons have a 25% chance of having hemophilia. f. Daughters have a 50% chance of having hemophilia.

ANS: A, B, D

In an X-linked disorder, each son has a 50% chance of having the disorder and each daughter has a 50% chance of being a carrier. In a family pedigree, the absence of direct male-tomale transmission makes this condition identifiable as an X-linked disorder.

PTS: 1 DIF: Cognitive Level: Evaluating REF: p. 46 OBJ: Nursing Process Step: Diagnosis TOP: Genetics in Critical Care MSC: NCLEX: Health Promotion and Maintenance

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Chapter 05: Sleep Alterations Test Bank MULTIPLE CHOICE 1. Which stage of NREM sleep is associated with anabolic processes? a.

N1 b.

N2 c.

N3 d.

N4 ANS: C

In stage N3 sleep, slow waves continue to develop until 50% of the EEG waveforms are slow wave. This stage of sleep is often referred to as slow-wave sleep. The release of other hormones, such as prolactin and testosterone, suggests that anabolism occurs during the slow- wave sleep of stage N3. N1 sleep is a transitional, lighter sleep state from which the patient can be easily aroused by light touch or by softly calling his or her name. Stage N2 sleep occupies about 45% to 55% of the night, with sleep deepening and a higher arousal threshold being required to awaken the patient. N4 sleep does not exist.

2. What occurs physiologically during REM sleep? a. Growth hormone is secreted. b. Metabolic needs are decreased. c. Sympathetic nervous system predominates. d. Heart rate and blood pressure decrease.

ANS: C

The sympathetic nervous system predominates during REM sleep. Oxygen consumption increases, and cardiac output, blood pressure, heart rate, and respiratory rate may become erratic. NREM sleep is dominated by parasympathetic nervous system. Blood pressure, heart and respiratory rates, and the metabolic rate return to basal levels. About 80% of total daily growth stimulating hormone is released in NREM sleep.

3. Interventions to help with circadian synchronization include a. opening the window blinds. b. encouraging the patient to take frequent naps during the day. c. administering sedatives at bedtime. d. keeping the patient awake during the early morning hours.

ANS: A

Nursing interventions that maintain normal rhythm of the day–night cycle, such as opening window blinds, should be encouraged.

4. The patient has been in the critical care unit for 3 weeks and has been on an intra-aortic

balloon pump for the past 3 days. The patient’s condition has been serious, and hourly assessments and vital signs have been necessary. The nursing staff has noted that the patient has been unable to achieve sleep for more than 30 minutes at a time. The patient has been given diazepam (Valium) prn. The anticipated effect of diazepam on the patient’s sleep is a. a decrease in NREM stage 1. b. an increase in NREM stage 3.

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c. total NREM suppression. d. REM suppression in larger doses.

ANS: D

Diazepam increases NREM stage 1 and reduces NREM stages 3 and REM. REM suppression is dose related.

5. The patient has been in the critical care unit for 3 weeks and has been on the intra-aortic

balloon pump for the past 3 days. The patient’s condition has been serious, and hourly assessments and vital signs have been necessary. The nursing staff has noted that the patient has been unable to achieve sleep for more than 30 minutes at a time. The patient has been given diazepam (Valium) prn. Which techniques may assist in assessing the patient’s sleep pattern? a. Correlating sleep time with vital signs b. Documenting sleep periods of more than 90 minutes c. Assessing degree of arousal on hourly checks d. Observing the length of NREM sleep periods ANS: B

Keeping a sleep chart for 48 to 72 hours and documenting sleep periods greater than 90 minutes, the number and length of awakenings, and the total possible sleep time can help assess sleep patterns in the critical care unit.

6. Where are EMG leads placed to detect muscle atonia? a. Scalp b. Intercostal c. Anterior tibialis d. Chin ANS: D

Electromyography involves leads placed over various muscle groups. When placed over the chin, the leads can help detect muscle atonia associated with REM sleep. Intercostal leads detect respiratory effort, and leads over the anterior tibialis detect leg movements that may be causing the patient to arouse. Electroencephalographic electrodes are attached to the patient’s scalp to measure brain waves.

7. Hypnotic benzodiazepines a. promote deeper sleep stages. b. can produce prolonged effects in older adults. c. are metabolized more rapidly in the presence of steroids. d. enhance short-term recall.

ANS: B

Hypnotic benzodiazepines have a high lipophilicity, resulting in increased half-life in older adults. They also promote lighter sleep stages, are potentiated by steroids, and cause memory failure.

8. Which of the following patients would the nurse most strongly suspect of having

obstructive sleep apnea? a. A severely obese woman with diabetes b. A moderately obese man who snores

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c. A nonobese woman with hypertension d. A severely obese man with renal dysfunction ANS: B

Obesity associated with snoring is a hallmark of obstructive sleep apnea.

9. Which of the following older patients demonstrates changes in sleep patterns attributable

to central sleep apnea? a. A patient who wakes up two to three times per night and is tired during the day b. A patient who reports sleeping less soundly and not feeling rested c. A patient who consistently awakens at 4 AM and goes to bed at 7 PM d. A patient who has irregular respiration during sleep and whose inspiratory muscles intermittently fail ANS: D

Inspiratory muscle paralysis is a symptom of central sleep apnea. The other answers are associated with lifestyle habits that should be modified or changed to enhance sleep hygiene.

10. Sleep deprivation can result from which of the following? a. CPAP machine use b. Mechanical ventilation c. Use of nonbenzodiazepine short-acting hypnotics d. Use of analgesic medications to control pain ANS: B

Not surprisingly, mechanical ventilation and the required care associated with it contribute to sleep disturbances. CPAP treats the obstruction and the snoring, choking, and gasping that accompany it, and it provides cardiovascular benefits. Hypnotics and analgesic medications may aid sleep. Nurses have a responsibility to administer these medications in the most efficient manner to promote sleep and to monitor effectiveness.

11. During a sleep study, which of the following groups of information are gathered? a. Airflow, snoring, and tonsil size b. Electroencephalogram, electrocardiogram, and end-tidal carbon dioxide c. Oxygen saturation, number of arousals, and airflow d. Frequency of awakenings, REM speed, and apnea–hypopnea index ANS: C

Polysomnography is used to determine the number and length of apnea episodes and sleep stages, number of arousals, airflow, respiratory effort, and oxygen desaturation.

12. A patient with mild obstructive sleep apnea (OSA) can expect treatment to consist of a. medical management with protriptyline. b. weight loss, elimination of alcohol before bedtime, and side sleeping. c. immediate use of continuous positive airway pressure (CPAP). d. surgical intervention with uvulopalatopharyngoplasty (UPPP).

ANS: B

For patients with mild OSA (apnea–hypopnea index of 5 to 10), weight loss, sleeping on the side (if apnea is associated with sleeping on the back), avoidance of sedative medications and alcohol before bedtime, and avoidance of sleep deprivation may be all that is necessary.

CPAP would be the next treatment choice.

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13. The primary determinant in the efficacy of CPAP in patients with OSA is a. compliance. b. weight. c. tonsil size. d. respiratory effort.

ANS: A

CPAP, although the treatment of choice, is effective only if the patient is compliant with therapy. Regular attendance at CPAP clinics can improve patient compliance.

14. A patient was given the diagnosis of congestive heart failure (CHF) 2 years ago. The patient

complains of increased daytime sleepiness and states his support system has been complaining more and more about snoring. Central sleep apnea is suspected. Treatment depends on whether the patient has hypercapnic or nonhypercapnic central sleep apnea. Which of the following indicates a diagnosis of nonhypercapnic central sleep apnea (CSA)? a. Polysomnography with absence of airflow for at least 5 seconds b. Apnea–hypopnea index of 10 c. Peripheral edema, polycythemia, and obesity d. Insomnia, awakenings accompanied by choking, and normal body mass index ANS: D

Nonhypercapnic central sleep apnea characteristics include daytime sleepiness, insomnia or poor sleep, mild or intermittent snoring, and awakenings accompanied by choking or feeling short of breath; frequently, patients are of normal body weight. CSA can be seen on polysomnography as an absence of airflow and respiratory effort for at least 10 seconds.

15. A patient was given the diagnosis of congestive heart failure (CHF) 2 years ago. The patient

complains of increased daytime sleepiness and states his support system has been complaining more and more about snoring. Central sleep apnea is suspected. Treatment depends on whether the patient has hypercapnic or nonhypercapnic central sleep apnea. The patient’s primary treatment plan should include a. CPAP. b. bilevel positive airway pressure (BiPAP). c. acetazolamide and medroxyprogesterone. d. modafinil and zolpidem.

ANS: A

One treatment for the nonhypercapnic or heart failure patients is nasal CPAP, which also may provide a beneficial cardiovascular effect. Nocturnal oxygen supplementation may be effective as well. If CPAP is not tolerated, pharmacologic management may be tried.

16. a. b. c. d.

is a diagnostic test used to determine sleep disturbances.

Electrooculography Electromyography Electroencephalography Polysomnography

ANS: D

Polysomnography uses electroencephalography, electrooculography, myography, and electrocardiography to assess the quality of sleep.

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17. a. b. c. d.

is used during polysomnography to determine when the patient enters REM sleep.

Electrooculography Electromyography Electroencephalography Polysomnography

ANS: A

Electrooculography is used during polysomnography to determine when the patient enters REM sleep.

18. a. b. c. d.

is the external element that has the most significant effect on circadian rhythms.

Lower body temperature Light Melatonin cycle Background noise

ANS: B

Light is the external element that has the most significant effect on circadian rhythms.

Lower body temperature and melatonin cycles are internal elements that help with the sleep–wake cycle. Background noise can influence the circadian rhythms but not as significantly as light.

19. Sleep disturbance in critically ill patients is defined as insufficient duration or stages of

sleep that results in less sleep that promotes recovery. discomfort and interferes with quality of life. adaptation of the environment to promote sleep. more sleep that promotes recovery.

a. b. c. d.

ANS: B

Sleep disturbance in critically ill patients is defined as insufficient duration or stages of sleep that result in discomfort and interferes with quality of life. When ill, most people need more sleep than usual, and sleep seems to promote recovery.

20. Identify the usual cycle of sleep onset. a. NR1, NR2, NR3, NR2, REM b. NR1, NR2, NR3, REM c. NR1, NR2, NR3, NR1, REM d. NR1, NR2, NR3, REM, NR3 ANS: A

Sleep onset usually occurs in stage 1 sleep, progressing through stages 2 and 3 and then going back to stage 2, at which time the person usually enters REM. 21. REM sleep comprises what percent of the sleep cycle? a.

70% to 75% b. 45% to 65% c.

15% to 20% d.

20% to 25% ANS: D

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NREM sleep usually occupies 70% to 75% of the sleep cycle, with REM sleep comprising 20% to 25%.

22. A sufficient amount of sleep has been achieved when a person a. b. c. d.

awakens after 8 to 10 hours of uninterrupted sleep. with external stimuli and gets through the day without feeling sleepy. without external stimuli and gets through the day without feeling sleepy. feeling rested in the morning and takes a nap in the afternoon.

ANS: C

A sufficient amount of sleep has been achieved when one awakens without external stimuli and gets through the day without feeling sleepy. The amount of sleep required is uncertain.

No set number of hours has been established.

MULTIPLE RESPONSE 1. Which of the following occur during REM sleep stages? (Select all that a. b. c. d. e.

apply.)

Vital signs remain at basal levels.

Dreams occur.

Myocardial infarction often occurs.

Sweating or shivering is common.

Growth hormone is released.

ANS: B, C

The sympathetic nervous system predominates during REM sleep. Vital signs remain at basal levels, sweating or shivering commonly occurs with extreme temperature changes, and releases of growth hormone are parasympathetic nervous system responses.

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Chapter 06: Nutritional Alterations Test Bank MULTIPLE CHOICE 1. A patient with poorly controlled diabetes mellitus is to be started on enteral tube feeding.

What type of formula would be most appropriate?

Whole proteins and glucose polymers Concentrated in calories Low sodium High fat, low carbohydrate

a. b. c. d.

ANS: D

Individuals with diabetes mellitus whose blood sugar is poorly controlled with standard formulas should be given a glucose intolerance formula that is high in fat and low in carbohydrate. High protein is associated with polymeric formulas. Concentrated calories is associated with renal failure. Low sodium is associated with hepatic failure.

2. Most of the energy produced from carbohydrate metabolism is used to form what substance? a. Galactose b. Glycogen c. Adenosine triphosphate d. Antibodies ANS: C

Most of the energy produced from carbohydrate metabolism is used to form adenosine triphosphate (ATP), the principal form of immediately available energy within all body cells. One gram of carbohydrate provides approximately 4 kcal of energy. Through the process of digestion, carbohydrates are broken down into glucose, fructose, and galactose.

Antibodies are produced through the immune system.

3. A patient has a new order for intermittent nasogastric feedings every 4 hours. The

nasogastric tube is placed by the nurse. The best method for confirming the placement of the tube before feeding would be to a. obtain radiography of the abdomen. b. check the pH of fluid aspirated from the tube. c. auscultate the left upper quadrant of the abdomen while injecting air into the tube. d. auscultate the right upper quadrant of the abdomen while injecting air into the tube.

ANS: A

After the tube has been placed, correct location must be confirmed before feedings are started and regularly throughout the course of enteral feedings. Radiographs are the most accurate way of assessing tube placement.

4. A person with a BMI of 28 would be considered a. obese. b. overweight or pre-obese. c. of normal weight. d. underweight.

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ANS: B

A body mass index between 25 and 30 is considered overweight or pre-obese. The other BMIs are underweight = 2; normal = 18.5 to 24.99 kg/m2; overweight = ?5=25 kg/m2; preobese = 25 to 29.99 kg/m2; obese class I = 30 to 34.99 kg/m2; obese class II = 35 to 39.99 kg/m2; and obese class III = ?5=40 kg/m2.

5. Diet therapy for a person with hypertension 1 day after a myocardial infarction would

include a. three meals a day with two snacks. b. a low-protein diet. c. a low-salt, low-cholesterol diet. d. a high-carbohydrate diet.

ANS: C

Because fluid accompanies sodium, limitation of sodium is necessary to reduce fluid retention. Specific interventions include limiting salt intake, usually to 2 g a day or less, and limiting fluid intake because appropriate meal size, caffeine intake, and food temperatures are some of the dietary factors that are of concern. Small, frequent snacks are preferable to larger meals for patients with severe myocardial compromise or postprandial angina.

6. Two types of protein-caloric malnutrition are kwashiorkor and marasmus. Kwashiorkor

results in a. weight loss and muscle wasting. b. low levels of serum proteins, low lymphocyte count, and hair loss. c. elevated serum albumin and increased creatinine excretion in the urine. d. hyperpigmentation and a hard, easily palpated liver margin.

ANS: B

Kwashiorkor results in low levels of serum proteins, low lymphocyte count, low immunity and edema from low plasma oncotic pressure, and hair loss. Marasmus is recognizable by weight loss, loss of subcutaneous fat, and muscle wasting.

7. The patient history plays an important role in assessing the patient’s nutritional status.

Significant laboratory and clinical findings in the patient with cardiovascular disease include low levels of high-density lipoprotein (HDL) cholesterol and transferrin. elevated low-density lipoprotein (LDL) cholesterol and decreased subcutaneous fat. elevated sodium levels and a soft, fatty liver on palpation. normal triglyceride levels and the presence of S3 on auscultation.

a. b. c. d.

ANS: B

Laboratory and clinical findings in patients with cardiovascular disease include elevated total cholesterol and triglycerides as well as cardiac cachexia (muscle and subcutaneous fat wasting).

8. Proteins serve the function of a. maintaining osmotic pressure. b. providing minerals in the body. c. maintaining

blood glucose. d. providing a stored source of energy.

ANS: A

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Proteins are the basis for lean body mass and are important for chemical reactions, transportation of other substances, preservation of immune function, and maintenance of osmotic pressure (albumin) and blood neutrality (buffers) in the body. Carbohydrates help with maintaining osmotic pressure, gluconeogenesis, and providing minerals to the body. Lipids provide source of energy.

9. The loss of exocrine function of pancreatitis results

in a. b. c. d.

anorexia. obesity. malabsorption. hyperglycemia.

ANS: C

The loss of exocrine function leads to malabsorption and steatorrhea. In chronic pancreatitis, the loss of endocrine function results in impaired glucose intolerance. Anorexia is the result of an inability to eat or not eating. Obesity would result from consuming more than the RDA of calories based on one’s body type.

10. Obtaining height and weight measurements for the critically ill patient a. should be deferred until the medical condition stabilizes. b. should be measured rather than obtained through patient or family report. c. requires consistent weights in pounds. d. requires weight, but height can be deferred.

ANS: B

Height and current weight are essential anthropometric measurements that should be measured rather than obtained through patient or family report. The most important reason for obtaining anthropometric measurements is to detect changes in the measurements over time (e.g., response to nutritional therapy). Weight is measured in kilograms and height in meters. BMI values are independent of age and gender and are used for assessing health risk.

11. A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which of

the following is true?

Excessive calorie intake can cause an increase in PaCO2.

The patient’s head should remain elevated at 45 degrees to avoid aspiration.

Lipid intake should be maintained at greater than 2 g/kg/day.

TPN is preferred over the use of enteral feeding to avoid the complication of aspiration.

a. b. c. d.

ANS: A

Excessive calorie intake can raise PaCO2 sufficiently to make it difficult to wean a patient from the ventilator. A balanced regimen with both lipids and carbohydrates providing the nonprotein calories is optimal for patients with respiratory compromise, and these patients need to be reassessed continually to ensure that caloric intake is not excessive.

12. A primary nutritional intervention for hypertension is a. decreasing carbohydrates. b. limiting salt. c. increasing protein. d. increasing fluids.

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ANS: B

For hypertensive cardiac disease, sodium chloride restriction is recommended.

Some individuals are more salt sensitive than others, and this salt sensitivity contributes to hypertension.

13. Patients with coronary artery disease should be taught about cholesterol. Which situation

is most desirable?

Low levels of HDL cholesterol b. Low levels of c.

LDL cholesterol Hypocholesterolemia d. Low levels of both HDL and LDL cholesterol a.

ANS: B

Interventions for patients with coronary artery disease are geared toward lowering the LDL cholesterol to desirable levels.

14. An effect of malnutrition on respiratory function is a. decreased surfactant. b. increased vital capacity. c. decreased PaCO2. d. tachypnea.

ANS: A

Malnutrition has extremely adverse effects on respiratory function, decreasing both surfactant production and vital capacity. Excessive lipid intake can impair capillary gas exchange in the lungs, although this is not usually sufficient to produce an increase in PaCO2 or decrease in PaO2; this results in decreased respiratory function.

15. What is the rationale for careful intake and output for patients with pulmonary alterations? a. Fluid retention occurs with tachypnea. b. Hemodilution may cause deleterious hypernatremia. c. Fluid volume excess can lead to right-sided heart failure. d. Excessive fluid losses may lead to dehydration and hypovolemic shock.

ANS: C

Pulmonary edema and failure of the right side of the heart may result from fluid volume excess, which can further worsen the status of patients with respiratory compromise.

16. A patient who has sustained a head injury has increased nutritional needs related to the a. decrease in metabolism as a result of coma. b. decrease in blood sugar from a lack of dietary supplementation. c. anabolism and wound healing. d. hypermetabolism and catabolism associated with the injury.

ANS: D

Patients with neurologic alterations have increased needs because of hypermetabolism and catabolism after head injury. Poor food intake is related to altered state of consciousness, dysphagia or other chewing or swallowing difficulties, or ileus resulting from spinal cord injury or use of pentobarbital.

17. The patient is receiving corticosteroid treatment for neurologic alterations. The nurse

should assess the patient for episodes of

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a. b. c. d.

hyponatremia. hyperalbuminemia. hyperkalemia. hyperglycemia.

ANS: D

Hyperglycemia is a common complication in patients receiving corticosteroids. Needs for protein and calories are increased by infection and fever, as may occur in the patient with encephalitis or meningitis. Needs for protein, calories, zinc, and vitamin C are increased during wound healing, as occurs in trauma patients and patients with pressure ulcers.

18. Which of the following nutritional interventions is a priority for the patient with renal

disease who is receiving dialysis?

Increase fluids to replace losses.

Encourage potassium-rich foods to replace losses.

Ensure an adequate amount of protein to prevent catabolism.

Limit all nutrients to account for altered renal excretion.

a. b. c. d.

ANS: C

Proteins and amino acids are removed during peritoneal dialysis, creating a greater nutritional requirement for protein. The renal patient must receive an adequate amount of protein to prevent catabolism of body tissues to meet energy needs. Approximately 1.5 to 2.0 g protein/kg/day is required. Certain nutrients such as potassium and phosphorus are restricted because they are excreted by the kidney. The patient has no specific requirement for the fat- soluble vitamins A, E, and K because they are not removed in appreciable amounts by dialysis, and restriction generally prevents development of toxicity.

19. Prevention of pulmonary aspiration is best accomplished a. b. c. d.

by administering intermittent feedings. adding thickening agents to the tube feeding solution. suctioning the patient hourly. elevating the head of the bed 30 to 45 degrees.

ANS: D

To reduce the risk of pulmonary aspiration during enteral tube feeding, keep the patient’s head elevated at least 30 to 45 degrees during feedings unless contraindicated.

20. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic

failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. For which of the following complications should the patient be evaluated immediately after insertion of the catheter? a. Pneumothorax b. Hypoglycemia c. Central venous thrombosis d. Pulmonary aspiration ANS: A

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Central vein TPN carries an increased risk of sepsis as well as potential insertion-related complications such as pneumothorax and hemothorax. Repeated traumatic catheterizations are most likely to result in thrombosis. To prevent hypoglycemia, administer oral carbohydrates or an IV bolus of dextrose. Elevate the head of bed 30 to 45 degrees to prevent pulmonary aspiration after the infusion has begun.

21. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic

failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. On the third day of infusion, the patient develops symptoms of fever and chills. Which of the following complications should be suspected? a. Air embolism b. Pneumothorax c. Central venous thrombosis d. Catheter-related sepsis ANS: D

Because TPN requires an indwelling catheter in a central vein, it carries an increased risk for sepsis and potential insertion-related complications such as pneumothorax and hemothorax. Signs and symptoms of catheter-related sepsis include fever, chills, glucose intolerance, and positive blood cultures. Air embolism is also more likely with central vein TPN. 22. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic

failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and TPN is started. Which of the following dietary restrictions should be maintained for the patient? a. Fat and magnesium b. Protein and sodium c. Carbohydrate and potassium d. Protein and calcium ANS: B

Protein should be restricted because it contributes to the development of encephalopathy; sodium should be restricted because it contributes to the development of edema. Release of lipids from their storage depots is accelerated, but the liver has decreased ability to metabolize them for energy. Moreover, inadequate production of bile salts by the liver results in malabsorption of fat from the diet.

23. Which of the following medical interventions may be initiated with the onset

of hyperglycemia?

Discontinuing the infusion Adding insulin to the TPN Weaning from the TPN over a 6-hour period Starting an infusion of 0.9% normal saline

a. b. c. d.

ANS: B

One method for controlling hyperglycemia in a patient receiving TPN is to add insulin to the infusion. Rapid cessation of TPN may not lead to hypoglycemia; however, tapering the infusion over 2 to 4 hours is recommended. Slow advancement of the rate of TPN (25 mL/hr) to the goal rate allows pancreatic adjustment to the dextrose load.

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24. A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube.

To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours.

During a residual check later in the shift, the nurse aspirates a total residual volume of 350 mL. The nurse will a. stop the tube feeding, wait 1 hour, and recheck the residual. b. discontinue the feeding tube and tube feeding and call the physician for TPN orders. c. continue the tube feeding, if no other gastrointestinal symptoms exist, and reassess the patient with the next residual check. d. continue the tube feeding and place the patient in the left lateral decubitus position to facilitate gastric emptying.

ANS: C

There is little evidence to support a correlation between gastric residual volumes and tolerance to feedings, gastric emptying, and potential aspiration. Except in selected highrisk patients, there is little evidence to support holding tube feedings in patients with gastric residual volumes less than 400 mL. 25. A tracheostomy patient is experiencing regurgitation of tube feeding formula. The nurse’s

first priority should be a. checking to make sure the tracheostomy cuff is inflated during tube feedings. b. placing the patient in the right lateral decubitus position to promote

gastric emptying. c. discussing the use of metoclopramide to facilitate gastric motility with

the physician. d. placing the patient in prone position to improve draining from mouth.

ANS: A

When regurgitation of formula is an issue, the following interventions can be used as appropriate: keep the cuff of the endotracheal or tracheostomy tube inflated during feedings to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless contraindicated; if head cannot be raised, position the patient in the right lateral position or prone position to improve drainage of vomitus from the mouth; and consider giving metoclopramide to improve gastric emptying.

26. The patient’s feeding tube is occluded and cannot be flushed. The nurse knows that the

best irrigant for feeding tube occlusion is cola. pancreatic enzyme. water. juice.

a. b. c. d.

ANS: C

Although cranberry juice or cola beverages are sometimes used to reduce the incidence of tube occlusion, water is the preferred irrigant because it has been shown to be superior in maintaining tube patency.

27. The nutritional alteration most frequently encountered in hospitalized patients is a. respiratory quotient (RQ). b. protein-calorie malnutrition. c. fat-calorie malnutrition.

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d. gluconeogenesis.

ANS: B

The nutritional alteration most frequently encountered in the hospitalized patient is proteincalorie malnutrition. The respiratory quotient (RQ) is equal to the VCO2 divided by the VO2. Fat, protein, and carbohydrates each have a unique RQ; thus, RQ identifies which substrate is being preferentially metabolized and may provide target goals for calorie replacement. This process of manufacturing glucose from nonglucose precursors is called gluconeogenesis. Gluconeogenesis is carried out at all times, but it becomes especially important in maintaining a source of glucose in times of increased physiologic need and limited supply. Fat is used as a source of energy.

28. Sodium and fluid restrictions ordered for the patient with heart failure are primarily aimed

at reducing use of medications. weight. cardiac workload. serum lipids.

a. b. c. d.

ANS: C

Myocardial infarction, nutrition interventions, and education are designed to reduce angina, cardiac workload, and the risk of dysrhythmia. Sodium restriction applies in the treatment of patients with heart failure because water follows sodium. Fluids should be restricted to 1500 to 2000 mL/day. Weight is an anthropometric measurement and is a long-term goal. Serum lipids is a biochemical data and is a long-term goal. Medications are used to control fluid levels in the body and prevention of angina and dysrhythmia.

MULTIPLE RESPONSE 1. Which of the following signs would alert the nurse to possible nutritional alterations?

(Select all that apply.)

Impaired wound healing Edema Nail growth Muscle atrophy diaphoresis

a. b. c. d. e.

ANS: A, B, D

Impaired wound healing, edema, and muscle wasting atrophy are indicative of impaired nutrition. Nail growth would indicate normal caloric intake. Diaphoresis refers to sweating and is indicated with exercising and infection.

2. A patient was admitted with ESRD and on hemodialysis. Which of the following

elements should be restricted? (Select all that apply.)

Fluid Protein Carbohydrates Fats Phosphorus

a. b. c. d. e.

ANS: A, B, E

The kidneys are responsible for the balance of fluids, protein, and other nutrients. When the kidneys are functioning suboptimally, dietary intake of those substances must be restricted.

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Chapter 07: Gerontological Alterations Test Bank MULTIPLE CHOICE 1. A 68-year-old patient has been admitted to the coronary care unit after an inferior

myocardial infarction. Age-related changes in myocardial pumping ability may be evidenced by a. increased contractility. b. decreased contractility. c. decreased left ventricle afterload. d. increased cardiac output.

ANS: B

Collagen is the principal noncontractile protein occupying the cardiac interstitium.

Because myocardial collagen content increases with age, increased myocardial collagen content renders the myocardium less compliant and may be responsible for increased loading of blood vessels.

2. Age-related pulmonary changes that may affect this patient include a. increased tidal volumes. b. weakening of intercostal muscles and the diaphragm. c. improved cough reflex. d. decreased sensation of the glottis.

ANS: B

Respiratory muscle function is affected by skeletal muscle and peripheral muscle strength. During aging, skeletal muscle progressively atrophies, and its energy metabolism decreases, which may partially explain the declining strength of the respiratory muscles.

3. A 68-year-old patient has been admitted to the coronary care unit after an inferior

myocardial infarction. Dopamine 3 mcg/kg/min has been ordered for this patient. What nursing implications should be considered when administering this drug to an older patient? a. No changes are noted in older patients with this drug. b. Drug effect is enhanced by increased receptor site action. c. Increased breakdown by liver hepatocytes occurs, increasing dosage requirements. d. Drug metabolism and detoxification are slowed, increasing the risks of drug toxicity.

ANS: D

Reduced drug-metabolizing capacity is caused by a decline in activity of the drugmetabolizing enzyme system, microsomal ethanol oxidizing system, and decrease in total liver blood flow. Medications that depend on the cytochrome P450 group of liver enzymes are most affected because age-associated changes cause as much as a 50% decline in enzymatic function.

4. A 68-year-old patient has been admitted to the coronary care unit after an inferior

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a. thickening of the epidermal skin layer. b. loss of sebaceous glands.

c. increased fragility from loss of protective subcutaneous layers. d. decreased melanocyte production.

ANS: C

Ecchymotic areas may be seen because of decreased protective subcutaneous tissue layers, increased capillary fragility, and flattening of the capillary bed, predisposing older adults to developing ecchymoses. Medications and physiologic factors may result in an augmented bleeding tendency and appearance of ecchymotic areas; nevertheless, consideration should be given to the possibility of older adult abuse if ecchymosis is widespread or in unusual areas.

5. An older patient is admitted to the hospital with an acute onset of mental changes and

recent falls. The nurse knows that the most common cause of mental changes is hypoxia. infection. cerebrovascular accident. electrolyte imbalance.

a. b. c. d.

ANS: B

Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or medications are usually reversible after identification and treatment.

6. A nurse is teaching an older patient about the signs and symptoms of a myocardial

infarction.

Which statement by the patient would indicate that the teaching was effective? a. “The pain in my chest may last a long time.” b. “I will feel like I have an elephant sitting on the center of my chest.” c. “The chest pain will be sharp and over the center of my chest.” d. “The pain may not be severe and may not be in my chest.”

ANS: D

Myocardial infarction in older adults is often associated with ST-segment depression rather than ST elevation. Sensation of chest pain may be altered and may be less intense and of shorter duration. Other atypical symptoms may include dyspnea, confusion, and failure to thrive, which results in unrecognized signs and symptoms of cardiac problems and delays in diagnosis and treatment.

7. An older patient is starting a new medication that is metabolized in the liver and excreted

by the kidneys. Which is the best assessment to monitor the patient’s ability to tolerate the medication? a. Liver function tests b. Drug side effects experienced by the patient c. Kidney function tests d. Therapeutic drug levels ANS: B

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Adverse drug effects and medication interactions may be related to pharmacokinetics or the manner in which the body absorbs, distributes, metabolizes, and excretes a drug. The aging process is associated with changes in gastric acid secretion, which can alter ionization or solubility of a drug and hence its absorption. Medication distribution depends on body composition and on physiochemical drug properties. With advancing age, a patient’s fat content increases, lean body mass decreases, and total body water decreases, which can alter drug disposition.

8. An older patient is receiving a nephrotoxic medication. Which of the following would

be a priority for the nurse to monitor?

Electrocardiogram Lung sounds Blood pressure Level of consciousness

a. b. c. d.

ANS: C

Decrease in number and size of nephrons begins in the cortical regions and progresses toward the medullary portions of the kidney. This decrease in number of nephrons corresponds to a 20% decrease in weight of the kidneys between 40 and 80 years of age. Initially, this loss of nephrons does not appreciably alter renal function because of the large renal reserve and a simultaneous decrease in lean muscle mass.

9. Which of the following can be a normal assessment finding for an older patient? a. Asymptomatic dysrhythmias b. Decreased urine output c. Increased respiratory effort d. Difficulty problem solving ANS: A

The incidence of asymptomatic cardiac dysrhythmias increases in older patients. The most common dysrhythmia is the premature ventricular contraction. Other common types are atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia and atrioventricular conduction disturbances. All of the other findings are abnormal.

10. Chemical changes in a drug that renders it active or inactive is known as a. absorption. b.

metabolism. c. excretion. d. distribution.

ANS: B

Metabolism is the chemical change in a drug that renders it active or inactive. Absorption is the receptor-coupled or diffusional uptake of drug into the tissue. Distribution is the theoretic space (tissue) or body compartment into which free form of a drug distributes.

Excretion is the removal of a drug through an eliminating organ, often the kidneys; some drugs are excreted in bile or feces, in saliva, or through the lungs.

11. Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) has the side effect

of renal failure, HTN, heart failure, and GI bleed in the elderly population? a. Indomethacin b. Ketorolac

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c. Aspirin greater than 325 mg d. Naproxen ANS: D

Possible side effects of select NSAIDs include indomethacin: central nervous system (CNS) effects (highest of all NSAIDs); ketorolac: asymptomatic gastrointestinal conditions (ulcers); aspirin (>325 mg): asymptomatic gastrointestinal conditions (ulcers); and naproxen: gastrointestinal bleeding, renal failure, high blood pressure, and heart failure.

MULTIPLE RESPONSE 1. An older patient is started on amitriptyline to control depression. The nurse knows to

monitor for (Select all that apply) impaired psychomotor function. irregular heart rate. polyuria. pulmonary edema.

a. b. c. d.

ANS: A, B, C

Tricyclic antidepressants (amitriptyline and amitriptyline compounds) have strong anticholinergic effects; may lead to ataxia, impaired psychomotor function, syncope, falls; cardiac arrhythmias (QT interval changes); may produce polyuria or lead to urinary incontinence; may exacerbate chronic constipation

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Chapter 08: Pain and Pain Management Test Bank MULTIPLE CHOICE 1. The subjective characteristic implies that pain is a. an uncomfortable experience present only in the patient with an intact

nervous system. b. an unpleasant experience accompanied by crying and tachycardia. c. activation of the sympathetic nervous system from an injury. d. whatever the patient experiencing it says it is, occurring when that patient

says it does.

ANS: D

Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists whenever he or she says it does.

2. The neural processes of encoding and processing noxious stimuli necessary but not

sufficient for pain is known as a.

perception. b. nociception. c. transduction. d.

transmission.

ANS: B

Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain. Transduction refers to mechanical (e.g., surgical incision), thermal (e.g., burn), or chemical (e.g., toxic substance) stimuli that damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception. Pain sensation transmitted by the NS pathway reaches the thalamus, and the pain sensation transmitted by the PS pathway reaches brainstem, hypothalamus, and thalamus. These parts of the CNS contribute to the initial perception of pain.

3. Which of the following assessment findings might indicate respiratory depression after

opioid administration?

Flushed, diaphoretic skin Shallow respirations with a rate of 24 breaths/min Tense, rigid posture Sleep apnea

a. b. c. d.

ANS: D

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Opioids may cause this complication because they reduce the responsiveness of carbon dioxide chemoreceptors in the respiratory center located in the medulla. Risk factors for opioid-induced respiratory depression include advanced age, obesity, sleep apnea, impaired kidney/lung/liver/heart function, patients in whom pain is controlled after a period of poor control, patients who are opioid naïve (i.e., receiving opioids for less than a week), concurrent use of central nervous system depressants, and postoperative day 1 were described. In addition to side effects common to all opioids, morphine may stimulate histamine release from mast cells, resulting in cardiac instability and allergic reactions.

4. The patient is admitted to the CCU with hemodynamic instability and an allergy to

morphine.

The nurse anticipates that the physician will order which medication for severe pain? a. Hydromorphone b. Codeine c. Fentanyl d. Methadone ANS: C

Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent than morphine.

Hydromorphone produces an inactive metabolite (i.e., hydromorphone-3-glucuronide), making it the opioid of choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid.

Methadone is a synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This makes it difficult to titrate in the critical care patient.

5. Which of the following combinations of drugs has been found to be effective in managing

the pain associated with musculoskeletal and soft tissue inflammation?

Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids NSAIDs and antidepressants Opioid agonists and opioid antagonists Adjuvants and partial agonists

a. b. c. d.

ANS: A

The use of NSAIDs in combination with opioids is indicated in patients with acute musculoskeletal and soft tissue inflammation.

6. A patient underwent a thoracotomy 12 hours ago. The patient currently has an epidural

catheter in place and is receiving continuous epidural analgesia with morphine. In addition to respiratory depression, the patient should be monitored for which of the following complications? a. Urinary retention, undue somnolence, itching, nausea, and vomiting b. Urinary incontinence, photophobia, headache, and skin rash c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain ANS: A

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Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence, itching, seizures, nausea, and vomiting.

7. Acute pain usually corresponds to a. the healing process but should not exceed 9 months. b. the healing process but should not exceed 6 months. c. persistent pain more than 6 months after the healing process. d. damage to the patient’s nervous system unrelated to the initial injury.

ANS: B

Acute pain has a short duration, and it usually corresponds to the healing process (30 days) but should not exceed 6 months. It implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response and lead to permanent damage to the patient’s nervous system. In such instance, acute pain can become chronic.

8. A patient complains of pain at his incision site. The nurse is aware that four processes

are involved in nociception. The proper order of the processes is transmission, perception, modulation, and transduction. b. perception, modulation, transduction, and transmission. c. modulation, transduction, transmission, and perception. d. transduction, transmission, perception, and modulation. a.

ANS: D

Four processes are involved in nociception: transduction, transmission, perception, and modulation.

9. Using a specific pain intensity scale in the CCU a. eliminates the need for the subjectivity of the patient. b. allows for one tool for all patient types. c. provides consistency of assessment and documentation. d. is not necessary because all pain is treated equally in the CCU. ANS: C

Many CCUs use a specific pain intensity scale because a single tool provides consistency of assessment and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient’s pain.

However, the patient’s tool preference should be considered.

10. The patient is sedated and breathing with the use of mechanical ventilation. The patient is

unable to communicate any aspects of his pain to the nurse. The nurse knows that the best tool for pain assessment for this patient is a. FLACC. b. Wong-Baker FACES. c. BIS. d. BPS or CPOT. ANS: D

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The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the ICU. 11. A patient states that he has been taking Demerol 50 mg tablets four times a day for the

past 5 years, but they are not working like they use to. The nurse is concerned that the patient has developed a. addiction to Demerol. b. physical dependence and tolerance. c. physical dependence and addiction. d. a method to withdraw himself off the medication.

ANS: B

Addiction is defined by a pattern of compulsive drug use that is characterized by an incessant longing for an opioid and the need to use it for effects other than pain relief.

Tolerance is defined as a diminution of opioid effects over time. Physical dependence and tolerance to opioids may develop if the medication is given over a long period. Physical dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped.

12. The use of PCA infusion pumps allows the patient to a. act preemptively by administering a bolus of medication when pain begins. b. choose between the use of opioids or NSAID medication to control pain. c. decrease the risk of respiratory depression. d. control pain medication in 2-hour increments.

ANS: A

The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely monitored during the first 2 hours of therapy and after every change in the prescription. If the patient’s pain does not respond within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily available to reverse adverse opiate respiratory effects.

13. Relaxation, distraction, guided imagery, and music therapy are all examples of a. physical techniques for pain management. b. cognitive-behavioral techniques for pain management. c. PCA management of pain. d. equianalgesic management of pain.

ANS: B

Using the cortical interpretation of pain as the foundation, several interventions can reduce the patient’s pain report. These modalities include cognitive techniques such as relaxation, distraction, guided imagery, and music therapy.

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MULTIPLE RESPONSE 1. Which of the following statements are true regarding pain assessment and management?

(Select all that apply.) a. The single most important assessment tool available to the nurse is the

patient’s self-report.

b. The only way to assess pain in patients unable to verbalize because of

mechanical ventilation is through observation of behavioral indicators. c. The concept of equianalgesia uses morphine as a basis for dosage comparison

for other medications. d. Transcutaneous electrical nerve stimulation and application of heat or cold

therapy stimulate the nonpain sensory fibers. e. Meperidine, a synthetic form of morphine, is much stronger and is given at

lower doses at less frequent intervals.

ANS: A, C, D

Appropriate pain assessment is the foundation of effective pain treatment. Because pain is recognized as a subjective experience, the patient’s self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of consciousness, may impact communication with patients.

These obstacles make pain assessment more complex. Meperidine (Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another.

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Chapter 09: Sedation, Agitation and Delirium Management Test Bank MULTIPLE CHOICE 1. To achieve ventilator synchrony in a mechanically ventilated patient with acute

respiratory distress syndrome (ARDS), which level of sedation might be most effective? a. Light b.

Moderate c.

Conscious d. Deep ANS: D

Deep sedation is used when the patient must be unresponsive to deliver necessary care safely.

2. A patient has been taking benzodiazepines and suddenly develops respiratory depression

and hypotension. After careful assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse’s next step? a. Decrease benzodiazepines to half the prescribed dose. b. Increase IV fluids to 500 cc/hr for 2 hours. c. Administer flumazenil (Romazicon). d. Discontinue benzodiazepine and start propofol.

ANS: C

The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients.

3. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress

syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The nurse's first intervention for this patient would be to a. administer midazolam (Versed) 5 mg by intravenous push immediately. b. assess the patient to see if a physiologic reason exists for his agitation. c. obtain a stat arterial blood gas level; his agitation indicates he is becoming increasingly hypoxic. d. apply soft wrist restraints to keep him from pulling out the endotracheal tube.

ANS: B

The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem.

4. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress

syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure alarm. The next step should be to a. administer midazolam 5 mg by intravenous push immediately. b. eliminate noise and other stimuli in the room and speak softly and reassuringly to

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him. c. obtain a stat arterial blood gas level; his agitation indicates he is becoming increasingly hypoxic. d. call respiratory therapy to replace this obviously malfunctioning ventilator.

ANS: B

Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic means to decrease anxiety.

5. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress

syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. Despite the nurse’s actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator. Which of the following medications would be appropriate for sedation? a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the patient is no longer triggering the alarm b. Haloperidol 5 mg IVP stat c. Propofol 5 mcg/kg/min by IV infusion d. Fentanyl 25 mcg IVP over a 15-minute period ANS: A

Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia.

Fentanyl is a narcotic and is not appropriate for use as a sedative.

6. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress

syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently triggered. After the patient’s agitation is controlled, which of the following drugs would be most appropriate for long-term sedation? a. Morphine 2 mg/hr continuous IV drip b. Haloperidol 15 mcg/kg/min continuous IV infusion c. Propofol 5 mcg/kg/min by IV infusion d. Lorazepam 0.01 to 0.1 mg/kg/hr by IV infusion ANS: D

Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1– 3 days) and should be coupled with a short-acting opioid analgesic. Morphine is an opioid analgesic and is not sedation. Lorazepam infusion (0.01–0.1 mg/kg/hr) is recommended for long-term sedation.

7. When administering propofol over an extended period, it is important to monitor which of

the following?

Serum triglyceride level Sodium and potassium levels Platelet count Acid–base balance

a. b. c. d.

ANS: A

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Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content.

8. A major side effect of benzodiazepines is a. hypertension. b. respiratory depression. c. renal failure. d. phlebitis at the IV site.

ANS: B

The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related.

9. The major advantage of using propofol for short-term sedation is that it a. has fewer side effects. b. is slow to cross the blood–brain barrier. c. has a shorter half-life and rapid elimination rate. d. is an excellent amnesiac.

ANS: C

Propofol is an effective short-term anesthetic agent, useful for rapid “wake-up” of patients for assessment; if continuous infusion is used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of sedation, and length of time sedated.

10. Which of the following drugs is used for sedation in patients experiencing

withdrawal syndrome?

Dexmedetomidine Hydromorphone Diazepam Clonidine

a. b. c. d.

ANS: D

Clonidine (often prescribed as a Catapres patch) is a central recommended for sedation during withdrawal syndrome.

-agonist and is

11. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from

mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her room and pulling at her gown. You suspect this patient is a. experiencing delirium or “ICU psychosis.” b. experiencing confusion caused by increased hypoxia. c. hypocalcemic. d. acting out to receive the attention she was getting while intubated.

ANS: A

Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation, impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior.

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12. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from

mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her room and pulling at her gown. The drug of choice for treating this patient is a. diazepam. b.

haloperidol. c.

lorazepam. d. propofol.

ANS: B

Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with an increased incidence of delirium. Propofol is indicated for sedation use. Diazepam is not an appropriate choice for this patient.

13. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from

mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her room and pulling at her gown. Which of the following interventions is indicated to adequately monitor the patient during haloperidol use? a. Continuous bispectral index (BIS) monitoring b. Continuous electrocardiographic (ECG) monitoring c. Continuous pulse oximetry d. Continuous electrocardiogram (ECG) monitoring ANS: B

ECG monitoring is recommended because haloperidol use can produce dose-dependent QTc- interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use.

14. The most common contributing factor to the development of delirium in critically ill

patients is a. sensory overload. b. hypoxemia. c. electrolyte disturbances. d. sleep deprivation.

ANS: D

Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to reduce the incidence of delirium.

15. Which benzodiazepine has a greater advantage for treatment of alcohol withdrawal

syndrome (AWS) because of its longer half-life and high lipid solubility? a. Ativan b. Midazolam c. Propofol d. Valium Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility.

Lipid-soluble medications quickly cross the blood–brain barrier and enter the central nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because of rapid withdrawal. Propofol is indicated for sedation use.

16. Risk factors for delirium include a. hypertension, alcohol abuse, and benzodiazepine administration.

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b. coma, hypoxemia, and trauma. c. dementia, hypertension, and pneumonia. d. coma, alcohol abuse, hyperglycemia ANS: A

Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine administration.

17. The two scales that are recommended for assessment of agitation and sedation in

adult critically ill patients are the a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS). b. Ramsay Scale and Motor Activity Assessment Scale (MAAS). c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale

(RASS). d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale

(MAAS).

ANS: C

The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the RASS. 18. For sedation and analgesia management of mechanically ventilated critical care patients,

put the following steps in the appropriate order in which the nurse should perform them.

1. Using an accepted pain scale, assess the patient's level of pain, and if the patient is hemodynamically stable, medicate appropriately with morphine sulfate.

2. Assess the degree of agitation and anxiety with an appropriate sedation scale and select an appropriate medication treatment.

3. Attempt nonpharmacologic treatments; optimize the environment.

4. Reassess the level of sedation, agitation and anxiety, and pain minimally every 2 hours or as indicated per facility standards.

5. Rule out and correct reversible causes.

6. Assess the patient’s level of comfort. a. 1, 2, 6, 5, 3, 4 b. 6, 5, 1, 2, 3, 4 c. 6, 5, 3, 1, 2, 4 d. 4, 1, 2, 6, 5, 3 ANS: C

Pain and sedation scales should be used to accurately assess the patient's needs; adequate interventions should be applied and the patient frequently reassessed.

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MULTIPLE RESPONSE 1. Causes of delirium in critically ill patients include (Select all that apply.) a. hyperglycemia. b. meningitis. c. cardiomegaly. d. pulmonary embolism. e. alcohol withdrawal syndrome. f. hyperthyroidism.

ANS: B, E, F

The causes of delirium in critically ill patients include metabolic causes (acid–base disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).

2. Which of the following complications can result from oversedation? (Select all that apply.) a. Pressure ulcers b.

Thromboemboli c. Diarrhea d. Nosocomial pneumonia e. Delayed weaning from mechanical ventilation f. Hypertension ANS: A, B, D, E

Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of immobility, including pressure ulcers, thromboemboli, gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.

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Chapter 10: End-of-Life Care Test Bank MULTIPLE CHOICE 1. Which of the following statements about comfort care is accurate? a. Withholding and withdrawing life-sustaining treatment are distinctly different

in the eyes of the legal community.

b. Each procedure should be evaluated for its effect on the patient’s comfort

before being implemented. c. Only the patient can determine what constitutes comfort care for him or her. d. Withdrawing life-sustaining treatments is considered euthanasia in most states.

ANS: B

The goal of comfort care is to provide only treatments that do not cause pain or other discomfort to the patient.

2.

is a powerful influence when the decision-making process is dealing with recovery or a peaceful death. a. Hope b.

Religion c.

Culture d.

Ethics ANS: A

Hope is a powerful influence on decision making, and a shift from hope for recovery to hope for a peaceful death should be guided by clinicians with exemplary communication skills. Ethics, religion, and culture can influence the decision process regarding care and end-of-life decisions.

3. The patient’s condition has deteriorated to the point where she can no longer make

decisions about her own care. Which of the following nursing interventions would be most appropriate? a. Obtain a verbal DNR order from the physician. b. Continue caring for the patient as originally ordered because she obviously wanted this. c. Consult the hospital attorney for recommendations on how to proceed. d. Discuss with the family what the patient’s wishes would be if she could make those decisions herself.

ANS: D

If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next steps because they may have insight into what her wishes would be.

4. The two basic ethical principles underlying the provision of health care are a. beneficence and nonmaleficence. b. veracity and beneficence. c. fidelity and nonmaleficence. d. veracity and fidelity.

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The two basic ethical principles underlying the provision of health care are beneficence and nonmaleficence.

5. A patient was admitted to the critical care unit several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient does not have an advance directive. Which of the following statements would be the best way to approach the family regarding his ongoing care? a. “I will refer this case to the hospital ethics committee, and they will contact you when they have a decision.” b. “What do you want to do about the patient’s care at this point?” c. “Dr. Smith believes that there is no hope at this point and recommends DNR status.” d. “What would the patient want if he knew he were in this situation?”

ANS: D

Approaching the family and asking what they know about the patient’s wishes and preferences is the best way to begin this discussion. Emotional support for the patient and the family is important as they discuss advance care planning in the critical care setting.

6. A patient was admitted to the critical care unit several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. After a family conference, the physician orders a DNR order, and palliative care is begun. This means a. the patient will continue to receive the same aggressive treatment short of resuscitation if he has another cardiac arrest. b. all treatment will be stopped, and the patient will be allowed to die. c. all attempts will be made to keep the patient comfortable without prolonging his life. d. the patient will be immediately transferred to hospice.

ANS: C

When palliative care is begun, the primary goal is to keep the patient comfortable by continuing assessments and managing symptoms that might cause pain, anxiety, or distress.

7. A patient was admitted to the critical care unit several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The patient continues to grimace and fight the ventilator. What nursing intervention would be appropriate? a. Increase the morphine dosage until no signs of pain or discomfort are present. b. Increase the morphine drip, but if the patient’s respiratory rate drops below 10 breaths/min, return to the original dosage. c. Gradually decrease the morphine and switch to Versed to avoid respiratory depression. d. Ask the family to leave the room because their presence is causing undue stress to

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the patient.

ANS: A

Even though opiates can cause respiratory depression, the goal in palliative care is to alleviate pain and suffering. A bolus dose of morphine (2–10 mg IV) and a continuous morphine infusion at 50% of the bolus dose per hour is recommended. Because many critical care patients are not conscious, assessment of pain and other symptoms becomes more difficult. Gélinas and colleagues recommended using signs of body movements, neuromuscular signs, facial expressions, or responses to physical examination for pain assessment in patients with altered consciousness.

8. A patient was admitted to the critical care unit several weeks ago with an acute myocardial

infarction and subsequently underwent coronary artery bypass grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no meaningful brain activity. The decision is made to remove the patient from the ventilator. Which of the following statements is most accurate? a. The cardiac monitor should be left on so everyone will know when the patient has died. b. Opioids, sedatives, and neuromuscular blocking agents should be discontinued just before removing the ventilator. c. The family and health care team should decide the best method for removing the ventilator: terminal wean versus immediate extubation. d. If terminal weaning is selected, the family should be sent to the waiting room until the ventilator has actually been removed.

ANS: C

The choice of terminal wean as opposed to extubation is based on considerations of access for suctioning, appearance of the patient for the family, how long the patient will survive off the ventilator, and whether the patient has the ability to communicate with loved ones at the bedside.

9. A patient was admitted to the critical care unit after having a CVA and MI. The patient has

poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the physician approach to discuss decisions of care and possible DNR status? a. The patient b. The family c. The hospital legal system d. The hospital ethics committee ANS: A

Patients’ capacity for decision making is limited by illness severity; they are too sick or are hampered by the therapies or medications used to treat them. When decision making is required, the patient is the first person to be approached.

10. Organ donation a. is a choice only the patient can make for him- or herself. b. is mandated by legal and regulatory agencies. c. must be requested by the nurse caring for the dying patient. d. is controlled by individual institutional policies.

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ANS: B

The Social Security Act Section 1138 requires that hospitals have written protocols for the identification of potential organ donors. The Joint Commission has a standard on organ donation. The nurse must notify the organ procurement official to approach the family with a donation request.

11. Hospice care can help families a. b. c. d.

with organ donations. aggressive symptom management and family support. writing advance directives and living wills. legal euthanasia.

ANS: B

Health professionals can assist patients and families by providing information about the hospice benefit, particularly regarding the aggressive symptom management and family support. Organ donations must follow Social Security Act Section 1138 regarding written protocols for identification of potential organ donors and notification of organ recovery agencies. Advance directives can be taken care of at the hospital or legal firm. Euthanasia is also known as assisted suicide and is legal in Oregon, Washington, and Montana.

12. Disagreement and distress among physicians, nurse practitioners, and critical care nurses

can lead to emotional distress only. ethical distress only. emotional and ethical distress. pessimistic opinions of care.

a. b. c. d.

ANS: C

Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses consider withdrawal before physicians and patients do, and they then believe the care they are giving is unnecessary and possibly harmful. This issue is a serious one for critical care nurses because emotional and ethical distress can lead to burnout.

13. Antiemetics should be used to treat a. dyspnea. b. nausea and vomiting. c. anxiety. d. edema.

ANS: B

Nausea and vomiting are common and should be treated with antiemetics. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety.

14. Haloperidol is recommended as useful treatment of a. anxiety b. dyspnea c.

.

delirium

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d. pain ANS: C

Delirium is commonly observed in critically ill patients and in those approaching death.

Haloperidol is recommended as useful, and restraints should be avoided. Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

Benzodiazepines, especially midazolam with its rapid onset and short half-life, are frequently used to treat anxiety. Morphine is the most common drug used for pain management.

15. A patient tells the nurse to call his family and tell them they need to come so they can say

their goodbyes. The patient is sure he will not be here tomorrow because his grandparent is waiting for him. This is an example of a. signs and symptoms of anxiety. b. signs and symptoms of delirium. c. the need for hospice care. d. near-death awareness.

ANS: D

The same behaviors may be seen in conscious critical care patients near death. Having an awareness of the phenomenon enables more careful assessment of behaviors that may be interpreted as delirium, acid–base imbalance, or other metabolic derangements. These behaviors include communicating with someone who is not alive, preparing for travel, describing a place the patient can see, or even knowing when death will occur.

16. Recommendations for creating a supportive atmosphere during withdrawal

discussions include telling the family when and where the procedure will occur. beginning the conversation by inquiring about the emotional state of the family. ending the conversation by inquiring about the emotional state of the family. recommendations that the family not be present when the procedure occurs.

a. b. c. d.

ANS: B

Recommendations for creating a supportive atmosphere during withdrawal discussions include taking a moment at the beginning of the conversation to inquire about the family’s emotional state. During the family meeting in which a decision to withdraw life support is made, a time to initiate withdrawal is usually established.

17. Family members become dissatisfied and stressed because of a lack of

among

health care providers. care provided communication patient’s prognosis patient’s outcome

a. b. c. d.

ANS: B

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Family members have reported dissatisfaction with communication and decision making.

Increasing the frequency of communication and sharing concerns early in the hospitalization will make subsequent discussions easier for the patient, family, and health professional. Based on the level of communication and patient understanding of care, prognosis and outcomes will influence the satisfaction of services being provided to their family member and decrease stress levels.

MULTIPLE RESPONSE 1. Which of the following are considerations when making the decision to allow family at

the bedside during resuscitation efforts? (Select all that apply.) a. The patient’s wishes b. Experience of the staff c. The family’s need to participate in all aspects of the patient’s care d. State regulatory issues e. Seeing the resuscitation may confirm the impact of decisions made or delayed ANS: E

The decision to allow family members at the bedside during resuscitative efforts should be made by the family and caregivers and be based on needs and experiences. The family may become more aware of what is involved in decisions if they are present during procedures or resuscitative attempts. Seeing the steps of resuscitation may make clearer the impact of decisions made or delayed.

2. According to the Society for Critical Care Medicine, which of the following are among

the most important needs of the family of the dying patient? (Select all that apply.)

To be helpful To stay informed To achieve a sense of control To vent emotions To be fed, hydrated, and rested

a. b. c. d. e.

ANS: A, B, D, E

The needs of the patient and the needs of the family may be very different during this stressful time.

3. Which of the following statements apply to DNR orders? (Select all that apply.) a. DNR orders are often delayed because of difficulty predicting the time of death. b. The patient’s wishes are often not known or are vaguely stated. c. A DNR order indicates that all care should be stopped. d. End-of-life care skills are not emphasized in medical curricula. e. DNR orders do not address pain management.

ANS: A, B, D, E

A do-not-resuscitate (DNR) order is intended to prevent the initiation of life-sustaining measures such as endotracheal intubation or CPR. Families should be assured that patients will continue to receive care but that aggressive measures to extend life will not be used.

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Chapter 11: Cardiovascular Anatomy and Physiology Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. Which structure is the

primary or natural pacemaker of the heart?

a.

Ventricular tissue

b.

Atrioventricular node

c.

Sinoatrial node

d.

Purkinje fibers

ANS: C

With an intrinsic rate of 60 to 100 beats/min, the sinoatrial node is the primary pacemaker in a healthy heart. The atrioventricular node beats 40 to 60 beats/min. Ventricular tissue must have an electrical impulse to contract. Purkinje fibers beat 15 to 40 beats/min.

2. The atrioventricular (AV) node delays the conduction impulse from the atria

(0.8–1.2 seconds) for what reasons? a.

To limit the amount of blood that fills the ventricle from the atria

b.

To provide time for the ventricles to fi ll during diastole

c.

To limit the number of signals the ve ntricles receive in some rhythms To allow the atria to rest between sig nals

d.

ANS: B

T he atrioventricular (AV) node delays the conduction impulse from the at ria (0.8–1.2 seconds) to provide time for the ventricles to fill during diastole.

3. Why do many

patients with very high heart rates frequently have chest pain and shortness of breath? a.

Patients with heart disease fre- quent ly ha ve an anxiety disorder as well.

The rapid pounding of the heart in the b. chest wall causes the physical pain.

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c.

The heart muscle gets tired from the increased work.

The decreased diastolic time de- creas es oxygen delivery to the myocardium.

d.

ANS: D

The coronary arteries are perfused during diastole. When the heart rate increases, the diastolic time decreases as each contraction has less time to be completed. This decreases the time the coronary arter- ies have to deliver oxygenated blood to the myocardium. The symp- toms described are caused by a lack of oxygen in the myocardium.

4.A patient reports feeling dizzy after standing quickly. Which finding could provide

a clue regarding the cause? a.

Hemoglobin level of 14.0 g/dL and hematocrit level of 42.3%

b.

Poor skin turgor with extended tenting Supine blood pressure of 146/93 mm Hg

c. d.

Resting heart rate of 96 be ats/min

ANS: B

Poor skin turgor could suggest dehydr ation. Dehydration can cause or- th ostatic hypotension because of low capacitance reserves from hypo- volemia. Supine blood pressure of 146/93 mm Hg would be considered hypertensive, and the patient would most likely experience a headache rather than dizziness. A resting heart rate of 96 beats/min is still con- sidered a normal value.

5.A patient presents with atrial fibrillation, a heart rate of 156 beats/min, and a

blood pressure of 124/76 mm Hg. The practitioner orders dilti- azem, a calcium channel blocker, to be given slowly by intravenous push. Why did the practitioner choose this medication to treat this pa- tient’s atrial tachyarrhythmia? a.

D iltiazem decreases the calcium influx int o the atrioventricular (AV) nodal tiss ue and decreases the speed of impulse co nduction.

b.

Diltiazem increases the calcium influx into the AV nodal tissue

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and decreases the speed of im- pulse co nduction. c.

Diltiazem decreases the calcium influx int o the myocardial tissue and decreas es the strength of heart contraction.

Diltiazem increases the calcium influx into the myocardial tissue and decreas es the strength of heart contraction.

d.

ANS: A

C alcium channel–blocking drugs, suc h as verapamil and diltiazem, in- hib it the inward Ca++ current into pacemaker tissue, especially the atrioventricular (AV) node. For this reason, they are used therapeuti- cally to slow the rate of atrial tachydysrhythmias and protect the ven- tricle from excessive atrial impulses.

6. What is one hemodynamic effect of a pericardial effusion?

a.

Inc reased ventricular ejection

b.

Decreased ventricular filling

c.

Myocardial ischemia

d.

Increased afterload

ANS: B

If the fluid collection in the sac (pericardial effusion) impinges on ven- tricular filling, ventricular ejection, or coronary artery perfusion, a clini- cal emergency may exist that necessitates removal of the excess peri- cardial fluid to restore normal cardiac function. Myocardial ischemia is damage of the myocardium muscle as the result of a heart attack.

7. What percentage of volume does atrial kick contribute to

b.

10% 20%

c.

5%

d.

45%

a.

A

ventricular fill- ing?

NS: B

Atrial contraction, also known as “atrial kick,” contributes approxi- mately 20% of blood flow to ventricular filling; the other 80% occurs passively during diastole.

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8. What is the

a. b. c. d.

function of the atrioventricular (AV) valves?

Prevent backflow of blood into the atri a du ring ventricular con- traction Prevent blood regurgitation back into the ventricles Assist with blood flow to the lungs and aorta C ontribute to ventricular filling by atri al kick

ANS: A

The atrioventricular (AV) valves are open during ventricular diastole (filling) and prevent backflow of blood into the atria during ventricular systole (contraction). Semilunar valves prevent the backflow of pul- monic and aortic blood back into the ventricles.

9. Which step of impulse conduction is most conducive to atrial kick?

a. b.

c. d.

The firing of the sinoatrial node, which results in atrial depolariza- tion The conduction delay at the atriove ntricular (AV) node, allowing time for filling Conduction through the bundle of His , enhancing ventricular de- polarization C onduction to the Purkinje fibers, allo wing fo r ventricular contrac- tion

A NS: B

The conduction delay at the atriovent ricular (AV) node allows adequate t ime for ventricular filling from atrial contracti on.

10. Which is an example of a physiologic shunt?

a.

A ventricular septal defect

b.

Blood returning from the inferior vena cava to the right atrium

c.

A septal infarct

d.

The thebesian vessels returning

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deoxygenated blood to the left ventricle ANS: D

The thebesian vessels return blood to the left ventricle. The mixing of unoxygenated blood with freshly oxygenated blood is called a physio- logic shunt. A ventricular septal defect (VSD) allows mixing of blood from both ventricles. The clinical impact depends on the size of the in- tracardiac shunt. A VSD is a congenital opening between the ventri- cles; a ventricular septal rupture can occur as a complication of a large anterior wall myocardial infarction.

11. What is the

name of outermost layer of an artery?

a.

Tunica

b.

In tima

c.

Adventitia

d.

Media

ANS: C

The adventitia is the outermost layer of the artery that helps strengthen and shape the vessel. The media is the middle layer that is made up of smooth muscle and elastic tissue. The intima is the inner- most layer consists of a thin lining of endothelium and a small amount of elastic tissue.

12. Which of the

following is most descriptive of the capillary?

a.

Large diameter, low pressure b.

Small diameter, high pressure c.

Large

diameter, high pressure d.

Small

diameter, low pressure ANS: D

The diameter of a capillary is less than that of an arteriole, but the pressure is relatively low as a result of the large cross-sectional area of the branching capillary bed.

13. Depolarization of one myocardial cell will likely result in what physiologic

response? a.

Comp letion of the action poten- tial in that an cell before a new cell can accept impulse

b.

Q uick depolarization and spread to a ll of the heart

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Depolarization of only cells supe- rior to the initial depolarization Quick depolarization of only cells infe rior to the initial depolariza- tion

c. d.

ANS: B

The cardiac muscle is a functional syncytium in which depolarization started in any cardiac cell is quickly spread to all of the heart.

14. What is the

normal resting membrane potential of a myocardial cell?

a.

10 to 20 mV

b.

30 to 40 mV

c.

–20 to –30 mV

d.

–80 to –90 mV

ANS: D

In a myocardial cell, the normal resting membrane potential is –80 to – 90 mV. 15. Which phase is the

final repolarization phase of the action potential?

a.

Phase 1 b.

Phase 2 c.

Phase 3

d.

Phase 4

ANS: C

The final repolarization phase is phase 3 of the action potential. Phases 1 and 2 (partial repolarization) occur as the AP slope returns toward zero. The plateau that follows is described as phase 2. In phase 4 the AP returns to an RMP of –80 to –90 mV. 16. Which statement regarding the autonomic nervous system’s role in the

regulation of heart rate is true?

a.

Parasympathetic influences in- crease heart rate.

b.

Sy mpathetic influences are predominantly present.

c.

Parasympathetic influences are only compensatory.

d.

Both sympathetic and parasym-

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pathetic influences are normally active.

ANS: D

The parasympathetic nervous system and the sympathetic nervous system operate to create a balance between relaxation and fight-or- flight readiness.

They affect cardiovascular function by slowing the heart rate during periods of calm and increasing it in response to sym- pathetic stimulation.

17.A

patient is admitted with a diagnosis of acute myocardial infarction. The monitor pattern reveals bradycardia. Occlusion of which coronary artery most likely resulted in bradycardia from sinoatrial node is- chemia? a. b.

Right Left anterior descending

c.

Circumflex

d.

Dominant

ANS: A

The right coronary artery provides the blood supply to the sinoatrial and atrioventricular (AV) nodes in more than half the population. The left coronary artery is a short but important artery that divides into two large arteries, the left anterior descending and the circumflex arteries. These vessels serve the left atrium and most of the left ventricle. The term dominant coronary artery is used to describe the artery that sup- plies the posterior part of the heart.

18. An echocardiogram reveals an ejection fraction of 55%. On the basis of this

information, how would the patient’s cardiac function be de- scribed? a. b.

Adequate Mildly decreased

c.

Moderately decreased

d.

Severely decreased

ANS: A

Ejection fraction is expressed as a percent, with normal being at least greater than 50%. An ejection fraction of less than 35% indicates poor ventricular function (as in cardiomyopathy), poor ventricular filling, ob- struction to outflow (as in some valve stenosis conditions), or a combi- nation of these.

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19.

Which of the following values reflects a normal cardiac output at rest? a.

2.5 L/min b.

5. 8 L/min c. d.

7.3 L/min 9.6 L/min

ANS: B

Cardiac output is normally expressed in liters per minute (L/min). The normal cardiac output in the human adult is approximately 4 to 8 L/min. It is approximately 4 to 6 L/min at rest and increases with exercise.

20.A patient is admitted with right- and left-sided heart failure. The nurse’s

assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest dis- comfort. On the basis of this information, how would the nurse evalu- ate the patient’s preload status? a. b.

c. d.

The patient is hypovolemic and has too little preload.

The patient is experiencing con- gesti ve heart failure (CHF) and has too little preload.

The patient is experiencing heart failu re and has too much preload.

The patient is hypertensive and the preload is not a factor.

ANS: C

Whereas a patient with hypovolemia has too little preload, a patient with heart failure has too much preload.

21.A patient is admitted with right- and left-sided heart failure. The nurse’s

assessment reveals that the patient has 3+ pitting edema on the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath and chest dis- comfort. Increased afterload is probably present related to the pa- tient’s blood pressure. Which therapeutic measure will most likely de- crease afterload in this patient? a. b.

Administration of vasodilators Placement in high Fowler position

c.

Elevation of extremities

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d.

Increasing intravenous fluids

ANS: A

Therapeutic management to decrease afterload is aimed at decreasing the work of the heart with the use of vasodilators. Placing the patient in high Fowler position will cause an increase in the workload of the heart. Elevation of the extremities will ease the venous return back to the heart.

Increasing IV fluids will cause an increased workload on the heart.

22. What are the two important proteins contained within the cardiac cells that

contribute to contraction?

a.

Z-disk and A-band

b.

Actin and myosin

c.

I-band and M-band

d.

Renin and angiotensin

ANS: B

Actin and myosin form cross-bridges, allowing myocardial contraction to take place. Z-disk, A-band, I-band, and M-band are all portions of the sarcomere functional unit to promote contraction in the heart. Renin converts the protein angiotensinogen to angiotensin I. When an- giotensin I passes through the pulmonary vascular bed, it is activated by angiotensin-converting enzyme to become angiotensin II. 23. What is the

name of the valve that allows blood flow into pulmonary artery?

a. b.

Aortic Tricuspid

c.

Mitral valve

d.

Pulmonic valves

ANS: D

The pulmonic valve allows blood flow into the pulmonary artery, and the aortic valve allows blood flow into the aorta. The tricuspid (right) and mitral valves (left) are located between the atria and the ventri- cles.

24. Place the following components of the cardiac conduction pathway in the correct

anatomic order.

1. Atrioventricular node 2. Bundle branches

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3. Bundle of His 4. Internodal pathways 5. Purkinje fibers 6. Sinoatrial node a.

6, 1, 4, 3, 2, 5

b.

6, 1, 3, 2, 4, 5

c.

6, 1, 4, 2, 3, 5

d.

4, 3, 2, 5, 6, 1

ANS: A

The three main areas of impulse propagation and conduction are (1) the sinoatrial node, (2) the atrioventricular node, and (3) the conduc- tion fibers within the ventricle, specifically the bundle of His, the bun- dle branches, and the Purkinje fibers. Interruption or malfunction of any part of the conduction pathway can result in dysrhythmias specific to that structure.

MULTIPLE RESPONSE 1. Which factors influence

stroke volume? (Select all that apply.)

a.

Afterload

b.

C ardiac output

c.

Contractility

d.

He art rate

e.

Preload

ANS: A, C, E

Stroke volume (SV) as a value is influenced by three primary factors: preload, afterload, and contractility. Cardiac output (CO) is determined by SV × HR = CO. Preload is the volume of blood in the left ventricle at the end of diastole.

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Chapter 13: Cardiovascular Diagnostic Procedures Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. A patient with a serum potassium level of 6.8 mEq/L may exhibit what type of

electrocardiographic changes? a. A prominent U wave b. Tall, peaked T waves c. A narrowed

QRS d. Sudden ventricular dysrhythmias ANS: B

Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually, although not uniquely, associated with early hyperkalemia and are followed by prolongation of the PR interval, loss of the P wave, widening of the QRS complex, heart block, and asystole. Severely elevated serum potassium (greater than 8 mEq/L) causes a wide QRS tachycardia.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 269 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 2. A patient with heart failure may be at risk for hypomagnesemia as a result of which factor? a. Pump failure b. Diuretic use c. Fluid overload d. Hemodilution ANS: B

Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes to low serum magnesium levels.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 270 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 3. Which diagnostic test is most effective for measuring overall heart size? a. 12-lead electrocardiography b. Echocardiography c. Chest radiography d. Vectorcardiography ANS: C

Chest radiography is the oldest noninvasive method for visualizing images of the heart, and it remains a frequently used and valuable diagnostic tool. Information about cardiac anatomy and physiology can be obtained with ease and safety at a relatively low cost. Radiographs of the chest are used to estimate the cardiothoracic ratio and measure overall heart size.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 277|Figure 13-88 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular

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MSC: NCLEX: Physiologic Integrity 4. ST segment monitoring for ischemia has gained increasing importance with the advent of

thrombolytic therapy. What is the most accurate method for monitoring the existence of true ischemic changes? a. Biomarkers b. Echocardiogram c. 5-lead ECG d. 12-lead ECG ANS: D

Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial elevation of cTnI, cTnT, and CK-MB occurs 3 to 6 hours after the acute myocardial damage. This means that if an individual comes to the emergency department as soon as chest pain is experienced, the biomarkers will not have risen. For this reason, it is clinical practice to diagnose an acute myocardial infarction by 12-lead electrocardiography and clinical symptoms without waiting for elevation of cardiac biomarkers.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 244 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 5. Which criteria are representative of the patient in normal sinus rhythm? a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04 second b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second c. Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08 second d. Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04 second ANS: B

The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 250-251 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 6. What is the major factor influencing the patient’s response to atrial flutter? a. Atrial rate b. Ventricular response rate c. PR interval d. QRS duration ANS: B

The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is 300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min and should be well tolerated. If, on the other hand, the atrial rate is 300 beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause angina, acute heart failure, or other signs of cardiac decompensation.

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PTS: 1 DIF: Cognitive Level: Understanding REF: p. 255 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 7. What characteristic is associated with junctional escape rhythms? a. Irregular rhythm b. Rate greater than 100 beats/min c. P wave may be present or absent d. QRS

greater than 0.10 seconds ANS: C

Characteristics of a junctional escape rhythm include a rate of 40 to 60 beats/min, regular rhythm, present or absent P waves, PR less than 0.12 seconds, and QRS between 0.06 and 0.10 seconds.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 259|Table 13-12 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 8. When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal because

it appears in what way? a. In various shapes in the same lead b. With increasing frequency c. Wider than a normal QRS d. On the T wave ANS: A

If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal.

Multifocal ventricular ectopics are more serious than unifocal ventricular ectopics because they indicate a greater area of irritable myocardial tissue and are more likely to deteriorate into ventricular tachycardia or fibrillation.

PTS: 1 DIF: Cognitive Level: Understanding Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

REF: p. 260|Figure 13-67B OBJ:

9. What major clinical finding present in a patient with ventricular fibrillation (VF)? a. Hypertension b. Bradycardia c. Diaphoresis d. Pulselessness ANS: D

In ventricular fibrillation (VF), the patient does not have a pulse, no blood is being pumped forward, and defibrillation is the only definitive therapy. No forward flow of blood or palpable pulse is present in VF. PTS: 1 DIF: Cognitive Level: Applying REF: p. 263 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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10. Which portion of the electrocardiogram (ECG) is most valuable in diagnosing atrioventricular

(AV) conduction disturbances?

P wave PR interval QRS complex QT interval

a. b. c. d.

ANS: B

The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial depolarization. The QRS complex represents ventricular depolarization, corresponding to phase 0 of the ventricular action potential. The QT interval is measured from the beginning of the QRS complex to the end of the T wave and indicates the total time interval from the onset of depolarization to the completion of repolarization.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 267 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 11. Which findings would be reasons to abort an exercise stress test? a. Ventricular axis of +90 degrees b. Increase in blood pressure c. Inverted U wave d. ST segment depression or elevation ANS: D

Signs that can alert the nurse to stop the test include ST segment elevation equal to or greater than 1.0 mm (one small box) or ST depression equal to or greater than 2.0 mm (2 small boxes). Blood pressure is expected to rise during exercise, but a systolic blood pressure greater than 250 mm Hg or a diastolic blood pressure greater than 115 mm Hg is considered high enough to stop the test.

Parameters for ventricular axis in degrees are –30 to +90. Left- axis deviation is present if the axis falls between –30 and –90 degrees.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 280 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 12. What is the rationale for giving the patient additional fluids after a cardiac catheterization? a. Fluids help keep the femoral vein from clotting at the puncture site. b. The patient had a nothing-by-mouth order before the procedure. c. The radiopaque contrast acts as an osmotic diuretic. d. Fluids increase cardiac output.

ANS: C

Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic. Fluid is also used to prevent contrast-induced nephropathy or damage to the kidney from the contrast dye used to visualize the heart structures.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 276 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 13. Pulsus paradoxus may be noted on the bedside monitor when what is observed?

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a. b. c. d.

A decrease of more than 10 mm Hg in the arterial waveform during inhalation A single, nonperfused beat on the electrocardiogram (ECG) waveform Tall, tented T waves on the ECG waveform An increase in pulse pressure greater than 20 mm Hg on exhalation

ANS: A

Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs during inhalation. It is caused by a fall in cardiac output (CO) as a result of increased negative intrathoracic pressure during inhalation.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 205 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 14. When assessing the pulmonary arterial waveform, the nurse notices dampening. After tightening

the stopcocks and flushing the line, the nurse decides to calibrate the transducer. What are two essential components included in calibration? a. Obtaining a baseline blood pressure and closing the transducer to air b. Leveling the air–fluid interface to the phlebostatic axis and opening the transducer to air c. Having the patient lay flat and closing the transducer to air d. Obtaining blood return on line and closing all stopcocks ANS: B

Ensuring accuracy of waveform calibration of the system includes opening the transducer to air and leveling the air–fluid interface of the transducer to the phlebostatic axis.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 199 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 15. What is the formula for calculating mean arterial pressure (MAP)? a. Averaging three of the patient’s blood pressure readings over a 6-hour period b. Dividing the systolic pressure by the diastolic pressure c. Adding the systolic pressure and two diastolic pressures and then dividing by 3 d. Dividing the diastolic pressure by the pulse pressure ANS: C

The mean arterial pressure is one-third systole and two-thirds diastole.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 202 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 16. What is the physiologic effect of left ventricular afterload reduction? a. Decreased left atrial tension b. Decreased systemic vascular resistance c. Increased filling pressures d. Decreased cardiac output ANS: B

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Afterload is defined as the pressure the ventricle generates to overcome the resistance to ejection created by the arteries and arterioles. After a decrease in afterload, wall tension is lowered. The technical name for afterload is systemic vascular resistance (SVR). Resistance to ejection from the right side of the heart is estimated by calculating the pulmonary vascular resistance (PVR). The PVR value is normally one-sixth of the SVR. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 215 OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 17. What parameter is used to assess the contractility of the left side of the heart? a. Pulmonary artery occlusion pressure b. Left atrial pressure c. Systemic vascular resistance d. Left ventricular stroke work index ANS: D

Contractility of the left side of the heart is measured by the left ventricular stroke work index.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 217 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 18. Which intervention should be strictly followed to ensure accurate cardiac output readings? a. Inject 5 mL of iced injectate at the beginning of exhalation over 30 seconds. b. Inject 10 mL of warmed injectate into the pulmonary artery port three times. c. Ensure at least 5° C difference between injectate and the patient temperature. d. Administer the injectate

within 4 seconds during inspiration.

ANS: D

To ensure accurate readings, the difference between injectate temperature and body temperature must be at least 10° C, and the injectate must be delivered within 4 seconds, with minimal handling of the syringe to prevent warming of the solution. This is particularly important when iced injectate is used.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 222 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 19. Why is mixed venous oxygen saturation (SVO2) monitoring helpful in the management of the

critically ill patient?

It facilitates oxygen saturation monitoring at the capillary level.

It can detect an imbalance between oxygen supply and metabolic tissue demand.

It assesses the diffusion of gases at the alveolar capillary membrane.

It estimates myocardial workload during heart failure and acute pulmonary edema.

a. b. c. d.

ANS: B

Continuous venous oxygen monitoring permits a calculation of the balance achieved between arterial oxygen supply ( ) and oxygen demand at the tissue level by sampling desaturated venous blood from the PA catheter distal tip.

PTS: 1

DIF:

Cognitive Level: Understanding

REF: p. 222|Figure 14-22

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OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 20. A patient reports that he has been having “indigestion” for the last few hours. Upon further review the

nurse suspects the patient is having of chest pain. Cardiac biomarkers and a 12-lead electrocardiogram (ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACS) within the first 3 hours? a. Inverted T waves b. Elevated troponin I c. Elevated B-type natriuretic peptide (BNP) d. Indigestion and chest pain ANS: B

The troponins are biomarkers for myocardial damage. The elevation of Troponin I and troponin T occurs 3 to 6 hours after acute myocardial damage. Because troponin I is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage. B-type natriuretic peptide (BNP) are usually drawn when heart failure is suspected, not acute coronary syndrome (ACS). Usually within 4 to 24 hours from the onset of the infarction, abnormal Q waves begin to develop in the affected leads, and T waves begin to invert.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 271 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 21. Which serum lipid value is a significant predictor of future acute myocardial infarction (MI)

in persons with established coronary artery atherosclerosis?

High-density lipoprotein (HDL) b. c.

Low-density lipoprotein (LDL) Triglycerides d. Very-low-density lipoprotein a.

ANS: B

Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary artery disease, and high levels of each are significant predictors of future acute myocardial infarction in persons with established coronary artery atherosclerosis. LDL-C is the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 274 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 22. Which of the electrocardiogram (ECG) findings would be positive for an inferior wall

myocardial infarction (MI)?

ST segment depression in leads I, aVL, and V2 to V4 Q waves in leads V1 to V2 Q waves in leads II, III, and aVF T-wave inversion in leads V4 to V6, I, and aVL

a. b. c. d.

ANS: C

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Abnormal Q waves develop in leads overlying the affected area. An inferior wall infarction is seen with changes in leads II, III, and aVF. Leads I and aVF are selected to detect a sudden change in ventricular axis. If ST segment monitoring is required, the lead is selected according to the area of ischemia. If the ischemic area is not known, leads V3 and III are recommended to detect ST segment ischemia.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 246 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 23. A patient’s bedside electrocardiogram (ECG) strips show the following changes: increased PR

interval; increased QRS width; and tall, peaked T waves. Vital signs are temperature 98.2° F; heart rate 118 beats/min; blood pressure 146/90 mm Hg; and respiratory rate 18 breaths/min. The patient is receiving the following medications: digoxin 0.125 mg PO every day; D51/2 normal saline with 40 mEq potassium chloride at 125 mL/hr; Cardizem at 30 mg PO q8h; and aldosterone at 300 mg PO q12h. The practitioner is notified of the ECG changes. What orders should the nurse expect to receive? a. Change IV fluid to D51/2 normal saline and draw blood chemistry. b. Give normal saline with 40 mEq of potassium chloride over a 6-hour period. c. Hold digoxin and draw serum digoxin level. d. Hold Cardizem and give 500 mL normal saline fluid challenge over a 2-hour period.

ANS: A

The electrocardiographic (ECG) changes are most consistent with hyperkalemia. Removing the potassium from the intravenous line and drawing laboratory values to check the potassium level is the best choice with the least chance of further harm. Digoxin toxicity can be suspected related to the prolonged PR interval, but hyperkalemia explains all the ECG changes. The patient is not hypotensive or bradycardic, so holding the Cardizem is not indicated.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 269 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 24. A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period. A repeat

potassium level is obtained, and the current potassium level is 3.2 mEq/L. In addition to administering additional potassium supplements, what intervention should now be considered? a. Discontinue spironolactone b. Drawing a serum magnesium level c. Rechecking the potassium level d. Monitoring the patient’s urinary output ANS: B

The patient should have serum magnesium level drawn. Hypomagnesemia is commonly associated with other electrolyte imbalances, most notably alterations in potassium, calcium, and phosphorus.

Low serum magnesium levels can result from many causes.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 270-271 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular

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MSC: NCLEX: Physiologic Integrity 25. Which cardiac biomarker is elevated in decompensated heart failure? a. Triglycerides b. Troponin I c. Troponin T d. B-type natriuretic peptide (BNP) ANS: D

In decompensated heart failure, ventricular distension from volume overload or pressure overload causes myocytes in the ventricle to release B-type natriuretic peptide (BNP). With greater ventricular wall stress, more natriuretic peptide is released from the myocardium, reflected as an elevated BNP level. The BNP value is combined with the physical examination, the 12-lead ECG, and a chest radiograph to increase the accuracy of heart failure diagnosis. Troponins are elevated with acute coronary syndrome. Triglycerides are not a biomarker and are reflective of lipids in the bloodstream.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 272 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 26. The physician is going to place a central venous catheter. Which anatomic site is associated with a

lower risk of infection? a. Subclavian vein b.

External jugular vein c.

Internal jugular vein d. Femoral

vein ANS: A

The subclavian site should be used for insertion rather than jugular or femoral insertion sites to minimize infection risk.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 209 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 27. Most chest radiographs of critically ill patients are obtained using a portable chest radiograph machine.

What is the difference between a chest radiograph taken in the radiology department and one taken in the critical care unit? a. Portable chest radiographs are usually clearer. b. Only posterior views can be obtained in the critical care unit. c. The sharpness of the structures is decreased with a portable chest radiograph. d. Chest radiographs taken in radiology enlarge some thoracic structures.

ANS: C

In the supine radiograph with the patient lying flat on the bed, the x-ray tube can be only approximately 36 inches from the patient’s chest because of ceiling height and x-ray equipment construction. This results in a lower quality film from a diagnostic standpoint because the images of the heart and great vessels are magnified and are not as sharply defined.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 277 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular

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MSC: NCLEX: Physiologic Integrity 28. A patient asks why he had to take a deep breath when the radiology technician took his chest

radiograph. Which statement is the best response?

a. “Deep breaths get the chest wall closer to the machine.” b. “When the lungs are filled with air, you get a clearer picture.” c.

“Taking a deep breath decreases the error caused by motion.” d. “Holding

your breath makes the heart appear larger.”

ANS: B

A radiograph is taken when the patient has taken a deep breath (inspiration). During exhalation, the lungs are less full of air, which can make the lung tissue appear “cloudy” as if there is additional lung water. The heart also appears larger during exhalation. This could lead to an erroneous diagnosis of heart failure.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 277 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 29. What is the most common complication of a central venous catheter (CVC)? a. Air embolus b. Infection c. Thrombus formation d. Pneumothorax ANS: B

Infection related to the use of central venous catheters (CVCs) is a major problem. The incidence of infection strongly correlates with the length of time the CVC has been inserted, with longer insertion times leading to a higher infection rate. The risk of air embolus, although uncommon, is always present for a patient with a central venous line in place. Air can enter during insertion through a disconnected or broken catheter by means of an open stopcock, or air can enter along the path of a removed CVC. Unfortunately, clot formation (thrombus) at the CVC site is common. Thrombus formation is not uniform; it may involve development of a fibrin sleeve around the catheter, or the thrombus may be attached directly to the vessel wall.

Pneumothorax has a higher occurrence during placement of a CVC than during removal.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 210 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 30. A physician orders removal of the central venous catheter (CVC) line. The patient has a diagnosis of

heart failure with chronic obstructive pulmonary disease. The nurse would place the patient in what position for this procedure? a. Supine in bed b. Supine in a chair c. Flat in bed d. Reverse Trendelenburg position ANS: A

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Recommended techniques to avoid air embolus during central venous catheter (CVC) removal include removing the catheter when the patient is supine in bed (not in a chair) and placing the patient flat or in the reverse Trendelenburg position if the patient’s clinical condition permits this maneuver.

Patients with heart failure, pulmonary disease, and neurologic conditions with raised intracranial pressure should not be placed flat.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 211 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 31. Mechanical contraction of the heart occurs during which phase of the cardiac cycle? a.

Phase 0 b.

Phase 2 c. Phase 3 d. Phase 4 ANS: B

During phases 1 and 2, an electrical plateau is created, and during this plateau, mechanical contraction occurs. Because there is no significant electrical change, no waveform appears on the electrocardiogram (ECG). During phase 0 (depolarization), the electrical potential changes rapidly from a baseline of –90 mV to +20 mV and stabilizes at about 0 mV. Because this is a significant electrical change, it appears as a wave on the ECG as the QRS. During phase 3 (repolarization), the electrical potential again changes, this time a little more slowly, from 0 mV back to –90 mV. This is another major electrical event and is reflected on the ECG as a T wave. During phase 4 (resting period), the chemical balance is restored by the sodium pump, but because positively charged ions are exchanged on a one-for-one basis, no electrical activity is generated, and no visible change occurs on the ECG tracing.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 235 OBJ: Nursing Process Step: N/A TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 32. What does the P wave component of the electrocardiographic waveform represent? a. Atrial contraction b. Atrial depolarization c. Sinus node discharge d. Ventricular contraction ANS: B

The P wave is an electrical event and represents atrial depolarization. Atrial contraction should accompany the P wave but does not always. The sinus node discharge is too faint to be recorded on the surface electrocardiogram. Ventricular contraction usually accompanies the QRS complex.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 239 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 33. Why is the measurement of the QT interval important? a. It facilitates rhythm identification and is best assessed in Lead II. b. It helps differentiate myocardial ischemia from infarction.

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c. An increasing QT interval increases the risk of torsades de pointes. d. A decreasing QT interval increases the risk of torsades de pointes.

ANS: C

A prolonged QT interval is significant because it can predispose the patient to the development of polymorphic ventricular tachycardia, known also as torsades de pointes. A long QT interval can be congenital, as a result of genetic inheritance, or it can be acquired from an electrolyte imbalance or medications.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 240 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 34. Which lead is best to monitor a patient? a. Varies based on the patient’s clinical condition and recent clinical history b. Lead aVF c. Lead V1 d. Lead II ANS: A

The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The monitoring lead should be chosen with consideration of the patient’s clinical condition and recent clinical history. Lead II is recommended for monitoring of atrial dysrhythmias. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a sudden change in ventricular axis.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 242 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 35. When performing a 12-lead electrocardiogram (ECG), how many wires are connected to the

patient?

3 5 10 12

a. b. c. d.

ANS: C

The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart using 10 different electrode positions to create 12 unique views of electrical activity occurring within the heart.

Fours wires are applied to the extremities to produce leads I, II, III, aVR, aVL, and aVF. Six wires are attached to the V1 to V6 chest lead positions.

PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 236-237 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 36. A patient returns from the cardiac catheterization laboratory after angioplasty and stent placement

(ECG changes had indicated an inferior wall myocardial infarction in progress). Which lead would best monitor this patient? a. Varies based on the patient’s clinical condition and recent clinical history b. Lead V3

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c. Lead V1 d. Lead II ANS: D

A The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The monitoring lead should be chosen with consideration of the patient’s clinical condition and recent clinical history. Lead II is recommended for monitoring of atrial dysrhythmias and would be appropriate in this case as due to inferior wall injuries. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a sudden change in ventricular axis.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 243 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 37. The patient’s admitting 12-lead ECG shows tall, peaked P waves. What diagnosis could be

responsible for this finding?

Mitral stenosis Pulmonary edema Ischemia Pericarditis

a. b. c. d.

ANS: B

Tall, peaked P waves occur in right atrial hypertrophy and are referred to as P pulmonale because this condition is often the result of chronic pulmonary disease. Ischemia occurs when the delivery of oxygen to the tissues is insufficient to meet metabolic demand. Cardiac ischemia in an unstable form occurs because of a sudden decrease in supply, such as when the artery is blocked by a thrombus or when coronary artery spasm occurs. If the pulmonary edema is caused by heart failure, sometimes described as hydrostatic pulmonary edema, the fluid may be in a “bat-wing” distribution, with the white areas concentrated in the hilar region (origin of the major pulmonary vessels). However, as the heart failure progresses, the quantity of fluid in the alveolar spaces increases, and the white, fluffy appearance is seen throughout the lung. Pericarditis is inflammation of the sac around the heart.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 245 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 38. A nurse is obtaining the history of a patient who reveals that he had an myocardial infarction (MI) 5

years ago. When the admission 12-lead electrocardiogram (ECG) is reviewed, Q waves are noted in leads V3 and V4 only. Which conclusion is most consistent with this situation? a. The patient may have had a posterior wall MI. b. The patient must have had a right ventricular MI. c. The admission 12-lead ECG was done incorrectly. d. The patient may have had an anterior MI. ANS: D

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Not every acute myocardial infarction (MI) results in a pathologic Q wave on the 12-lead electrocardiogram (ECG). When the typical ECG changes are not present, the diagnosis depends on symptomatic clinical presentation, specific cardiac biomarkers (eg, cTnI, cTnT, CK-MB), and non-ECG diagnostic tests such as cardiac catheterization. Anterior and posterior wall MIs have ST changes, not Q wave changes.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 246|Table 13-8 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 39. A new-onset myocardial infarction (MI) can be recognized by what electrocardiogram (ECG)

change?

Q waves Smaller R waves Widened QRS ST segment elevation

a. b. c. d.

ANS: D

Any change from baseline is expressed in millimeters and may indicate myocardial ischemia (one small box equals 1 mm). ST segment elevation of 1 to 2 mm is associated with acute myocardial injury, preinfarction, and pericarditis. ST segment depression (decrease from baseline more of 1 to 2 mm) is associated with myocardial ischemia. Widened QRS complexes are indicative of ventricular depolarization abnormalities such as bundle branch blocks and ventricular dysrhythmias. Q waves and smaller R waves are indications usually present 24 hours to 1 week after the myocardial infarction is completely evolved; they represent necrosis.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 246 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 40. To accurately measure the heart rate of a patient in normal sinus rhythm, which technique would

be the most accurate?

The number of R waves in a 6-second strip The number of large boxes in a 6-second strip The number of small boxes between QRS complexes divided into 1500 The number of large boxes between consecutive R waves divided into 300

a. b. c. d.

ANS: C

Calculation of heart rate if the rhythm is regular may be done using the following methods. Method 1: number of RR intervals in 6 seconds multiplied by 10 (eg, 8 ´ 10 = 80/min). Method 2: number of large boxes between QRS complexes divided into 300 (eg, 300 ¸ 4 = 75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (eg, 1500 ¸ 18 = 84/min).

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 249 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 41. What is the initial intervention in a patient with sinus tachycardia with the following vital signs:

heart rate, 136 beats/min; blood pressure, 102/60 mm Hg; respiratory rate, 24 breaths/min; temperature, 99.2° F; SpO2, 94% on oxygen 2 L/min by nasal cannula?

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a. b. c. d.

Administer adenosine IV push.

Identify the cause.

Administer nitroglycerine 0.4 mg sublingual.

Administer lidocaine 75 mg IV push.

ANS: B

Sinus tachycardia can be caused by a wide variety of factors, such as exercise, emotion, pain, fever, hemorrhage, shock, heart failure, and thyrotoxicosis. Many medications used in critical care can also cause sinus tachycardia; common culprits are aminophylline, dopamine, hydralazine, atropine, and catecholamines such as epinephrine. This patient has a stable heart rate and SpO2; therefore, there is time to identify the cause of the sinus tachycardia. Lidocaine is indicated for ventricular dysrhythmias. Nitroglycerine is not indicated because the patient is not having chest pain at this time.

Adenosine is usually not indicated unless the heart rate is greater than 150 beats/min.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 251 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 42. A patient presents with atrial flutter with an atrial rate of 280 beats/min and a ventricular rate of 70

beats/min. Which statement best explains this discrepancy in rates? a. The ventricles are too tired to respond to all the atrial signals. b. The atrioventricular (AV) node does not conduct all the atrial signals to the

ventricles. c. Some of the atrial beats are blocked before reaching the AV node. d. The ventricles are responding to a ventricular ectopic pacemaker.

ANS: B

The atrioventricular (AV) node does not allow conduction of all these impulses to the ventricles.

In this case, the rhythm would be described as atrial flutter with a 4:1 AV block, indicating that only one of every four atrial signals is conducted to the ventricles.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 254 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 43. Why is a new-onset of atrial fibrillation serious? a. It increases the patient’s risk for a stroke. b. It increases the patient’s risk for a deep venous thrombosis. c. It may increase cardiac output to dangerous levels. d. It indicates the patient is about to have a myocardial infarction.

ANS: A

In atrial fibrillation the atria do not contract normally; they quiver. This increases the chance of the blood clotting in the atria because of a lack of complete emptying of the atria. These clots can break free and cause embolic strokes and pulmonary emboli. Atrial fibrillation does not indicate impending myocardial infarction or an increased risk of deep venous thrombosis. Atrial fibrillation decreases cardiac output from the loss of atrial kick.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 257 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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44. Which electrocardiographic (ECG) abnormality is most often found in ventricular

dysrhythmias?

Retrograde P waves Wide QRS complexes No P waves An inverted T wave

a. b. c. d.

ANS: B

Ventricular dysrhythmias result from an ectopic focus in any portion of the ventricular myocardium.

The usual conduction pathway through the ventricles is not used, and the wave of depolarization must spread from cell to cell. As a result, the QRS complex is prolonged and is always greater than 0.12 second. It is the width of the QRS, not the height that is important in the diagnosis of ventricular ectopy.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 252 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 45. The patient has a heart rate (HR) of 84 beats/min and a stroke volume (SV) of 65 mL.

Calculate the cardiac output (CO).

149 mL 500 mL 4650 mL 5460 mL

a. b. c. d.

ANS: D

Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is the volume of blood ejected by the heart during each beat (reported in milliliters). 84 ´ 65 = 5460 mL. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 213 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 46. After a myocardial infarction, a patient presents with an increasing frequency of premature

ventricular contractions (PVCs). The patient's heart rate is 110 beats/min, and electrocardiogram (ECG) indicates a sinus rhythm with up to five unifocal PVCs per minute. The patient is alert and responsive and denies any chest pain or dyspnea. What action should the nurse take next? a. Administer lidocaine 100 mg bolus IV push stat. b. Administer Cardizem 20 mg IV push stat. c. Notify the physician and monitor the patient closely. d. Nothing; PVCs are expected in this patient.

ANS: C

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Although premature ventricular contractions (PVCs) are frequently present after myocardial infarction, they are not always benign. In individuals with underlying heart disease, PVCs or episodes of self-terminating ventricular tachycardia (VT) are potentially malignant. Nonsustained VT is defined as three or more consecutive premature ventricular beats at a rate faster than 110 beats/min lasting less than 30 seconds. The patient does not appear symptomatic from the PVCs at this time; therefore, lidocaine is not indicated. Cardizem is not prescribed for ventricular ectopy.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 243|pp. 259-260 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 47. A patient becomes unresponsive. The patient’s heart rate is 32 beats/min in an idioventricular rhythm;

blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which intervention would the nurse do first? a. Notify the physician and hang normal saline wide open. b. Notify the physician and obtain the defibrillator. c. Notify the physician and obtain a temporary pacemaker. d. Notify the physician and obtain a 12-lead ECG. ANS: C

If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their own intrinsic rate of 20 to 40 times per minute. This is called an idioventricular rhythm and is naturally protective mechanism. Rather than trying to abolish the ventricular beats, the aim of treatment is to increase the effective heart rate (HR) and reestablish dominance of a higher pacing site such as the sinus node or the AV junction. Usually, a temporary pacemaker is used to increase the HR until the underlying problems that caused failure of the other pacing sites can be resolved.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 262 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 48. What effect does ventricular tachycardia have on cardiac output? a. Increases cardiac output due to an increase in ventricular filling time b. Decreases cardiac output due to a decrease in stroke volume c. Increases cardiac output due to an increase in preload d. Decreases cardiac output due to a decrease in afterload ANS: B

Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time for ventricular filling, decreases stroke volume, and compromises cardiac output. Tachycardia increases heart work and myocardial oxygen demand while decreasing oxygen supply by decreasing coronary artery filling time.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 263 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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49. The patient is admitted with a diagnosis of cardiogenic shock. The patient’s heart rate (HR) is

135 beats/min with weak peripheral pulses. The patient has bilaterally crackles in the bases of the lungs. O2 saturation is 90% on 4L/NC. The practitioner orders diuretics and vasodilators. What response should the nurse expect after starting the medications? a. Decreased preload and afterload b. Increased preload and afterload c. Decreased preload and increased afterload d. Increased preload and decreased afterload ANS: A

Vasodilators are used to decrease afterload, and diuretics are used to decrease preload.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 215|p. 217 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 50. Which diagnostic tool can be used to detect structural heart abnormalities? a. Echocardiogram b. Electrocardiogram (ECG) c. Exercise stress test d. 24-hour Holter monitor ANS: A

Echocardiography is used to detect structural heart abnormalities such as mitral valve stenosis and regurgitation, prolapse of mitral valve leaflets, aortic stenosis and insufficiency, hypertrophic cardiomyopathy, atrial septal defect, thoracic aortic dissection, cardiac tamponade, and pericardial effusion.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 281 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 51. What is the target range for an international normalized ratio (INR)? a. 1.0 to 2.0 b. 1.5 to 3.0 c. 1.5 to 2.5 d.

2.0 to 3.0 ANS: D

A target international normalized ratio of 2.5 (range, 2.0 to 3.0) is desirable.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 258 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 52. What type of atrioventricular (AV) block can be described as a gradually lengthening PR

interval until ultimately the final P wave in the group fails to conduct? a. First-degree AV block b. Second-degree AV block, type I c.

Second-degree AV block, type II d. Third-

degree AV block

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ANS: B

In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen until a P wave is not conducted. This typically occurs in a pattern of grouped beats and is observed on the electrocardiogram (ECG) by a gradually lengthening PR interval until ultimately the final P wave in the group fails to conduct. When all atrial impulses are conducted to the ventricles but the PR interval is greater than 0.20 second, a condition known as first-degree AV block exists. Mobitz type II block is always anatomically located below the AV node in the bundle of His in the bundle branches or even in the Purkinje fibers. This results in an all-or-nothing situation with respect to AV conduction. Sinus P waves are or are not conducted. When conduction does occur, all PR intervals are the same.

Because of the anatomic location of the block, on the surface, ECG the PR interval is constant and the QRS complexes are wide. Third-degree, or complete, AV block is a condition in which no atrial impulses can conduct from the atria to the ventricles. This is also described by the term complete heart block.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 267 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 53. Which blood test standardizes prothrombin time (PT) results among worldwide clinical

laboratories? a. aPTT b. ACT c. HDL d. INR ANS: D

The international normalized ratio (INR) was developed by the World Health Organization in 1982 to standardize prothrombin time results among clinical laboratories worldwide. High- density lipoproteins (HDLs) are particles of the total serum cholesterol. Activated coagulation time (ACT) is also known as the activated clotting time. The ACT is a point of care test that is performed outside of the laboratory setting in areas such as the cardiac catheterization laboratory, the operating room, or critical care units. The activated partial thromboplastin time (aPTT) is used to measure the effectiveness of intravenous or subcutaneous ultrafractionated heparin therapy.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 274 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 54. On returning from the cardiac catheterization laboratory, the patient asks if he can get up in the

chair. What should the nurse tell the patient?

“You cannot get up because you may pass out.”

“You cannot get up because you may start bleeding.”

“You cannot get up because you may fall.”

“You cannot get up until you urinate.”

a. b. c. d.

ANS: B

After catheterization, the patient remains flat for up to 6 hours (varies by institutional protocol and catheter size) to allow the femoral arterial puncture site to form a stable clot. Most bleeding occurs within the first 2 to 3 hours after the procedure.

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PTS: 1 DIF: Cognitive Level: Applying REF: p. 275 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 55. Which statement made by a patient would indicate the need for further education before an

electrophysiology procedure?

“I need to take all my heart medications the morning of the procedure.”

“The doctor is going to make my heart beat wrong on purpose.”

“I will be awake but relaxed during the procedure.”

“I will be x-rayed during the procedure.”

a. b. c. d.

ANS: A

All antidysrhythmic medications are discontinued several days before the study so that any ventricular dysrhythmias may be readily induced during the electrophysiology procedure (EPS).

Anticoagulants, especially warfarin, are also stopped before EPS. Premedication is administered before the study to induce a relaxed state, and during the procedure, the patient is conscious but receives sedative agents (midazolam) at regular intervals.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 276 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 56. A positive signal-averaged electrocardiogram (ECG) indicates that a patient is at risk for what

problem?

Myocardial infarction Sudden cardiac death Coronary artery disease Stroke

a. b. c. d.

ANS: B

A positive signal-averaged electrocardiogram (ECG)—in combination with other specific indicators— is a predictor of increased risk for sudden cardiac death. Many patients with a positive signalaveraged ECG (abnormal) display a normal signal-averaged ECG when placed on antidysrhythmic medications. The signal-averaged ECG is not analyzed in isolation. It is used in conjunction with other cardiac diagnostic tests, including the electrophysiology study (EPS). It is a helpful adjunct to the EPS but does not replace it.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 281 OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 57. Zeroing the pressure transducer on hemodynamic monitoring equipment occurs when the

displays reads which number?

0 250 600 760

a. b. c. d.

ANS: A

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The monitor is adjusted so that “0” is displayed, which equals atmospheric pressure. Atmospheric pressure is not zero; it is 760 mm Hg at sea level. Using zero to represent current atmospheric pressure provides a convenient baseline for hemodynamic measurement purposes.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 199 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 58. Which statement expresses the correct order when working with an invasive pressure

monitor? a. Level the transducer, locate the phlebostatic axis, zero the transducer, and take the reading. b. Locate the phlebostatic axis, level the transducer, zero the transducer, and take the reading. c. Take the reading, level the transducer, locate the phlebostatic axis, and zero the transducer. d. Locate the phlebostatic axis, zero the transducer, level the transducer, and take the reading.

ANS: B

The correct order is locate the phlebostatic axis, level the transducer, zero the transducer, and take the reading. The transducer cannot be zeroed before it is leveled. Readings cannot be taken before the transducer is zeroed, and leveling the transducer cannot occur until the phlebostatic axis has been identified.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 199 OBJ: Nursing Process Step: Planning TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 59. A patient’s central venous pressure (CVP) reading suddenly increased from 10 to 48 mm Hg.

His lungs are clear except for fine rales at the bases. What should the nurse do next?

Nothing as this reading is still within normal limits.

Place a STAT call into the physician.

Administer ordered prn Lasix.

Check the level of the transducer.

a. b. c. d.

ANS: D

If the transducer falls below the correct level, the reading would be falsely elevated. This rise is consistent with a transducer having fallen from the correct level on the bed to the floor. Lasix is not indicated. Central venous pressure (CVP) of 45 mm Hg, if true, is severely elevated. Not enough information has been provided to call the physician. If the CVP value is true and the patient’s condition is poor, a call to the physician would be appropriate after assessment.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 200 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 60. Why is the Allen test performed before placement of a radial arterial line placement? a. To evaluate collateral circulation to the hand

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b. To estimate patency of the radial artery c. To appraise the neurologic function of the hand d. To assess the sensitivity of the insertion point ANS: A

The Allen test involves occluding the radial or ulnar artery after blanching the hand. If the hand turns pink, then the nonoccluded artery provides enough circulation to the hand. If the hand remains blanched, then no collateral circulation exists, and that wrist should not be used for arterial line placement.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 202 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 61. Which statement regarding the use of cuff blood pressures is true? a. Cuff pressures may be unreliable when a patient is in shock. b. Cuff pressures are more accurate than arterial line pressures. c. Cuff pressures and arterial line pressures should be nearly identical. d. Cuff pressures should not be compared to arterial line pressures.

ANS: A

If the arterial line becomes unreliable or dislodged, a cuff pressure can be used as a reserve system. In the normotensive, normovolemic patient, little difference exists between the arm cuff blood pressure and the intravascular catheter pressure, and differences of 5 to 10 mm Hg do not generally alter clinical management. The situation is different if the patient has a low cardiac output (CO) or is in shock. The concern is that the cuff pressure may be unreliable because of peripheral vasoconstriction, and an arterial line is generally required. It is usual practice to compare a cuff pressure after the arterial line is inserted.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 202 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 62. A patient’s arterial line waveform has become damped. What action should the nurse take to correct

the situation?

Check for kinks, blood, and air bubbles in the pressure tubing.

Prepare for a normal saline fluid challenge for hypotension.

Discontinue the arterial line as it has become nonfunctional.

Check the patient’s lung sounds for a change in patient condition.

a. b. c. d.

ANS: A

A damped waveform occurs when communication from the artery to the transducer is interrupted and produces false values on the monitor and oscilloscope. Damping is caused by a fibrin “sleeve” that partially occludes the tip of the catheter, by kinks in the catheter or tubing, or by air bubbles in the system.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 206|Table 13-2 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 63. Patient education for a patient with a Holter monitor should include which instruction? a. Keep a diary of activities, symptoms, and any medications that are taken.

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b. Do not drink coffee while the recorder is on. c. Do not take a bath but a shower is alright. d. Carry the monitor in a purse or backpack.

ANS: A

The patient should be instructed to keep a diary of activities, symptoms, and any medications that are taken and to carry the monitor by a shoulder strap or clipped to a belt or pocket. The only activities that are restricted while wearing a Holter monitor are those that would get the chest electrodes or monitor wet, eliminating swimming and taking a shower or tub bath. The patient can drink coffee during the test.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 279 OBJ: Nursing Process Step: Planning TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 64. A 55-year-old patient is scheduled for a stress test. What is the estimation of the patient’s

maximal predicted heart rate? a. 65 beats/min b. 155 beats/min c. 165 beats/min d. 265

beats/min ANS: C

The maximal predicted heart rate is estimated using the formula: 220 – Patient’s age: 220 – 55 = 165.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 280 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 65. Which of the following is most indicative of decreased left ventricular preload? a. Increased pulmonary artery occlusion pressure (PAOP) b.

Decreased pulmonary artery occlusion pressure (PAOP) c.

Increased central venous pressure (CVP) d. Decreased central venous pressure (CVP) ANS: B

Pulmonary artery occlusion pressure (PAOP) normally reflect the pressure in the left ventricle at the end of diastole. Left ventricular end-diastolic pressure is preload, and so an increase in preload will first increase the PAOP measurements and vice versa. Central venous pressure changes are reflective of right ventricular preload.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 213|Table 13-1 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 66. What is the effect of preload on cardiac output? a. As preload increases, cardiac output increases. b. As preload increases, cardiac output decreases. c. As preload increases, cardiac output increases until it overstretches the ventricle and

cardiac output decreases. d. Increased preload has no effect on cardiac output.

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ANS: C

According to the Frank-Starling law of the heart, if preload increases stroke volume, then cardiac output may increase. If, however, preload causes excessive left ventricular stretch, it can actually decrease cardiac output and may result in congestive heart failure.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 214 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 67. Which condition can cause an artificial increase in the pulmonary artery occlusion pressure

(PAOP)?

Aortic regurgitation Aortic stenosis Mitral stenosis Mitral regurgitation

a. b. c. d.

ANS: D

If mitral regurgitation is present, the mean pulmonary artery occlusion pressure reading is artificially elevated because of abnormal backflow of blood from the left ventricle to the left atrium during systole.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 215 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 68. The patient’s admitting 12-lead ECG shows wide, M-shaped P waves. What diagnosis could be

responsible for this finding?

Mitral stenosis Chronic pulmonary disease Hypotension Pericarditis

a. b. c. d.

ANS: A

Wide, M-shaped P waves are seen in left atrial hypertrophy and are called P mitrale because left atrial hypertrophy is often caused by mitral stenosis.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 245 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 69. Identify the rhythm.

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a. b. c. d.

Junctional escape rhythm Atrial fibrillation Unifocal premature ventricular contractions Ventricular tachycardia

ANS: B

The electrocardiographic tracing in atrial fibrillation is notable for an uneven atrial baseline that lacks clearly defined P waves and instead shows rapid oscillations or fibrillatory wavelets that vary in size, shape, and frequency. Junctional escape rhythm has a rate of 40 to 60 beats/min and regular rhythm but P waves maybe present or absent, inverted in lead II, PR interval less than 0.12 second, and QRS complex is 0.06 to 0.10 seconds. With premature ventricular contractions, the QRS can manifest in an unlimited number of shapes or patterns. If all of the ventricular ectopic beats look the same in a particular lead, they are called unifocal, which means that they probably all result from the same irritable focus. Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or more per minute, usually maintained by a re-entry mechanism within the ventricular tissue.

The complexes are wide, and the rhythm may be slightly irregular, often accelerating as the tachycardia continues.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 256 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 70. Identify the rhythm.

a. b. c. d.

Junctional escape rhythm Atrial fibrillation Unifocal premature ventricular contractions Ventricular tachycardia

ANS: A

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Under normal conditions, the junction never has a chance to escape and depolarize the heart because it is overridden by the sinus node. However, if the sinus node fails, the junctional impulses can depolarize completely and pace the heart. In this strip, the ventricular rate is 38. P waves are absent, and the QRS has a normal width.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 260 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 71. Identify the rhythm.

a. b. c. d.

Junctional escape rhythm Atrial fibrillation Unifocal premature ventricular contractions Ventricular tachycardia

ANS: C

When all of the ventricular ectopic beats look the same in a particular lead, they are called unifocal, which is what is shown in this strip. This means that they probably all result from the same irritable focus.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 260 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 72. Identify the rhythm.

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a. b. c. d.

Junctional escape rhythm Atrial fibrillation Unifocal premature ventricular contractions Ventricular tachycardia

ANS: D

Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or more per minute, usually maintained by a re-entry mechanism within the ventricular tissue. The complexes are wide, and the rhythm may be slightly irregular, often accelerating as the tachycardia continues. In most cases, the sinus node is not affected, and it continues to depolarize the atria on schedule. P waves can sometimes be seen on the electrocardiographic tracing. They are not related to the QRS and may even appear to conduct a normal impulse to the ventricles if their timing is just right.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 263 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 73. Identify the rhythm.

a. b. c. d.

Ventricular tachycardia Ventricular fibrillation Supraventricular tachycardia Torsades de pointes

ANS: B

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On an electrocardiogram, ventricular fibrillation appears as a continuous, undulating pattern without clear P, QRS, or T waves.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 264 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 74. Which noninvasive imaging technique is useful in diagnosing complications of a myocardial

infarction (MI)?

12-lead ECG CT MRI Echocardiography

a. b. c. d.

ANS: C

Magnetic resonance imaging is useful in diagnosing complications of myocardial infarction, such as pericarditis or pericardial effusion, valvular dysfunction, ventricular septal rupture, aneurysm, and intracardiac thrombus. Computed tomography is used to calculate the coronary artery calcium score.

Echocardiography uses ultrasound reflected best at interfaces between tissues that have different densities. In the heart, these are the blood, cardiac valves, myocardium, and pericardium. Because all these structures differ in density, their borders can be seen on the echocardiogram. The standard 12lead electrocardiogram provides a picture of electrical activity in the heart using 10 different electrode positions to create 12 unique views of electrical activity occurring within the heart.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 284 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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Chapter 14: Cardiovascular Disorders Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. a. b. c. d.

Which statement about coronary artery disease (CAD) is accurate?

There is a low correlation between modifiable risk factors and CAD. The onset of CAD occurs in middle age women sooner than men of the same age.

There is an association between development of specific risk factors and CAD. The lower the C-reactive protein level the higher the risk for a coronary event.

ANS: C

Research and epidemiologic data collected during the past 50 years have demonstrated a strong association between specific risk factors and the development of coronary artery disease (CAD).

In general, CAD symptoms are seen in persons age 45 years and older. Primary cardiovascular risk factors are different in men and women, with women having higher rates of diabetes and hypertension compared with men. C-reactive protein (CRP) is associated with an increased risk for development of other cardiovascular risk factors including diabetes, hypertension, and weight gain. The higher the value, the greater the risk of a coronary event, especially if all other potential causes of systemic inflammation such as infection can be ruled out.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 290 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 2. Which value, when elevated, places the patient at lowest risk for coronary artery disease

(CAD)?

Very-low-density lipoproteins (VLDLs) Triglycerides Low-density lipoproteins (LDLs) High-density lipoproteins (HDLs)

a. b. c. d.

ANS: D

All of the reasons are not completely understood, but one recognized physiologic effect is the ability of high-density lipoprotein (HDL) to promote the efflux of cholesterol from cells. This process may minimize the accumulation of foam cells in the artery wall and thus decrease the risk of developing atherosclerosis. High HDL levels confer both antiinflammatory and antioxidant benefits on the arterial wall. In contrast, a low HDL level is an independent risk factor for the development of CAD and other atherosclerotic conditions.

PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 290-291|Table 14-1 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 3. The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108,

respiratory rate 24, temperature 103° F, and oxygen saturation of 94% on oxygen 2L nasal cannula.

The patient is responsive and denies chest pain. The physician has ordered a work-up for coronary artery disease (CAD). These findings are suggestive of which diagnosis?

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a. b. c. d.

Silent ischemia Prehypertension Stage 1 hypertension Stage 2 hypertension

ANS: D

Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and a diastolic blood pressure of 100 mm Hg or above.

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 348|Table 14-2 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 4. Which statement regarding the difference between stable and unstable angina is accurate? a. Stable angina responds predictably well to nitrates. b. Stable angina is not precipitated by activity. c. Stable angina has a low correlation to coronary artery disease (CAD). d. Stable angina is a result of coronary artery spasm.

ANS: A

Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control is usually achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary artery lumen and thus has a high correlation to coronary artery disease (CAD), not coronary spasm.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 298 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 5. The nursing management plan for a patient with angina would include which intervention? a. Immediate administration of antiplatelet therapy b. Teaching the patient how to perform the Valsalva maneuver c. Assessment and documentation of chest pain episodes d. Administration of prophylactic lidocaine for ventricular ectopy ANS: C

Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications, maintenance of a calm environment, and patient and family education. It is important to document the characteristics of the pain and the patient’s heart rate and rhythm, blood pressure, respirations, temperature, skin color, peripheral pulses, urine output, mentation, and overall tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 298 OBJ: Nursing Process Step: Planning TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 6. Why do women have higher mortality rates from acute myocardial infarction (MI) than men? a. Women wait longer to seek medical care. b. Women have more risk factors for coronary artery disease than men. c. Women have a higher risk of coronary spasm than men.

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d. Women have smaller hearts than men.

ANS: A

Many reasons contribute to higher mortality rates from acute myocardial infarction (MI) in women, and these include waiting longer to seek medical care, having smaller coronary arteries, being older when symptoms occur, and experiencing very different symptoms from those of men of the same age.

Women do not have a higher risk of coronary spasm than men.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 293 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 7. What dysrhythmia is most frequently associated with sudden cardiac death? a. Premature ventricular contractions b. Ventricular tachycardia c. Third degree heart block d. Asystole ANS: B

When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into ventricular fibrillation.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 306|p. 315 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 8. Assessment of a patient with pericarditis may reveal which signs and symptoms? a. Ventricular gallop and substernal chest pain b. Narrowed pulse pressure and shortness of breath c. Pericardial friction rub and pain d. Pericardial tamponade and widened pulse pressure ANS: C

Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common initial sign. A friction rub is best auscultated with a stethoscope at the sternal border and is described as a grating, scraping, or leathery scratching. Pericarditis frequently produces a pericardial effusion.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 311 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 9. What are the clinical manifestations of right-sided heart failure? a. Elevated central venous pressure and sacral edema b. Pulmonary congestion and jugular venous distention c. Hypertension and chest pain d. Liver tenderness and pulmonary edema ANS: A

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The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 320 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 10. Which intervention is an essential aspect of the patient teaching plan for the patient with

chronic heart failure? a. Instructing the patient to call the practitioner prior to dental surgery b. Stressing the importance of compliance with diuretic therapy c. Instructing the patient to take nitroglycerin if chest pain occurs d. Teaching the patient how to take an apical pulse ANS: B

Primary topics of education include (1) the importance of a daily weight, (2) fluid restrictions, and (3) written information about the multiple medications used to control the symptoms of heart failure.

Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure.

PTS: 1 DIF: Cognitive Level: Creating REF: p. 326 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Health Promotion and Maintenance 11. In the acute phase after ST segment elevation myocardial infarction (STEMI), fibrinolytic therapy is

used in combination with heparin to recanalize the coronary artery. What dosage is the initial heparin bolus? a. 60 units/kg maximum 5000 units b. 30 units/kg maximum 3000 units c. 25 units/kg maximum of 2500 units d. 12 units/kg maximum of 1000 units ANS: A

In the acute phase after ST segment elevation myocardial infarction, heparin is administered in combination with fibrinolytic therapy to recanalize (open) the coronary artery. For patients who will receive fibrinolytic therapy, an initial heparin bolus of 60 units/kg (maximum, 5000 units) is given intravenously followed by a continuous heparin drip at 12 units/kg/hr (maximum 1000 units/hr) to maintain an activated partial thromboplastin time between 50 and 70 seconds (1.5 to 2.0 times control).

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 313 OBJ: Nursing Process Step: N/A TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 12. The nurse is caring for a patient with left-sided heart failure. The nurse suspects the patient is

developing pulmonary edema. Which finding would confirm the nurse’s suspicions? a. Pulmonary crackles b. Peripheral edema c. Pink, frothy sputum

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d. Elevated central venous pressure ANS: C

Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and have a sensation of suffocation. They expectorate pink, frothy sputum and feel as if they are drowning. They may sit bolt upright, gasp for breath, or thrash about. The respiratory rate is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck muscles. Respirations are characterized by loud inspiratory and expiratory gurgling sounds.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 324 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 13. A patient is admitted with hypertrophic cardiomyopathy. The nurse would expect the medical

management of this patient to include which intervention? a. Administration of beta-blockers b. Administration of positive inotropes c. Plans for intensive exercise regimen d. Plans for an

aortic valve replacement ANS: A

Pharmacologic management includes beta-blockers to decrease left ventricular workload, medications to control and prevent atrial and ventricular dysrhythmias, anticoagulation if atrial fibrillation or left ventricular thrombi are present, and, finally, drugs to manage heart failure.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 327 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 14. The nurse is developing a patient education plan for a patient with valvular heart disease.

Which instruction would be included as part of that plan? a. Increase fluid intake to increase cardiac output. b. Take sodium replacement tablets to replace sodium lost with diuretics. c. Increase daily activity until shortness of breath occurs. d. Take prophylactic antibiotics before undergoing any invasive procedure.

ANS: D

Education for the patient with acute or chronic heart failure secondary to valvular dysfunction includes (1) information related to diet, (2) fluid restrictions, (3) the actions and side effects of heart failure medications, (4) the need for prophylactic antibiotics before undergoing any invasive procedures such as dental work, and (5) when to call the health care provider to report a negative change in cardiac symptoms.

PTS: 1 DIF: Cognitive Level: Creating REF: p. 342 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Health Promotion and Maintenance 15. A patient has been admitted in hypertensive crisis. Which medication would the nurse expect the

practitioner to order for this patient? a. Digitalis b. Vasopressin

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c. Verapamil d. Sodium nitroprusside ANS: D

Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 352-353 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 16. Which description best describes the pain associated with aortic dissection? a. Substernal pressure b. Tearing in the chest, abdomen, or back c.

Numbness and tingling in the left arm d.

Stabbing in the epigastric area ANS: B

The classic clinical presentation is the sudden onset of intense, severe, tearing pain, which may be localized initially in the chest, abdomen, or back. As the aortic tear (dissection) extends, pain radiates to the back or distally toward the lower extremities. Many patients have hypertension upon initial presentation, and the focus is on control of blood pressure and early operation.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 343 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 17. Which clinical manifestation is usually the first symptom of peripheral arterial disease (PAD)? a. Cramping when walking b. Thrombophlebitis c. Pulmonary embolism d. Cordlike veins ANS: A

Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces ischemic muscle pain known as intermittent claudication. This cramping, aching pain while walking is often the first symptom of peripheral arterial occlusive disease. The pain is relieved by rest and may remain stable in occurrence and intensity for many years.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 346 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 18. The nurse developing a patient education plan for the patient with endocarditis. What

information would be included in the plan? a. Endocarditis is a viral infection that is easily treated with antibiotics. b. The risk of this diagnosis is occlusion of the coronary arteries.

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c. A long course of antibiotics is needed to treat this disorder. d. Complications are rare after antibiotics have been started.

ANS: C

Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the specific infective endocarditis microbe and patient circumstances. Antibiotic treatment is prolonged, administered in high doses intravenously, and may involve combination therapy. Best outcomes are achieved if therapy is initiated before hemodynamic compromise.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 355 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Health Promotion and Maintenance 19. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram

(ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for infarction? a. Inverted T waves b. Tall, peaked T waves c. ST segment depression d. Pathologic Q waves ANS: D

The changes in repolarization are seen by the presence of new Q waves. These new, pathologic Q waves are deeper and wider than tiny Q waves found on the normal 12-lead ECG. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 301 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 20. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram

(ECG) is done to validate the area of infarction. Which leads on the ECG would correlate with an inferior wall MI? a. II, III, aVF b. V5 to V6, I, aVL c. V2 to V4 d. V1 to V2 ANS: A

Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Anterior wall infarctions are manifested by ECG changes in leads V2 to V4. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 307 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 21. A patient is admitted with an acute myocardial infarction (MI). What common complication should

the nurse anticipate in this patient? a. Pulmonary edema b. Cardiogenic shock

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c. Dysrhythmias d. Deep vein thrombosis ANS: C

Many patients experience complications occurring either early or late in the postinfarction course.

These complications may result from electrical dysfunction or from a cardiac contractility problem.

Cardiac monitoring for early detection of ventricular dysrhythmias is ongoing. Pumping complications can cause heart failure, pulmonary edema, and cardiogenic shock. The presence of a new murmur in a patient with an acute myocardial infarction warrants special attention because it may indicate rupture of the papillary muscle. The murmur can be indicative of severe damage and impending complications such as heart failure and pulmonary edema.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 304 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 22. Which classification of dysrhythmia is most common with an inferior wall infarction in the first

hour after ST segment elevation myocardial infarction (STEMI)?

Sinus tachycardia b.

Multifocal PVCs c. Atrial fibrillation d.

Sinus bradycardia a.

ANS: D

Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain an acute myocardial infarction (MI). It is more prevalent with an inferior wall infarction in the first hour after ST segment elevation MI. Sinus tachycardia (heart rate more than 100 beats/min) most often occurs with an anterior wall MI. Premature atrial contractions (PACs) occur frequently in patients who sustain an acute MI. Atrial fibrillation is also common and may occur spontaneously or may be preceded by PACs. Premature ventricular contractions (PVCs) are seen in almost all patients within the first few hours after an MI. PTS: 1 DIF: Cognitive Level: Applying REF: p. 304 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 23. Which laboratory value indicates a heightened risk for the development of coronary artery

disease (CAD)?

Total cholesterol level of 170 mg/dL HDL cholesterol level of 30 mg/dL Triglyceride level of 120 mg/dL LDL cholesterol level >190 mg/dL

a. b. c. d.

ANS: D

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Low-density lipoprotein (LDL) cholesterol is usually described as the “bad cholesterol” because high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at low risk of coronary artery disease. Triglyceride levels below 150 are considered normal.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 291 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 24. A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly

awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation.

The nurse suspects the patient may have which disorder? a. Silent ischemia b. Stable angina c. Unstable angina d. Prinzmetal angina ANS: C

Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that persists for more than 5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Patients become used to the pattern of this type of angina and may describe it as “my usual chest pain.” Pain control should be achieved within 5 minutes of rest and by taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic, occurring at the same time every day.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 298 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 25. A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot

about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response indicates the need for additional education? a. He should stop smoking. b. He can no longer drink colas or coffee. c. He can no longer get a strong back massage. d. He should take stool softeners to prevent straining.

ANS: C

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Longer term education of the patient and the family can begin. Points to cover include (1) risk factor modification, (2) signs and symptoms of angina, (3) when to call the physician, (4) medications, and (5) dealing with emotions and stress. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to the patient as “bearing down” during defecation or breath holding when repositioning in bed. Relaxation therapy and techniques including back rubs are encouraged when appropriate.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 301 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 26. A patient presents with severe substernal chest pain. The patient exclaims, “This is the most severe

pain I have ever felt!” The patient reports that the pain came on suddenly about 2 hours ago and that three sublingual nitroglycerin tablets have not relieved the pain. The 12-lead electrocardiogram (ECG) reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and V5; pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4.

Which statement is accurate about this patient? a. This patient has an old lateral wall infarction. b. This patient is having an inferior wall infarction. c. This patient is having an acute anterior wall infarction. d. This patient is having a posterior wall infarction.

ANS: C

Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to V4. Inferior infarctions are manifested by ECG changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.

PTS: 1 DIF: Cognitive Level: Analyzing REF: p. 303 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 27. A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains

of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings the nurse suspects the patient may be experiencing which problem? a. Angina b. Anxiety c. Depression d. Endocarditis ANS: C

Depression is a phenomenon that occurs across a wide spectrum of human experience. Key symptoms of depression mentioned frequently by cardiac patients are fatigue, change in appetite, and sleep disturbance.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 314 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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28. Patient is admitted with heart failure. The patient has developed dyspnea with wheezing, a

nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema. The nurse suspects the patient may be developing with problem? a. Dyspnea b. Orthopnea c. Paroxysmal nocturnal dyspnea d. Cardiac asthma ANS: D

Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema are symptoms of cardiac asthma. With dyspnea, the patient feels shortness of breath from pulmonary vascular congestion and decreased lung compliance. In orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of orthopnea in which the patient awakens from sleep gasping for air.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 324 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 29. A patient is admitted for palliative care for end-stage heart failure. What is the nurse’s primary goal

when caring for this patient?

To reverse heart failure with the use of diuretics To increase activity tolerance To manage symptoms and relieve pain To increase cardiac output related to alteration of contractility

a. b. c. d.

ANS: C

The primary aim of palliative care is symptom management and the relief of suffering.

Fundamental to all symptom management strategies for heart failure is the optimization of medications, according to current guidelines.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 325 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 30. A patient is admitted with a fever of unknown origin. The patient is complaining of fatigue, malaise,

joint pain, and shivering. The patient’s vital signs include temperature, 103° F; heart rate, 90 beats/min; respiratory rate, 22 breaths/min; blood pressure, 132/78; and oxygen saturation, 94% on 2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient has developed which problem? a. Coronary artery disease b. Heart failure c. Endocarditis d. Pulmonary embolus ANS: C

Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise, with up to 50% of patients complaining of myalgias and joint pain. Blood cultures are drawn during periods of elevated temperature.

PTS: 1

DIF:

Cognitive Level: Remembering

REF: p. 336

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OBJ: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

TOP: Cardiovascular

31. At what size is an aortic aneurysm evaluated for surgical repair or stent placement? a. 2 cm b. 4 cm c. 5 cm d. >5 cm ANS: D

An aneurysm smaller than 4 cm in diameter can be managed on an outpatient basis with frequent blood pressure monitoring and ultrasound testing to document any changes in the size of the aneurysm. Management includes weight loss, smoking cessation, and control of hypertension as appropriate. An aortic aneurysm larger than 5 cm in diameter requires evaluation for surgical repair or placement of an aortic stent to eliminate the risk of rupture.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 343 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity MULTIPLE RESPONSE 1. Which physiologic effects can be associated with physical exercise? (Select all that apply.) a.

Decreased LDL cholesterol b.

Increased HDL cholesterol c.

Decreased triglycerides d. Increased insulin resistance e. Decreased incidence of depression ANS: A, B, C, E

Many research trials have demonstrated the positive effects of physical activity on the other major cardiac risk factors. Exercise alters the lipid profile by decreasing low-density lipoprotein (LDL) cholesterol and triglyceride levels and increasing high-density lipoprotein (HDL) cholesterol levels.

Exercise reduces insulin resistance at the cellular level, lowering the risk for developing type 2 diabetes, especially if combined with a weight loss program.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 292 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiologic Integrity 2. Which clinical manifestations are indicative of left ventricular failure? (Select all that apply.) a. Cool, pale extremities b. Jugular venous distention c. Liver tenderness d. Weak peripheral pulses e. Rales ANS: A, D, E

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Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance, (2) fluid retention, or (3) discovery during examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis.

PTS: 1 DIF: Cognitive Level: Analyzing REF: pp. 318-319 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders MSC: NCLEX: Physiologic Integrity 3. Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.) a. Coronary artery thrombosis b. Plaque rupture c. Coronary artery spasm near the ruptured plaque d. Preinfarction angina e. Hyperlipidemia ANS: A, B, C

The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the myocardium are (1) plaque rupture, (2) new coronary artery thrombosis, and (3) coronary artery spasm close to the ruptured plaque.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 301 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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Chapter 15: Cardiovascular Therapeutic Management Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. The possibility of microshock when handling a temporary pacemaker can be minimized by

which intervention? a. Decreasing the milliamperes b. Wearing gloves c. Positioning the patient on the left side d. Wearing rubber-soled shoes ANS: B

The possibility of “microshock” can be minimized by wearing gloves when handling the pacing wires and by proper insulation of terminal pins of pacing wires when they are not in use. The latter can be accomplished either by using caps provided by the manufacturer or by improvising with a plastic syringe or section of disposable rubber glove. The wires are to be taped securely to the patient’s chest to prevent accidental electrode displacement.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 366|Box 15-6 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Safe and Effective Care Environment 2. Which hemodynamic alteration is the most common cause of a decrease in cardiac output in the

postoperative cardiovascular patient? a. Reduced preload NURSINGTB.COM b. Increased afterload c. Increased contractility d. Bradycardia ANS: A

In most patients, reduced preload is the cause of low postoperative cardiac output. To enhance preload, volume may be administered in the form of crystalloid, colloid, or packed red blood cells.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 386 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 3. A patient has an implantable cardioverter defibrillator (ICD) for chronic ventricular

tachydysrhythmias. What action should the nurse take when the patient’s rhythm deteriorates to ventricular fibrillation? a. Apply an external defibrillator to the patient. b. Call a code and start cardiopulmonary resuscitation (CPR) on the patient. c. Wait for the ICD to defibrillate the patient. d. Turn the ICD off and administer epinephrine.

ANS: C

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If the dysrhythmia deteriorates into ventricular fibrillation, the implantable cardioverter defibrillator is programmed to defibrillate at a higher energy. If the dysrhythmia terminates spontaneously, the device will not discharge.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 368 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 4. How does a percutaneous transluminal coronary angioplasty (PTCA) improve blood flow? a. The balloon stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen. b. Medication is delivered through the catheter that dissolves the plague and enhances vessel

patency. c. The balloon removes blood clots from the vessel improving patency of the vessel. d. The balloon compresses the plaque against the vessel wall enlarging the vessel lumen.

ANS: A

Percutaneous transluminal coronary angioplasty involves the use of a balloon-tipped catheter that, when advanced through an atherosclerotic lesion (atheroma), can be inflated intermittently for the purpose of dilating the stenotic area and improving blood flow through it. The high balloon-inflation pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 374-375 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

NURSINGTB.COM 5. What is the rationale for administrating a fibrinolytic agent to a patient experiencing acute

ST-elevation myocardial infarction (STEMI)? a. Dilation of the blocked coronary artery b. Anticoagulation to prevent formation of new emboli c. Dissolution of atherosclerotic plaque at the site of blockage d. Restoration of blood flow via lysis of the thrombus ANS: D

The administration of a fibrinolytic agent results in the lysis of the acute thrombus, thus recanalizing, or opening, the obstructed coronary artery and restoring blood flow to the affected tissue. After perfusion is restored, adjunctive measures are taken to prevent further clot formation and reocclusion.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 370 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 6. A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements from the patient warrants further assessment and intervention by the nurse? a. “My back is killing

me!” b. “There is blood on my toothbrush!” c. “Look at the bruises on my arms!” d. “My arm is bleeding where my IV is!”

NURSINGTB.COM

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ANS: A

The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not causes for concern.

However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors, or both are administered.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 373|Box 15-12 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 7. Which finding is a reliable indicator of reperfusion after fibrinolytic therapy? a. Dysrhythmias b. Q waves c. Elevated ST segments d. Immediate rapid decrease in cardiac biomarkers ANS: A

Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored.

Another reliable indicator of reperfusion is the appearance of various “reperfusion” dysrhythmias.

Premature ventricular contractions, bradycardias, heart block, ventricular tachycardia, and (rarely) ventricular fibrillation may occur.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 373 OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

mpR nolyMtic therapy?

8. What is the most common coN Ulicat SIion NGofTfBib.riC O a. Reperfusion chest pain b. Lethargy c. Bleeding d. Heart blocks ANS: C

The most common complication related to thrombolysis is bleeding.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 373 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 9. Which mechanism is responsible for the augmentation of coronary arterial blood flow and increased

myocardial oxygen supply seen with the intraaortic balloon pump? a. The vacuum created in the aorta as a result of balloon deflation b. Diastolic inflation with retrograde perfusion c. Forward flow to the peripheral circulation d. Inflation during systole to augment blood pressure ANS: B

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The blood volume in the aorta below the level of the balloon is propelled forward toward the peripheral vascular system, which may enhance renal perfusion. Subsequently, the deflation of the balloon just before the opening of the aortic valve creates a potential space or vacuum in the aorta, toward which blood flows unimpeded during ventricular ejection. This decreased resistance to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and reduces myocardial oxygen demands.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 391 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 10. What parameter must be assessed frequently in the patient with an intraaortic balloon in place? a. Skin turgor in the affected extremity b. Peripheral pulses distal to the insertion site c. Blood pressures in both arms and legs d. Oxygen saturation ANS: B

One complication of intraaortic balloon support is lower extremity ischemia resulting from occlusion of the femoral artery by the catheter itself or by emboli caused by thrombus formation on the balloon.

Although ischemic complications have decreased with sheathless insertion techniques and the introduction of smaller balloon catheters, evaluation of peripheral circulation remains an important nursing assessment. The presence and quality of peripheral pulses distal to the catheter insertion site are assessed frequently along with color, temperature, and capillary refill of the involved extremity. Signs of diminished perfusion must be reported immediately.

NURSINGTB.COM

PTS: 1 DIF: Cognitive Level: Applying REF: p. 392 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 11. Which of the following statements regarding beta-blockers is correct? a. They increase heart rate and are contraindicated in tachydysrhythmias. b. They result in bronchospasm and should not be used in patients with chronic

obstructive pulmonary disease (COPD). c. They increase cardiac output and help with left ventricular failure. d. They are helpful in increasing atrioventricular node conduction and are used in heart

blocks.

ANS: B

Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the therapeutic responses brought about by beta-blockade but also the potential adverse effects of these agents. For example, bronchospasm can be precipitated by noncardioselective beta-blockers in a patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2 receptors in the lungs.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 399 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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12. Adenosine is an antidysrhythmic agent that is given primarily what reason? a. To convert supraventricular tachycardias b. To suppress premature ventricular contractions (PVCs) c. To treat second and third degree AV blocks d. To coarsen ventricular fibrillation so that defibrillation is effective ANS: A

Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP).

Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate the differential diagnosis of rapid dysrhythmias.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 400|Table 15-16 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 13. Which dosage of dopamine results in stimulation of beta1 receptors and increased myocardial

contractility? a. 1 mcg/kg/min b. 5 mcg/kg/min c. 15 mcg/kg/min d. 20 mcg/kg/min ANS: B

At low dosages of 1 to 2 mcg/kg/min, dopamine stimulates dopaminergic receptors, causing renal and mesenteric vasodilation. Moderate dosages result in stimulation of beta1 receptors to increase myocardial contractility and improve cardiac output. At dosages greater than 10 mg/kg/min, dopamine predom Nina URntly SIsti NGmul TBat.esCalp OMha receptors, resulting in vasoconstriction that often negates both the beta-adrenergic and dopaminergic effects.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 402|Table 15-18 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 14. A patient is admitted with left-sided heart failure and a blood pressure of 220/118 mm Hg.

Which drug will be most effective in decreasing the blood pressure and reducing afterload? a. Dopamine b. Verapamil c. Propranolol d. Sodium nitroprusside ANS: D

Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and systemic vascular resistance.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 403|Table 15-19 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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15. Through what mechanism does enalapril decrease blood pressure? a. Direct arterial vasodilation b. Block the conversion of angiotensin I to angiotensin II c. Increase fluid excretion at the loop of Henle d. Peripheral vasoconstriction and central vasodilation.

ANS: B

Enalapril is an angiotensin-converting enzyme (ACE) inhibitors that produces vasodilation by blocking the conversion of angiotensin I to angiotensin II. Because angiotensin is a potent vasoconstrictor, limiting its production decreases peripheral vascular resistance. In contrast to the direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce sodium and water retention.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 404 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 16. Noninvasive emergency pacing is best achieved via the use of which type of temporary pacing? a. Transvenous (endocardial) b. Epicardial c. Transthoracic d. Transcutaneous ANS: D

Transcutaneous cardiac pacing involves the use of two large skin electrodes, one placed anteriorly and the other posteriorly on the chest, connected to an external pulse generator. It is a rapid, noninvasive proceduN re thRat nIursG an.pCerfoMrm in the emergency setting and is U S NesTcB O recommended for the treatment of symptomatic bradycardia.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 361|Box 15-2 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 17. A transvenous pacemaker is inserted through the right subclavian vein and threaded into the right

ventricle. The pacemaker is placed on demand at a rate of 70. What is the three letter code for this pacing mode? a. VVI b.

AOO c. DDD d.

VAT ANS: A

The original code is based on three categories, each represented by a letter. The first letter refers to the cardiac chamber that is paced. The second letter designates which chamber is sensed, and the third letter indicates the pacemaker’s response to the sensed event. A VVI pacemaker paces the ventricle when the pacemaker fails to sense an intrinsic ventricular depolarization.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 362|Table 15-2 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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18. A patient is connected to an external temporary pulse generator. What does the sensitivity control

regulate? a. The time interval between the atrial and ventricular pacing stimuli b. The amount of electrical current and is measured in milliamperes c. The ability of the pacemaker to detect the heart's intrinsic electrical activity d. The number of impulses that can be delivered to the heart per minute ANS: C

The sensitivity control regulates the ability of the pacemaker to detect the heart’s intrinsic electrical activity. Sensitivity is measured in millivolts (mV) and determines the size of the intracardiac signal that the generator will recognize.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 363 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 19. When analyzing the electocardiogram (ECG) strip of the patient with a pacemaker, the nurse notices

there is a spike before each QRS complex. What is this phenomenon indicative of? a. 60-cycle electrical interference; check equipment b. Pacing artifact; the pacemaker is sensing and capturing c. Electrical artifact; the pacemaker is not sensing d. Patient movement; check electrodes ANS: B

The pacing artifact is the spike that is seen on the electrocardiographic tracing as the pacing stimulus is delivered to the heart. A P wave is visible after the pacing artifact if the atrium is being paced.

Similarly, a QRN S coRmpI lex fG olloBw.s C a veMntricular U S Npacing T artifact. With dual-chamber pacing, a pacing artifact precedes both the P wave and the QRS complex.

PTS: 1 DIF: Cognitive Level: Applying Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

REF: p. 363|Figure 15-4B OBJ:

20. A patient is undergoing ventricular pacing via a transvenous pacing lead. The nurse notes a pacing

artifact, but it is not followed by a QRS on the electrocardiogram (ECG) monitoring. Which nursing intervention may correct this situation? a. Position the patient on the left side b. Decrease the milliamperes as ordered c. Increase the rate as ordered d. Monitor the patient in a different lead ANS: A

The patient is experiencing “loss of capture,” which most often can be attributed either to displacement of the pacing electrode or to an increase in threshold as a result of drugs, metabolic disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the site of electrode placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For transvenous leads, repositioning the patient to the left side may improve lead contact and restore capture.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 365 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular

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MSC: NCLEX: Physiologic Integrity 21. A patient suddenly develops a wide QRS complex tachycardia. The patient’s heart rate is 220

beats/min and regular; blood pressure is 96/40 mm Hg; and respiratory rate is 22 breaths/min, and the patient is awake without complaint except for palpitations. Which of the following interventions would be best to try first? a. Adenosine 6 mg rapid IV push b. Lidocaine 1 mg/kg IV push c. Verapamil 5 mg IV push d. Digoxin 0.5 mg IV push ANS: A

Adenosine (Adenocard) is an antidysrhythmic agent that remains unclassified under the current system. Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to facilitate differential diagnosis of rapid dysrhythmias.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 400|Table 15-16 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 22. Why are vasopressors used cautiously in the treatment of critical care patients? a. They cause vasoconstriction of the smooth muscles. b. They cause vasodilation of the smooth muscles. c. They increase afterload. d. They decrease preload.

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ANS: C

Vasopressors are not widely used in the treatment of critically ill cardiac patients because the dramatic increase in afterload is taxing to a damaged heart. Vasopressin, also known as antidiuretic hormone, has become popular in the critical care setting for its vasoconstrictive effects. At higher doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in vasoconstriction of capillaries and small arterioles.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 405 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 23. Which calcium channel blocker is beneficial in the treatment of patients with coronary artery disease

or ischemic stroke? a. Nifedipine b.

Nicardipine c. d.

Clevidipine Diltiazem ANS: B

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Nicardipine was the first available intravenous calcium channel blocker and as such could be more easily titrated to control blood pressure. Because this medication has vasodilatory effects on coronary and cerebral vessels, it has proven beneficial in treating hypertension in patients with coronary artery disease or ischemic stroke. Nifedipine is available only in an oral form, but in the past it was prescribed sublingually during hypertensive emergencies. Clevidipine is a new, short-acting calcium channel blocker that allows for even more precise titration of blood pressure in the management of acute hypertension. Diltiazem (Cardizem) is from the benzothiazine group of calcium channel blockers. These medications dilate coronary arteries but have little effect on the peripheral vasculature. They are used in the treatment of angina, especially that which has a vasospastic component, and as antidysrhythmics in the treatment of supraventricular tachycardias.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 404 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 24. A patient is admitted after a femorotibial bypass graft. What nursing action is critical in the

immediate postoperative period? a. Frequent assessment of the skin b. Hourly assessment of intake and output c. Monitoring for ST segment changes d. Frequent pulse checks to the affected limb ANS: D

The primary focus of nursing care in the immediate postprocedural period is assessment of the adequacy of perfusion to the affected limb and identification of complications. Pulse checks are performed frequently, and the physician is notified of any decrease in the strength of the Doppler signal. Because distal U perfSusN ioNnR iT s cI ompGrO omBi. seC d inMthis patient population, nursing measures to prevent skin breakdown are implemented. If the repair was performed above the renal arteries, kidney function may be impaired as a result of interruption of renal blood flow during the procedure. Urine output is therefore assessed hourly and supported with fluids and diuretics as needed. Because patients with peripheral vascular disease are at high risk for cardiac events, ST segment monitoring is performed to detect episodes of myocardial ischemia throughout the perioperative period.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 398 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 25. When is a patient a candidate for a surgical repair of an abdominal aortic aneurysm (AAA)? a. Size is 1 cm b. Patient experiencing symptoms c. Aneurysm size unchanged over several years d. Size less than 4 cm ANS: B

An abdominal aortic aneurysm (AAA) is usually repaired when the aneurysm is 5 cm or larger, creating symptoms, or rapidly expanding. This is done to prevent the high mortality rate associated with abdominal rupture.

PTS: 1

DIF: Cognitive Level: Understanding

REF: p. 396

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OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 26. The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient’s

vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and O2 saturation 94% on 3L nasal cannula. The nurse suspects that the patient has developed what problem? a. Infection and notifies the physician immediately b. Infection, which is common postoperatively, and monitors the patient’s condition c. Cardiac tamponade and notifies the physician immediately d. Delirium caused by the elevated temperature ANS: A

Postoperative fever is fairly common after cardiopulmonary bypass. However, persistent temperature elevation to greater than 101° F (38.3° C) must be investigated. Sternal wound infections and infective endocarditis are the most devastating infectious complications, but leg wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal complication, cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart’s ability to pump. Signs of tamponade include elevated and equalized filling pressures (eg, central venous pressure, pulmonary artery diastolic pressure, pulmonary artery occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention, pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on radiographs. The risk of delirium is increased in cardiac surgery patients, especially elderly patients, and is associated with increased mortality rates and reduced quality of life and cognitive function. Nursing staff can play a critical role in the prevention and recognition of delirium.

PTS: 1

DIF:

N R I G B.C M

CogU nitivS e LN evelT : ApplyiO ng

REF: p. 388

OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 27. Identify complications with the above rhythm strip.

a. b. c. d.

Undersensing from a pacemaker Oversensing from a pacemaker ICD firing caused by VF Atrial pacing failure to capture

ANS: A

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Undersensing is the inability of the pacemaker to sense spontaneous myocardial depolarizations.

Undersensing results in competition between paced complexes and the heart’s intrinsic rhythm. This malfunction is manifested on the electrocardiogram by pacing artifacts that occur after or are unrelated to spontaneous complexes. Oversensing occurs as a result of inappropriate sensing of extraneous electrical signals that leads to unnecessary triggering or inhibition of stimulus output, depending on the pacer mode. The source of these electrical signals can range from tall peaked T waves to external electromagmetic interference in the critical care environment. The implantable cardioverter defibrillator system consists of leads and a generator and is similar to a pacemaker but with some key differences. The leads contain not only electrodes for sensing and pacing but also integrated defibrillator coils capable of delivering a shock. If the pacing stimulus fires but fails to initiate a myocardial depolarization, a pacing artifact will be present but will not be followed by the expected P wave.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 365 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 28. What is the preferred initial treatment of an acute myocardial infarction? a. Fibrinolytic therapy b. Percutaneous coronary intervention (PCI) c. Coronary artery bypass surgery (CABG) d. Implanted Cardioverter defibrillator (ICD) ANS: B

Percutaneous coronary intervention (PCI) is now preferred as the initial method of treatment for acute myocardial infarction (MI; primary PCI). PCI includes balloon angioplasty, RTll I B.C of adjunctive devices used to atherectomy, and stent implantU atioS n, N aN s we as aGnOumber facilitate successful revascularization in coronary vessels.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 374 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 29. What two medications are commonly prescribed at discharge for patients who have had a

coronary artery stent placed? a. Aspirin and prasugrel b. Aspirin and abciximab c. Clopidogrel and eptifibatide d. Tirofiban and tricagrelor ANS: A

Because platelet activation is a complex process involving multiple pathways, combination therapy with two or more agents has proven most effective. The current standard of care for percutaneous coronary intervention typically includes dual antiplatelet therapy with aspirin and a thienopyridine.

These oral agents are administered before the procedure and continued at discharge. Abciximab, eptifibatide, and tirofiban are all intravenous antiplatelet agents.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 376|Table 15-5 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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30. Which anticoagulant enhances the activity of antithrombin III and does not require activated partial

thromboplastin time (aPTT) or activated clotting time (ACT) monitoring? a. Heparin b.

Enoxaparin c. d.

Bivalirudin Argatroban ANS: B

Enoxaparin (Lovenox) enhances activity of antithrombin III, a more predictable response than heparin, because enoxaparin is not largely bound to protein. There is no need for activated partial thromboplastin time (aPTT) or activated clotting time (ACT) monitoring, and there is a lower risk of heparin-induced thrombocytopenia (HIT) than with unfractionated heparin (UFH). Heparin sodium enhances activity of antithrombin III, a natural anticoagulant, to prevent clot formation. The effectiveness of treatment may be monitored by aPTT or ACT. Response is variable because of binding with plasma proteins effects may be reversed with protamine sulfate. Bivalirudin (Angiomax) directly inhibits thrombin. It may be administered alone or in combination with glycoprotein IIb/IIIa inhibitors and produces a dose-dependent increase in aPTT and ACT. It may be used instead of UFH for patients with HIT. Argatroban (Argatroban) directly inhibits thrombin. It may be used instead of UFH for patients with HIT. Whereas ACT is monitored during percutaneous coronary intervention, aPTT is used during prolonged infusion.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 378|Table 15-8 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

Mill test with a diagnosis of coronary artery disease 31. A patient is admitted after a pNoU siR tivSeIeN xeG rcT isB e. treCaO dm (CAD) and stable angina. Radiographic tests show that the patient has blockage in the left main coronary artery and four other vessels. The nurse anticipates that the patient’s treatment plan will include what treatment or procedure? a. Medical therapy b. PCI c. TAVR d. CABG ANS: D

Early studies demonstrated coronary artery bypass graft (CABG) surgery was more effective than medical therapy for improving survival in patients with left main or three-vessel coronary artery disease and at relieving anginal symptoms. Medical therapy is recommended if the ischemia is prevented by antianginal medications that are well tolerated by the patient.

Surgical revascularization has been shown to be more efficacious than percutaneous coronary intervention (PCI) in patients with multivessel or left main coronary disease. Transcatheter aortic valve replacement (TAVR) is a transformational therapy for patients who have severe aortic stenosis but who are extremely high-risk surgical candidates or who are inoperable by virtue of associated comorbidities.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 382-383 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity

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MULTIPLE RESPONSE 1. A patient is diagnosed with third-degree heart failure. The nurse reviews the patient’s medication

list. Which classifications of drugs should be avoided with this patient? (Select all that apply.) a. Nonsteroidal antiinflammatory drugs (NSAIDs) b. Antidysrhythmics c. Angiotensin-converting enzyme (ACE) inhibitors d. Calcium channel blockers e. Beta-blockers ANS: A, B, D

Types of medications that have been found to worsen heart failure should be avoided, including most antidysrhythmics, calcium channel blockers, and nonsteroidal antiinflammatory medications. Angiotensin-converting enzyme inhibitors and beta-blockers are used to treat heart failure.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 405|Table 15-21 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular MSC: NCLEX: Physiologic Integrity 2. Which patients would be a candidate for fibrinolytic therapy? (Select all that apply.) a. The patient’s chest pain started 8 hours ago. She has a diagnosis of non-

ST-elevation myocardial infarction (NSTEMI).

b. The patient’s chest pain started 3 hours ago, and her electrocardiogram (ECG) c. shows a new left bundle b NranRch bIlocGk. B.C M

U Sdepartment N T with O chest pain of 30 minutes’ The patient presents to the emergency duration. She has a history of cerebrovascular accident 1 month ago. d. The patient has a history of unstable angina. He has been experiencing chest pain with sudden onset. e. The patient’s chest pain started 1 hour ago, and his ECG shows ST elevation.

ANS: B, E

Eligibility criteria for administering fibrinolytics include chest pain of less than 12 hours’ duration and persistent ST elevation. Exclusion criteria include recent surgery, cerebrovascular accident, and trauma.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 370-371 OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiologic Integrity 3. Which signs and symptoms would indicate successful reperfusion after administration of a

fibrinolytic agent? (Select all that apply.) a. Gradual decrease in chest pain b. Intermittent, multifocal premature ventricular contractions c. Rapid resolution of ST elevation d. Rapid rise in creatine kinase MB fraction ANS: B, C, D

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A reliable indicator of reperfusion is the appearance of various “reperfusion” dysrhythmias such as premature ventricular contractions, bradycardia, heart block, and ventricular tachycardia. Rapid resolution of the previously elevated ST segment should occur. The serum concentration of creatine kinase rises rapidly and markedly, a phenomenon termed washout.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 373 OBJ: Nursing Process Step: Diagnosis TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiologic Integrity 4. Nursing interventions after angioplasty would include which of the following? (Select all that apply.) a. Elevating the head of the bed to 45 degrees b. Hydration as a renal protection measure c. Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours after the

procedure d. Monitoring the vascular hemostatic device for signs of bleeding e. Educating the patient on the necessity of staying supine for 1 to 2 hours after the

procedure ANS: B, C, D

The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg straight. Bed rest is 6 to 8 hours in duration unless a vascular hemostatic device is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 380 OBJ: Nursing Process Step: Intervention TOP: Cardiovascular Therapeutic Management MSC: NCLEX: Physiologic InN tegUriR tySINGTB.COM

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Chapter 16: Pulmonary Anatomy and Physiology Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. At what anatomic site does the trachea divide into the right and left mainstem bronchi? a.

Posterior larynx b.

Cricoid cartilage c.

Epiglottis d. Major carina ANS: D The trachea is a hollow tube approximately 11 cm in length and 2.5 cm in diameter. It begins at the cricoid cartilage and ends at the bifurcation (the major carina) from which the two mainstem bronchi arise.

PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 415-416|Figure 16-5 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 2. Which physiologic mechanism is a passive event in a spontaneously breathing patient? a.

Coughing b.

Inhalation c.

Exhalation d.

Yawning ANS: C Inhalation involves the contraction of the diaphragm, an active event, as do yawning and coughing. Exhalation in the healthy lung is a passive event requiring very little energy.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 414

3. What substance do Alveolar type II cells secrete? a. Trypsin b.

Chyme c. Amylase d.

Surfactant ANS: D The most important function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant. Trypsin and amylase are proteins used for digestion. Chyme is a semifluid mass of partly digested food that is expelled by the stomach into the duodenum.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 418

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4. Which pulmonary condition is related to a lack of surfactant? a. Pulmonary embolus b. Pulmonary hypertension c.

Pulmonary atelectasis d. Pulmonary edema ANS: C Surfactant is responsible for preventing the alveoli from completely collapsing on exhalation.

Lack of this lipoprotein allows the alveoli to collapse, producing atelectasis. Lack of surfactant is not responsible for the other conditions.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 418

5. What is the main function of the conducting airways? a. Gas exchange b. Cool the inhaled air c. Remove moisture from inhaled air d. Prevent the entry of foreign material ANS: D The conducting airways consist of the upper airways, the trachea, and the bronchial tree. Their major functions are to warm and humidify the inhaled air, prevent the entrance of foreign matter into the gas exchange areas, and serve as a passageway for air entering and leaving the gas exchange regions of the lungs.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 414-415

6. A patient has sustained a stroke and is no longer able to control his epiglottis. Why should the nurse be concerned about the patient? a. The patient is at increased risk of aspiration. b. The patient will need surgery to close his epiglottis. c. The patient will need a tracheostomy to breathe. d. The patient is at risk for a pneumothorax.

ANS: A The epiglottis is responsible for closing over the trachea and preventing entry of swallowed material into the lungs. An inability to control the epiglottis increases the risk of aspiration and may warrant placement of a feeding tube. The patient will still be able to breathe. Closure of the epiglottis over the trachea will occlude the airway.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 415

7. Patients who have aspiration pneumonitis often present with right lower lobe involvement more than left lower lobe involvement. Why does this occur?

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a. The left mainstem bronchus angles down more than the right. b. More people are right-side dominant. c. The right mainstem bronchus angles down more than the left. d. The right mainstem bronchus is narrower than the left.

ANS: C The right bronchus is wider than the left and angles at 20 to 30 degrees from the midline. Because of this angulation and the forces of gravity, the most common site of aspiration of foreign objects is through the right mainstem bronchus into the lower lobe of the right lung.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 415-416

8. Which artery(s) have the lowest oxygen saturation? a. Aorta b. Subclavian c.

Carotid d. Pulmonary ANS: D The pulmonary artery delivers blood from the right ventricle to the lungs, where they receive oxygen from the alveoli. The aorta, subclavian artery, and carotid artery are all supplied from the left ventricle, where the oxygen concentration is highest.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 419

9. Which range would be considered normal for pulmonary artery systolic pressures? a. 15 to 30 mm Hg b. 4 to 12 mm Hg c. 25 to 35 mm Hg d. 1 to 11 mm Hg ANS: A Pulmonary artery systolic pressure ranges from 15 to 30 mm Hg, pulmonary artery diastolic pressure ranges from 4 to 12 mm Hg, and pulmonary artery mean pressure ranges from 9 to 18 mm Hg. Pulmonary hypertensions is defined as pulmonary artery systolic pressure of greater than 35 mm Hg. PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 419

10. The oxygen saturation of a healthy individual rarely reaches 100% on room air. This can best be explained by what concept? a. Physiologic shunting b. Alveolar capillary diffusion c.

Collateral air passages

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d. Anatomic dead space ANS: A The mixing of venous blood from the bronchial circulation with the oxygenated blood in the left atrium decreases the saturation of left atrial blood to a range between 96% and 99%.

This is referred to as physiologic shunting. For this reason, while a person is breathing room air, the oxygen saturation of arterial blood is less than 100%.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 420

11. Which pulmonary alteration increases the work of breathing in the patient with emphysema? a. Decreased lung recoil b. Decreased chest wall compliance c.

Increased lung compliance d. Increased airway resistance ANS: A Emphysema results in destruction and enlargement of the alveoli, leading to decreased lung recoil and increased work of breathing. Emphysema results in decreased lung compliance not increased compliance. Emphysema does not affect chest wall compliance or airway resistance.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 420-422|Box 16-2 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 12. What anatomic regions are considered physiologic dead space? a. Respiratory bronchiole and unperfused alveoli b.

Trachea and perfused alveoli c. Trachea and unperfused alveoli d.

Trachea and mainstem bronchi ANS: C Respiratory bronchioles participate in gas exchange. The areas in the lungs that are ventilated but in which no gas exchange occurs are known as dead space regions (trachea and mainstem bronchi).

These unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called physiologic dead space.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 421

13. If a patient sustained an injury to the apneustic center in the lower pons area, in which area should the nurse most expect the patient to exhibit problems? a. Respiratory rate b. Triggering exhalation c.

Respiratory rhythm d. Depth of respiration

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ANS: D The apneustic center in the lower pons is thought to work with the pneumotaxic center to regulate the depth of inspiration. The pneumotaxic center in the pons is responsible for limiting inhalation and triggering exhalation. This response also facilitates control of the rate and pattern of respiration. The ventral respiratory group, located in the medulla, is responsible for inspiration and expiration during periods of increased ventilation.

PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 423-44|Figure 16-18 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 14. Normally, the central chemoreceptors responsible for triggering ventilation changes respond to which of the following? a. Increased PaCO2 b.

Increased HCO3¯ c.

Decreased PaO2 d. Increased PaO2 ANS: A Ventilation increases when the hydrogen ion concentration increases and decreases when the hydrogen ion concentration decreases. An increase in the partial pressure of carbon dioxide (PaCO2) causes the movement of carbon dioxide across the blood–brain barrier into the cerebrospinal fluid, stimulating the movement of hydrogen ions into the brain’s extracellular fluid. Peripheral chemoreceptors respond to changes in PaO2 levels.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 424

15. Which V/Q ratio would most suggest intrapulmonary shunting? a. 0.8 b. 2.2 c.

0.4 d. V/Q ratios are not related to shunting.

ANS: C A V/Q ratio of 4:5 or 0.8 is considered normal. A V/Q less than 0.8 is considered shunt producing, and a V/Q greater than 0.8 is considered dead space producing.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 426-427

16. A shift to the left of the oxyhemoglobin dissociation curve would cause which physiologic alteration? a. Better tissue perfusion b.

Lower SpO2 c. Decreased hemoglobin affinity for O2 d.

Impaired tissue oxygen delivery

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ANS: D When the curve is shifted to the left, there is a higher arterial saturation for any given PaO2 because hemoglobin has an increased affinity for oxygen. Although the saturation is higher, oxygen delivery to the tissues is impaired because hemoglobin does not unload as easily.

PTS: 1 DIF: Cognitive Level: Remembering REF: pp. 428-429|Figure 16-23 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 17. A patient in diabetic ketoacidosis would exhibit what alteration to the pulmonary system? a. Breathe faster to increase pH b.

Breathe slower to increase pH c. Breathe faster to decrease pH d. Breathe slower to decrease pH ANS: C Breathing faster increases the expiration of CO2, which results in less acid in the bloodstream and a decreased pH. PTS: 1 DIF: Cognitive Level: Remembering REF: p. 428|Figure 16-23 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 18. What are the primary functions of the pulmonary system? a. Gas exchange and the movement of air in and out of the lungs b. Gas exchange and the transfer of oxygen to the tissues c. The movement of blood in and out of the lungs and the removal of waste products d. Gas exchange and the prevention of infections ANS: A The primary functions of the pulmonary system are ventilation and respiration. Ventilation is the movement of air in and out of the lungs. Respiration is the process of gas exchange, that is, the movement of oxygen from the atmosphere into the bloodstream and the movement of carbon dioxide from the bloodstream into the atmosphere.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 411

19. Which part of the pulmonary anatomy does most of the work of breathing? a. Pleura b. Intercostal muscles c.

Diaphragm d. Sternocleidomastoid ANS: C

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The main muscle of inhalation is the diaphragm. It is connected to the sternum, ribs, and vertebrae.

During normal, quiet breathing, the diaphragm does approximately 80% of the work of breathing.

The most important of these are the external intercostal muscles, which elevate the ribs and expand the chest cage outward. The scalene, anterior serratus, and sternocleidomastoid muscles also participate to elevate the first two ribs and sternum.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 413

20. Which statement best describes the left bronchus? a. The left bronchus has a slight angle of 20 to 30 degrees from the midline. b. The two mainstem bronchi are structurally and functionally similar. c. The left bronchus is slightly narrower. d. The bronchi are the end units of the bronchial tree.

ANS: C The two mainstem bronchi are structurally different. The right bronchus is wider and angles at 20 to 30 degrees from the midline. The right mainstem bronchus is the most common site of aspiration of foreign objects. The left bronchus is slightly narrower than the right, and because of its position above the heart, the left bronchus angles directly toward the left lung at approximately 45 to 55 degrees from the midline.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 415-416|Figure 16-5 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 21. What is the most important function of type I alveolar epithelial cells? a. They comprise 90% of total alveolar surface in the lungs for gas exchange. b. The ability to produce, store, and secrete pulmonary surfactant. c. The ability to trap foreign particles for auto digestion. d. The maintenance, repair, and restoration of the mucociliary escalator.

ANS: A Type I alveolar epithelial cells comprise approximately 90% of the total alveolar surface within the lungs. The most important function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 417

22. Which statement describes the relationship between the pulmonary circulation and the pulmonary vascular bed? a. The pulmonary circulation is a high-pressure system with normal pressures averaging 100/60 to 120/70 mm Hg. b. Because of the low pulmonary arterial pressures, the right ventricular wall thickness needs to be only one-third that of the left ventricle. c. Pulmonary hypertension is defined as increased pulmonary artery systolic pressure above 20 mm Hg.

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d. The most common cause of pulmonary hypertension is right-sided heart failure.

ANS: B Because of low pulmonary artery pressures, right ventricular wall thickness needs to be only approximately one-third of left ventricular wall thickness. Pulmonary hypertension is defined as increased pressure (pulmonary artery systolic greater than 35 mm Hg and pulmonary artery mean less than 25 mm Hg at rest or less than 30 mm Hg with exertion) within the pulmonary arterial system.

Pulmonary hypertension increases the afterload of the right ventricle and, when chronic, can result in right ventricular hypertrophy (cor pulmonale) and failure.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 419

23. Oxygen saturation of left atrial blood is normally between 96% and 99%. What is the explanation for less than 100% saturation? a. As blood passes to the alveolar–capillary membrane, a predicted percentage of hemoglobin will not bind with oxygen. b. During normal respiration, the majority of alveoli are not expanded. c. Venous blood from the bronchial circulation is returned to the left atrium. d. A small amount of blood leaks from the right atrium to the left atrium with each ventricular contraction.

ANS: C Venous blood from the bronchial circulation returns directly into the left atrium. The mixing of venous blood decreases the saturation of left atrial blood to a range between 96% and 99%.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 420

24. What is the movement of air into and out of the lungs termed? a.

Ventilation b.

Respiration c. Diffusion d. Perfusion ANS: A Ventilation is the movement of air into and out of the lungs and is distinct from respiration, which refers to gas exchange, not movement by air. Respiration is the process of gas exchange by means of movement of oxygen from the atmosphere into the bloodstream and movement of carbon dioxide from the bloodstream into the atmosphere. Diffusion moves molecules from an area of high concentration to an area of low concentration. The distribution of perfusion through the lungs is related to gravity and intra-alveolar pressures.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 420

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25. How much of the basal oxygen consumption is required by the pulmonary system during normal quiet breathing? a. 10% to 20% b. 5% to 10% c. 3% to 5% d. 1% to 2% ANS: D During normal quiet ventilation, only 1% to 2% of basal oxygen consumption is required by the pulmonary system.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 420

26. What is the portion of total ventilation that participates in gas exchange termed? a. Alveolar dead space b.

Anatomic dead space c. Physiologic dead space d.

Alveolar ventilation ANS: D The portion of total ventilation that participates in gas exchange is known as alveolar ventilation.

The areas in the lungs that are ventilated but in which no gas exchange occurs are known as dead space regions. The conducting airways are referred to as anatomic dead space because they are ventilated but not perfused and therefore not able to participate in gas exchange. These unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called physiologic dead space.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 421

27. Which physiologic alteration will stimulate the central chemoreceptors? a. Decreased PaO2 b.

Increased PaO2 c.

Decreased SaO2 d. Increased PaCO2 ANS: D The central chemoreceptors respond to changes in the hydrogen ion concentration of that fluid.

Ventilation is increased when the hydrogen ion concentration increases, as evidenced by a rise in the plasma arterial PaCO2.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 424

28. Which factor will increase diffusion of gases across the alveolar capillary membrane?

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a. A decrease in the surface area of the membrane b. An increase in the thickness of the membrane c. An increase in the driving pressure of the gas d. A decrease in the solubility coefficient of the gas ANS: C Several factors affect the rate of diffusion, including increasing the driving pressure of the gas. A decrease in surface area of the membrane, an increase in the thickness of the membrane, and a decrease in the solubility coefficient of the gas decrease diffusion of gases across the membrane.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 425

29. Atelectasis can cause a shunt-producing ventilation-perfusion mismatch. Which pathophysiologic mechanism explains how this occurs? a. An alveolus that is receiving perfusion exceeding ventilation b. An alveolus that is receiving ventilation exceeding perfusion c. An alveolus that is receiving ventilation but not perfusion d. An alveolus that is not receiving perfusion or ventilation ANS: A A shunt-producing ventilation-perfusion mismatch is one in which perfusion exceeds ventilation.

Whereas situations in which ventilation exceeds perfusion V/Q greater than 0.8 are considered to be dead space producing, situations in which perfusion exceeds ventilation V/Q less than 0.8 are considered to be shunt producing.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 426-427|Figure 16-21 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 30. Which factor will result in a shift of the oxyhemoglobin dissociation curve to the left? a. Increased PaCO2 b.

Increased pH c. Increased temperature d.

Increased 2,3-DPG ANS: B Factors shifting the curve to the left are increased pH, decreased PaCO2, decreased temperature, and decreased 2,3-DPG. PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 428-429|Figure 16-23 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 31. Which statement about methemoglobin is true? a. Methemoglobin does not carry oxygen. b. Methemoglobin occurs when carbon monoxide combines with hemoglobin. c.

Carbon dioxide is carried on methemoglobin.

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d. Hemoglobin S is responsible for methemoglobin.

ANS: A Methemoglobin occurs when the iron atoms within the hemoglobin molecule are oxidized from the ferrous state to the ferric state. Methemoglobin does not carry oxygen. The most common abnormality involving hemoglobin is a decrease in amount. This can be an acute or a chronic situation (anemia). Abnormal hemoglobin structure also can pose problems, such as hemoglobin S, which is responsible for sickle cell anemia. Hemoglobin carries approximately 97% of the total amount of oxygen held within the bloodstream.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 429

32. A patient is admitted with community-associated pneumonia. Respirations are 32 breaths/min.

Temperature is 102° F (38.6° C). Based on the readings the nurse would expect the oxyhemoglobin dissociation curve to shift. What other factors would cause the curve to shift in the same direction? a. Decreased 2,3-DPG b. Increased pH c. Increased CO2 d.

Increased O2 ANS: C The oxyhemoglobin dissociation curve will shift to the right as a result of the patient’s temperature.

Other factors that cause the curve to shift to the right are decreased pH, increased CO2, and increased 2,3-DPG. Increased O2 will not shift the curve either right or left.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 428-429|Figure 16-23 OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 33. A patient is admitted with an acute exacerbation of asthma. Respirations are 28 breaths/min.

Blood gases reveal an uncompensated respiratory acidosis. The patient’s work effort for breathing is increased due to which pathophysiologic mechanism? a. Increased lung compliance b.

Decreased lung recoil c. Increased chest wall compliance d.

Increased airway resistance ANS: D Pulmonary diseases that decrease lung compliance (eg, atelectasis, pulmonary edema), decrease chest wall compliance (eg, kyphoscoliosis), increase airway resistance (eg, bronchitis, asthma), or decrease lung recoil (eg, emphysema) can increase the work of breathing so much that one-third or more of the total body energy is used for ventilation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: N/A TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 421

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34. Based on the oxyhemoglobin dissociation curve, respiratory acidosis will have which effect? a. A shifting of the curve to the left b.

Increased oxygen saturation c. Enhanced oxygen delivery at the tissue level d.

Hypothermia ANS: C When the curve is shifted to the right, as occurs in acidosis, although the saturation is lower than expected, a right shift enhances oxygen delivery at the tissue level because hemoglobin unloads more readily.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 428-429|Figure 16-23 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 35. The lobes are divided into 18 segments. How many are on the right lung? a. 3 b. 8 c. 10 d. 15 ANS: C The lobes are divided into 18 segments, each of which has its own bronchus branching immediately off a lobar bronchus. Ten segments are located in the right lung and eight in the left lung.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 411

36. Which pleura adheres to the lungs? a. Parietal b.

Visceral c. Intrapleural d.

Surfactant ANS: B The visceral pleura adheres to the lungs, extending onto the hilar bronchi and into the major fissures.

The parietal pleura lines the inner surface of the chest wall and mediastinum. The pleural space has a pressure within it called the intrapleural pressure. Surfactant is responsible for preventing the alveoli from completely collapsing on exhalation.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 411

37. Which nerve stimulates movement of the diaphragm? a. Musculocutaneous nerve b.

Phrenic nerve

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c. Median nerve d.

Axillary nerve ANS: B The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and fifth cervical nerves. The other nerves control use and feeling of the arms.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 413-414

38. Trauma to which vertebrae will cause ventilation dysfunction? a. C3 to C5 b. C5 to T3 c. T4 to T6 d.

T7 to T10 ANS: A The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and fifth cervical nerves. For this reason and because the diaphragm does most of the work of inhalation, trauma involving levels C3 to C5 causes ventilation dysfunction.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 414

MULTIPLE RESPONSE 1. Muscles of exhalation include which of the following? (Select all that apply.) a. Abdominal b.

Diaphragm c. External intercostals d.

Internal intercostals e.

Scalene ANS: A, D Exhalation occurs when the diaphragm relaxes and moves back up toward the lungs. The intrinsic elastic recoil of the lungs assists with exhalation. Because exhalation is a passive act, there are no true muscles of exhalation other than the internal intercostal muscles, which assist the inward movement of the ribs.

PTS: 1 DIF: Cognitive Level: Remembering REF: p. 414 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Anatomy and Physiology MSC: NCLEX: Physiologic Integrity 2. The lymphatic system plays which of the following important roles? (Select all that apply.) a. Ridding lung tissue of excess CO2 b. Connecting the thebesian veins to the coronary circulation

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c. Removing fluid from the lungs d.

Producing immune responses e. Removing cell debris from the lungs ANS: C, D, E The lymphatic system in the lungs serves two purposes. As part of the immune system, it is responsible for removing foreign particles and cell debris from the lungs and for producing both antibody and cell-mediated immune responses. It also is responsible for removing fluid from the lungs and for keeping the alveoli clear.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 420 OBJ: Nursing Process Step: N/A TOP: Pulmonary Anatomy and Physiology MSC: NCLEX: Physiologic Integrity

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Chapter 17: Pulmonary Clinical Assessment Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what condition? a. Hypoxia b.

Dyspnea c. Dehydration d.

Malnutrition ANS: A Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty breathing.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 431

2. Which lung sounds would be most likely heard in a patient experiencing an asthma attack? a. Coarse rales b. Pleural friction rub c.

Fine crackles d. Expiratory wheezes ANS: D Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural surfaces rubbing together and is caused by inflammation of the pleura.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 436|pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 3. Which statement describes the major difference between tachypnea and hyperventilation? a. Tachypnea has increased rate; hyperventilation has decreased rate. b.

Tachypnea has decreased rate; hyperventilation has increased rate. c. Tachypnea has increased depth; hyperventilation has decreased depth. d.

Tachypnea has decreased depth; hyperventilation has increased depth.

ANS: D

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Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation.

Hyperventilation is manifested by an increase in both the rate and depth of ventilation.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 433

4. A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient’s tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern b. Absent breath sounds in the right lower lung fields c.

Absent breath sounds in the left lung fields d. Diminished breath sounds in the right upper lung fields ANS: C The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 438|Table 17-2

5. While palpating a patient’s lungs the nurse notes fremitus over the patient’s trachea but not the lung periphery. What do these findings indicate? a. Bilateral pleural effusion b.

Bronchial obstruction c. A normal finding d. Apical pneumothorax ANS: C Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 434

6. Which chest wall deformity is characterized by an increase in anteroposterior (AP) diameter with displacement of the sternum forward and the ribs outward? a. Funnel chest b.

Pigeon breast c. Barrel chest

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d. Harrison’s groove ANS: C Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are related to restrictive pulmonary disease. Harrison’s groove, a rib deformity, is a result of rickets.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 431

7. A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important. What is the appropriate intervention at this time for obtaining this data? a. Collect an overview of past medical history, present history, and current health status. b. Do not obtain any history at this time. c. Curtail the history to just a few questions about the patient’s chief complaint and precipitating events. d. Complete the history and then provide measures to assist the patient to breathe easier.

ANS: C The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient’s chief complaint and the precipitating events.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 431

8. While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient’s breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation b.

Tachypnea c. Obstructive breathing d.

Bradypnea ANS: B Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation.

Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.

PTS:

1

DIF:

Cognitive Level: Applying

REF: p. 433

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OBJ: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity

TOP: Pulmonary

9. Which condition is an example of a disorder with increased tactile fremitus? a. Emphysema b. Pleural effusion c.

Pneumothorax d. Pneumonia ANS: D Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease fremitus.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 434

10. What is the sequence for auscultation of the anterior chest? a. Right side, top to bottom, then left side, top to bottom b. Left side, top to bottom, then right side, top to bottom c. Side to side, bottom to top d. Side to side, top to bottom ANS: D Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.

PTS: 1 DIF: Cognitive Level: Remembering 8 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 436|Figure 17-

11. A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b.

Pneumonia c. Pulmonary fibrosis d.

Atelectasis ANS: A Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 433|p. 439|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

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12. When auscultating a patient’s lungs, the nurse notes breath sounds that sound like popping in the small airways. What should the nurse document in the patient’s record? a. Sonorous wheezes b.

Crackles c. Sibilant wheezes d. Pleural friction rub ANS: B Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.

PTS: 1 DIF: Cognitive Level: Applying 8 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 436|Figure 17-

13. In what condition are bronchophony, egophony, and whispering pectoriloquy increased? a. Pneumonia with consolidation b.

Pneumothorax c. Asthma d. Bronchiectasis ANS: A Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an “a” sound when the patient is saying “e.”

PTS: 1 DIF: Cognitive Level: Applying REF: p. 436|pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 14. A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease (COPD). Upon inspection of the patient, the nurse observes that the patient’s fingers appear discolored. What does this finding indicate the presence of? a. Clubbing b. Central cyanosis c. Peripheral cyanosis d.

Chronic tuberculosis ANS: C Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life- threatening situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of oxygen often related to a heart or lung disease.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 431

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15. A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which tone? a. Resonance b. Hyperresonance c.

Tympany d. Dullness ANS: B The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung.

Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 436|Table 17-1

16. A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema b.

Atelectasis c. Pulmonary fibrosis d.

Pleural effusion ANS: D A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 438|Table 17-2

17. A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurses notes that the patient has difficulty getting breath out. Which phrase best describes the patient’s breathing pattern? a. Deep sighing breaths without pauses b.

Rapid, shallow breaths c. Normal breathing pattern interspersed with forced expirations d.

Irregular breathing pattern with both deep and shallow breaths ANS: C Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until the patient actively and forcefully exhales.

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PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 433

18. A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right b. A shift to the left c. No deviation d. Subcutaneous emphysema ANS: A With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 433-434

19. The nurse is caring for a patient with respiratory failure. The nurse notes the patient’s diaphragmatic excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and emphysema b. Hepatomegaly and ascites c. Atelectasis and pleural effusion d.

Pneumonia and pneumothorax ANS: C Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 435

20. When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b.

Palpation c. Percussion d. Auscultation ANS: B

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Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient.

Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 431 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 21. When assessing a patient, the use of observation is referred to as what technique? a. Inspection b.

Palpation c. Percussion d. Auscultation ANS: A Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures.

Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 431 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 22. What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b.

Palpation c. Percussion d. Auscultation ANS: C Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 431 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 23. What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b.

Palpation

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c. Percussion d. Auscultation ANS: D Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 431 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 24. The nurse is observing a new graduate listen to a patient’s lungs. Which action by the new graduate indicates a need to review auscultation skills? a. The nurse starts at the apices and moves to the bases. b. The nurse compares breath sounds from side to side. c. The nurse listens during inspiration. d. The nurse listens posteriorly, laterally, and anteriorly.

ANS: C Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly PTS: 1 DIF: Cognitive Level: Applying REF: pp. 436-437|Figure 17-8 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 25. The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis.

Which finding is unexpected? a. Diminished thoracic expansion b. Tracheal deviation to the most affected side c.

Hyperresonant percussion tones d. Decreased breath sounds ANS: C Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 26. The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected? a. Rasping productive cough b.

Decreased tactile fremitus

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c. Resonant percussion tones d.

Crackles and wheezes ANS: B Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus.

Decreased tactile fremitus is not associated with acute bronchitis.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 27. The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected? a. Increased diaphragmatic excursion b.

Decreased tactile fremitus c. Dull percussion tones d.

Pleural friction rub ANS: A Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion.

Increased diaphragmatic excursion is not associated with acute bronchitis.

PTS: 1 DIF: Cognitive Level: Applying REF: pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity MULTIPLE RESPONSE 1. How does the patient history assist the nurse in developing the management plan? (Select all that apply.) a. Provides direction for the rest of the assessment b.

Exposes key clinical manifestations c. Aids in developing the plan of care d. The degree of the patient’s distress determines the extent of the interview e.

Determines length of stay in the hospital setting ANS: A, B, C, D The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient’s chief complaint and precipitating events.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 431 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 2. Deviation of the trachea occurs in which conditions? (Select all that apply.) a. Pneumothorax b. Pulmonary fibrosis

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c. Chronic obstructive pulmonary disease d.

Emphysema e. Pleural effusion ANS: A, B, E Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

PTS: 1 DIF: Cognitive Level: Applying REF: p. 433 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment MSC: NCLEX: Physiologic Integrity 3. Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that apply.) a. Normal lung b. Bronchiectasis c.

Emphysema d. Acute bronchitis e. Diffuse pulmonary fibrosis ANS: A, B, D The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment and evaluation.

PTS: 1 DIF: Cognitive Level: Understanding REF: pp. 439-443|Table 17-3 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

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Chapter 18: Pulmonary Diagnostic Procedures Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. The patient’s arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and , 24 mEq/L. What is the interpretation of the patient’s ABG? a.

Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c.

Compensated respiratory acidosis d. Compensated respiratory alkalosis ANS: B The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and

greater than 26 mEq/L. Compensated respiratory alkalosis

values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and

above 26 mEq/L.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 447|Table 18-1

2. On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm Hg. The patient’s arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38; PaCO2, 52 mm Hg; and , 34 mEq/L. What diagnoses would be most consistent with the above arterial blood gas values? a.

Acute pulmonary embolism b.

Acute myocardial infarction c.

Congestive heart failure d. Chronic obstructive pulmonary disease ANS: D The fact that the level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust.

The other choices would present with a lower level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary

REF: p. 447|Table 19-2

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MSC: NCLEX: Physiologic Integrity 3. On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient’s arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and action should the nurse anticipate for this patient? a. Initiate oxygen therapy. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d.

Initiate capnography.

, 26 mEq/L. What

ANS: A The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient’s arterial blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level. Capnography would not be indicated at this time as the patient’s CO2 is normal. A repeat ABG may be ordered to assess the patient’s ongoing respiratory status.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Intervention TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 446-447

4. The patient’s arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and , 16 mEq/L. What is the interpretation of the patient’s ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c.

Compensated metabolic acidosis d. Compensated respiratory acidosis ANS: B The pH is below normal range (7.35 to7.45), so this is uncompensated acidosis. The PaCO2 normal and the

is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated

metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and

of 22 to 26 mEq/L. Compensated

metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and

above 26 mEq/L.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 447|Table 18-1

5. In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? a. PaO2/FiO2 ratio

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b. A-a gradient c. Residual volume (RV) d. End-tidal CO2 ANS: D Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 450|p. 453

6. A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; PaCO2, 35 mm Hg; and , 11 mEq/L. What is the interpretation of the patient’s ABG? a. Uncompensated respiratory acidosis b.

Uncompensated metabolic acidosis c.

Uncompensated metabolic alkalosis d. Uncompensated respiratory alkalosis ANS: B The pH indicates acidosis, and the is markedly decreased, indicating a metabolic disorder.

Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and

of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include

a pH above 7.45, PaCO2 below 35 mm Hg, and

of 22 to 26 mEq/L. Uncompensated metabolic

alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and PTS: 1 DIF: Cognitive Level: Understanding REF: OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

above 26 mEq/L.

p. 447|Table 18-1

7. A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35 mm Hg; and , 11 mEq/L. What symptom would be most consistent with the ABG values? a. Diarrhea b. Shortness of breath c.

Central cyanosis

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d. Peripheral cyanosis ANS: A Diarrhea is one mechanism by which the body can lose large amounts of . The other choices are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 447|Table 18-2

8. A bronchoscopy is indicated for a patient with what condition? a. Pulmonary edema b. Ineffective clearance of secretions c.

Upper gastrointestinal bleed d. Instillation of surfactant ANS: B Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 448

9. A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The practitioner would be most likely to prescribe which procedure? a. Thoracentesis b.

Bronchoscopy c. Ventilation-perfusion (V/Q) scan d.

Repeat chest radiograph ANS: A Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 449

10. A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses the patient’s rapid shallow breathing index (RSBI). Which result best suggests that the patient is ready for a spontaneous breathing trial? a. RSBI = 150 b. RSBI = 125 c. RSBI = 110 d.

RSBI = 90

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ANS: D The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is considered predictive of weaning success. If the patient is receiving sedation, the medication is discontinued at least 1 hour before the RSBI is measured. If the patient meets criteria for weaning readiness and has an RSBI of less than 105, a spontaneous breathing trial can be performed.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Evaluation TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 451|Table 18-5

11. Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Acute myocardial infarction c.

Emphysema d. Acute respiratory distress syndrome ANS: A This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 451

12. A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest radiography and reading are obtained. Which finding best supports the nurse’s suspicions? a.

Blackness in the left lower lung area b.

Whiteness in the left lower lung area c. Blunted costophrenic angles d. Elevated left hemidiaphragm ANS: A With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 452

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13. A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the practitioner intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. Endtidal CO2 monitor c. Ventilation-perfusion (V/Q) scan d. Pulmonary artery catheter insertion ANS: B Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient’s respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 453

14. A patient’s pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient’s condition. c. Turn off the alarm and reapply the oximeter sensor. d.

Increase O2 level to 4L/NC. ANS: B The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 454

15. Which patient would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80 ANS: B

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Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg – 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg – 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg – 8 mm Hg = 72 mm Hg. PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 445

16. Which blood gas parameter is the acid–base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3¯ ANS: D The bicarbonate ( ) is the acid–base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: pp. 445-446

17. Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis? b. , 22 mEq/L pH, a. pH, 7.29; PaCO2, 57 mm Hg; c.

7.36; PaCO2, 33 mm Hg; , 18 mEq/L pH, 7.22; d.

PaCO2, 42 mm Hg; , 18 mEq/L pH, 7.52; PaCO2, 38 mm Hg; , 29 mEq/L ANS: C A pH of 7.22 is below normal, reflecting acidosis. The metabolic component ( ) is low, indicating that the acidosis is metabolic in origin. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and

below 22 mEq/L.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 446|Box 18-2 | p. 447|Table 18-1 OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 18. Which ABG values reflect compensation? a. pH, 7.26; PaCO2, 55 mm Hg; , 24 mEq/L

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b.

c. , 18 mEq/L pH, d.

7.48; PaCO2, 30 mm Hg; , 22 mEq/L pH, 7.38; PaCO2, 58 mm Hg; , 30 mEq/L pH, 7.30; PaCO2, 32 mm Hg;

ANS: D The pH is within normal limits, and both the PaCO2 and the values are abnormal.

Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L. PTS: 1 DIF: Cognitive Level: Understanding REF: p. 446|Box 18-3 | p. 448|Table 18-1 OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity 19. Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. d. Hemoglobin (Hgb) ANS: D Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 446

20. A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the following is important for obtaining the best specimen? a. After the specimen is in the container, dilute thick secretions with sterile water. b. Apply suction when the catheter is advanced to obtain secretions from within the endotracheal tube. c. Do not apply suction while the catheter is being withdrawn because this can contaminate the sample with sputum left in the endotracheal tube. d. Do not clear the endotracheal tube of all local secretions before obtaining the specimen.

ANS: C To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.

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PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Intervention TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 449|Box 18-4

21. What medication may be included in the preprocedural medications for a diagnostic bronchoscopy? a. Aspirin for anticoagulation b. Vecuronium to inhibit breathing c. Codeine to decrease the cough reflex d. Cimetidine to decrease hydrochloric acid secretion ANS: C Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular codeine. Whereas atropine lessens the vasovagal response and reduces the secretions, codeine decreases the cough reflex. When a bronchoscopy is performed therapeutically to remove secretions, decreased cough and gag reflexes are present, which may impair secretion clearance.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Intervention TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 449

22. Severe coughing and shortness of breath during a thoracentesis are indicative of what complication? a. Re-expansion pulmonary edema b.

Pleural infection c. Pneumothorax d.

Hemothorax ANS: A Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to 1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to discontinue the thoracentesis.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 450

23. A static lung compliance of 40 mL/cm H2O is indicative of which disorder? a. Pneumonia b. Bronchospasm c. Pulmonary emboli d. Upper airway obstruction ANS: A

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Static compliance is measured under no-flow conditions so that resistance forces are removed. Static compliance decreases with any decrease in lung compliance, such as occurs with pneumothorax, atelectasis, pneumonia, pulmonary edema, and chest wall restrictions. A normal value is 57 to 85 mL/cm of H2O. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 450

24. A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test most conclusive to determine this diagnosis? a. ABG b. Bronchoscopy c. Pulmonary function test d. V/Q scan ANS: D A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the bronchi, and pulmonary function tests are used to measure lung volume.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 451

25. What chest radiography finding is consistent with a left pneumothorax? a. Flattening of the diaphragm b. Shifting of the mediastinum to the right c.

Presence of a gastric air bubble d. Increased radiolucency of the left lung field ANS: B Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 452

26. What does an intrapulmonary shunting value of 35% indicate? a. Normal gas exchange of venous blood b. An abnormal finding indicative of a shunt-producing disorder c. A serious and potentially life-threatening condition d. Metabolic alkalosis ANS: C A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.

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PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 447

27. A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas (ABG) values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3¯, 27 mEq/L. What is the correct interpretation of the patient’s ABG values? a. Compensated respiratory acidosis b.

Compensated metabolic alkalosis c. Uncompensated respiratory alkalosis d.

Uncompensated metabolic acidosis ANS: A The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and

above 26 mEq/L. Uncompensated respiratory alkalosis

values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above 45 mm Hg, and

above 26 mEq/L. Uncompensated metabolic acidosis values include a pH

above 7.35, PaCO2 of 35 to 45 mm Hg, and

below 22 mEq/L.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Pulmonary MSC: NCLEX: Physiologic Integrity

REF: p. 447|Table 18-1

28. Place the steps for analyzing arterial blood gases in the proper order.

1. Assess level for metabolic abnormalities 2. Assess PaO2 for hypoxemia 3. Examine PaCO2 for acidosis or alkalosis 4. Re-examine pH to determine level of compensation 5. Examine pH for acidemia or alkalemia a. 5, 1, 2, 4, 3 b. 2, 5, 3, 1, 4 c. 1, 2, 4, 3, 5 d. 1, 3, 4, 5, 2 ANS: B A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes look at the PaO2 level, look at the pH level, look at the PaCO2 level, look at the

, and look again at the pH level.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 446|Box 18-1 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures MSC: NCLEX: Physiologic Integrity MULTIPLE RESPONSE

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1. What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that apply.) a. Coagulation defects b. Unstable hemodynamics c.

Pleural effusion d. Uncooperative patient e.

Empyema ANS: A, B, D No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an intraaortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 449 OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures MSC: NCLEX: Physiologic Integrity 2. Nursing management of a patient undergoing a diagnostic procedure entails what nursing actions?

(Select all that apply.) a. Positioning the patient for the procedure b. Monitoring the patient’s responses to the procedure c.

Monitoring vital signs d. Teaching the patient about the procedure e. Medicating the patient before and after procedure ANS: A, B, C, D, E Preparing the patient includes teaching the patient about the procedure, answering any questions, and positioning the patient for the procedure. Monitoring the patient’s responses to the procedure includes observing the patient for signs of pain and anxiety and monitoring vital signs, breath sounds, and oxygen saturation. Assessing the patient after the procedure includes observing for complications of the procedure and medicating the patient for any postprocedural discomfort.

PTS: 1 DIF: Cognitive Level: Understanding REF: p. 453 OBJ: Nursing Process Step: Intervention TOP: Pulmonary Diagnostic Procedures MSC: NCLEX: Physiologic Integrity

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Chapter 19: Kidney Clinical Assessment and Diagnostic Procedures Test Bank MULTIPLE CHOICE 1. Which of the following assessment findings would indicate fluid volume excess? a. Venous filling of the hand veins greater than 5 seconds b. Distended neck veins in the supine position c. Presence of orthostatic hypotension d. Third heart sound ANS: D

Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

2. Loss of albumin from the vascular space may result in a. peripheral edema. b. extra heart sounds. c.

hypertension. d. hyponatremia.

ANS: A

Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of proteincalorie malnutrition, which occurs in many critically ill patients in whom available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.

3. Which of the following auscultatory parameters may exist in the presence of hypovolemia? a. Hypertension b. Third or fourth heart sound c. Orthostatic hypotension d. Vascular bruit ANS: C

A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position.

The heart rate increases in an attempt to maintain cardiac output and circulation.

4. Percussion of kidneys is usually done to a. assess the size and shape of the kidneys. b. detect pain in the renal area. c. elicit a fluid wave. d. evaluate fluid status.

ANS: B

Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems.

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5. Differentiating ascites from distortion caused by solid bowel contents in the

distended abdomen is accomplished by assessing for bowel sounds in four quadrants. palpation of the liver margin. measuring abdominal girth. the presence of a fluid wave.

a. b. c. d.

ANS: D

Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.

6. The most important assessment parameters for evaluating the patient's fluid status is

to measure daily weights. urine and serum osmolality. intake and output. hemoglobin and hematocrit levels.

a. b. c. d.

ANS: A

One of the most important assessments of kidney and fluid status is the patient’s weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

7. Which of the following parameters is indicative of volume overload? a. Central venous pressure of 4 mm Hg b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c. Cardiac index of 2.5 L/min/m2 d. Mean arterial pressure of 40 mm Hg ANS: B

The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.

8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release

of a. b. c. d.

ketones. glucagon. antidiuretic hormone. potassium.

ANS: C

When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules.

This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.

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9. Which of the following urine values reflects a decreased ability of the kidneys to

concentrate urine? pH of 5.0 Specific gravity of 1.000 No casts Urine sodium of 140 mEq/24 hr

a. b. c. d.

ANS: B

Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

10. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse suspects the main cause of ascites is a. hypervolemia. b. dehydration. c. volume overload. d. liver damage.

ANS: C

Individuals with kidney failure may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess. Severe ascites in persons with compromised liver function may result from decreased plasma proteins. The ascites occurs because the increased vascular pressure associated with liver dysfunction forces fluid and plasma proteins from the vascular space into the interstitial space and abdominal cavity.

Although the individual may exhibit marked edema, the intravascular space is volume depleted, and the patient is hypovolemic.

11. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. Which of the following diagnostic tests would give the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a.

Kidney–ureter–bladder (KUB) b.

Intravenous pyelography (IVP) c. Renal ultrasonography (ECHO) d.

Renal angiography ANS: B

Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidney–ureter–bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests.

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fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

12. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient weight upon admission was 176 lb. The patient’s weight the next day is 184 lb. What is the approximate amount of fluid retained with this weight gain? a. 800 mL b.

2200 mL c. 3600 mL d.

8000 mL ANS: C

One liter of fluid equals 1 kg, which is 2.2 pounds; 8 pounds equals 3.6 kg, which is 3.6 liters; 3.6 liters is equal to 3600 mL. 13. When calculating the anion gap, the predominant cation is a. sodium. b. potassium. c. chloride. d. bicarbonate.

ANS: A

The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.

14. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The patient urinalysis has a specific gravity of 1.040. What could be the potential cause for this value? a. Volume overload b. Volume deficit c. Acidosis d. Urine ketones ANS: B

Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI).

Possible causes for decreased values include volume overload and interrenal AKI.

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15. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse is assessing the peripheral edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. The nurse would chart the following result: a. +1 pitting b. edema. +2 pitting edema. c. +3 pitting edema. d. +4 pitting edema.

ANS: C

The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 sec); +3 = 6-mm depth (lasting up to 60 sec); and +4 = 8-mm depth (lasting longer than 60 sec).

16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that

the patient has developed a.

glycosuria. b.

proteinuria. c.

myoglobin. d. uremia.

ANS: D

A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine. Myoglobin is the presence of red blood cells in the urine.

17. A patient has been on complete bed rest for 3 days. The health care provider has ordered

for the patient to sit at the bedside for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse anticipates that the patient is experiencing a. orthostatic b. hypertension. orthostatic hypotension. c. hypervolemia. d. electrolyte imbalance.

ANS: B

Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness.

Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.

MULTIPLE RESPONSE 1. Which of the following may be present in the patient with significant fluid volume

overload?

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(Select all that apply.) a.

S3 or S4 may develop. b.

Distention of the hand veins will disappear if the hand is elevated. c. When testing the quality of skin turgor, the skin will not return to the normal position for several seconds. d.

Tachycardia with hypotension may be present. e.

Dependent edema may be present.

ANS: A, E

A gallop and dependent edema are indicative of fluid excess; the other signs are indicative of fluid volume deficit.

2. A patient is admitted to the critical care unit in congestive heart failure secondary to renal

insufficiency. The patient reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse would expect to see elevated values in the following laboratory results: (Select all that apply). a. BUN. b. creatinine. c. glucose. d. hemoglobin and hematocrit. e. protein.

ANS: A, B, D

With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with kidney failure resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney failure, anemia may occur early in the disease.

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MULTIPLE CHOICE 1. An elderly patient is in a motor vehicle accident and sustains a significant internal

hemorrhage. Which category of renal failure is the patient at the greatest risk of developing? a. Intrinsic b. Postrenal c. Prerenal d. Acute tubular necrosis ANS: C

Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases. Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal AKI. Any obstruction that hinders the flow of urine from beyond the kidney through the remainder of the urinary tract may lead to postrenal AKI. When the internal filtering structures are pathologically affected, the condition was previously known as acute tubular necrosis.

2. Which of the following laboratory values is the most help in evaluating a patient for

acute renal failure? a. Serum sodium b.

Serum c. creatinine Serum potassium d.

Urine potassium ANS: B

Serum creatinine is the most reliable predictor of kidney function. In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function.

3. Which of the following IV solutions is recommended for treatment of prerenal

failure? a. b. c. d.

Dextrose in water Normal saline Albumin Lactated Ringer solution

ANS: B

Prerenal failure is caused by decreased perfusion and flow to the kidney. It is often associated with trauma, hemorrhage, hypotension, and major fluid losses. If contrast dye is used, aggressive fluid resuscitation with normal saline (NaCl) is recommended.

4. One therapeutic measure for treating hyperkalemia is the administration of dextrose

and regular insulin. How do these agents lower potassium? a. They force potassium out of the cells and into the serum, lowering it on a cellular

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leve l. b. They promote higher excretion of potassium in the urine. c. They bind with resin in the bowel and are eliminated in the feces. d. They force potassium out of the serum and into the cells, thus causing potassium to lower.

ANS: D

Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.

5. Which of the following IV solutions is contraindicated for patients with kidney or

liver disease or in lactic acidosis?

D5W 0.9% NaCl Lactated Ringer solution 0.45% NaCl

a. b. c. d.

ANS: C

Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.

6. To assess whether or not an arteriovenous fistula is functioning, what must be done and

why? a. Palpate the quality of the pulse distal to the site to determine whether a thrill is

present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. b. Palpate the quality of the pulse proximal to the site to determine whether a thrill is present; auscultate with a stethoscope to appreciate a bruit to assess the quality of the blood flow. c. Palpate gently over the site of the fistula to determine whether a thrill is present; listen with a stethoscope over this site to appreciate a bruit to assess the quality of the blood flow. d. Palpate over the site of the fistula to determine whether a thrill is present; check whether the extremity is pink and warm.

ANS: C

The critical care nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula.

7. To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the

blood and a negative hydrostatic pressure is applied to the dialysate bath. This process is known as a. ultrafiltration. b. hemodialysis. c. reverse osmosis. d. colloid extraction.

ANS: A

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To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space.

8. Which electrolytes pose the most potential hazard if not within normal limits for a person

with renal failure?

Phosphorous and calcium Potassium and calcium Magnesium and sodium Phosphorous and magnesium

a. b. c. d.

ANS: B

Although most electrolytes, such as potassium, become increasingly elevated in patients with acute renal failure, calcium levels are reduced. In each case, these conditions produce life- threatening cardiac dysrhythmias.

9. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection

developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic.

After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). Which dialysis method would be most appropriate for the patient’s condition? a. Peritoneal dialysis b. Hemodialysis c. Continuous renal replacement therapy d. Continuous venovenous hemodialysis (CVVH) ANS: B

As a treatment, hemodialysis literally separates and removes from the blood the excess electrolytes, fluids, and toxins by use of a hemodialyzer. Although hemodialysis is efficient in removing solutes, it does not remove all metabolites. Furthermore, electrolytes, toxins, and fluids increase between treatments, necessitating hemodialysis on a regular basis.

10. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection

developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic.

After 3 days of administration, oliguria occurred, and subsequent laboratory values indicated elevated BUN and creatinine levels. The patient is transferred to the critical care unit with acute kidney injury (previously known as acute tubular necrosis). The fluid that is removed each hour is not called urine; it is known as a. convection. b. diffusion. c. replacement fluid. d. ultrafiltrate.

ANS: D

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The fluid that is removed each hour is not called urine; it is known as ultrafiltrate.

Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it.

11. The most common site for short-term vascular access for immediate hemodialysis is

the a. b. c. d.

subclavian artery. subclavian vein. femoral artery. radial vein.

ANS: B

Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same catheterized vein. A dual-lumen venous catheter is most commonly used.

12. A patient has acute kidney injury (previously known as acute tubular necrosis). The following

blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3, a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum potassium, 4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately and why? a. Administration of 5% dextrose in water and insulin because the patient is hyperkalemic and needs this level reduced b. Administration of Epogen to treat anemia c. Administration of a broad-spectrum antibiotic to treat the elevated blood cell count d. Administration of a calcium supplement for low calcium ANS: B

A patient showing signs of anemia per his hematocrit and hemoglobin must be treated. Epogen is used because it helps stimulate erythrocyte production by the bone marrow.

13. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an

amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Which of the statements best describes CVVH? a. Complete renal replacement therapy requiring large volumes of ultrafiltrate and filter replacement b. Complete renal replacement therapy that allows removal of solutes and modification of the volume and composition of extracellular fluid to occur evenly over time c. Involves the introduction of sterile dialyzing fluid through an implanted catheter Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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into the abdominal cavity, which relies on osmosis, diffusion, and active transport to help remove waste from the body d. Complete renal replacement therapy that allows an exchange of fluid, solutes, and solvents across a semipermeable membrane at 100 to 300 mL/hr ANS: B

Continuous venovenous hemodialysis is indicated when the patient’s clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr. Removal of solutes such as urea, creatinine, and other small non–protein-bound toxins is accomplished by convection. The replacement fluid rate of flow through the continuous renal replacement therapy circuit can be altered to achieve desired fluid and solute removal without causing hemodynamic instability.

14. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an

amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Identify three complications of CVVH therapy. a. Fat emboli, increased ultrafiltration, and hypertension b. Hyperthermia, overhydration, and power surge c. Air embolism, decreased inflow pressure, and electrolyte imbalance d. Blood loss, decreased outflow resistance, and acid–base imbalance ANS: C

Air embolism, decreased inflow pressure, electrolyte imbalances, blood leaks, access failure, and clotted hemofilter are just a few complications that can occur with continuous venovenous hemodialysis.

15. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an

amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter, which was placed into her right femoral access, and started on vasopressors with a fair response (BP, 80/50 mm Hg; HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis, the patient was begun on CVVH. Why would this therapy be chosen for this patient? a. Hyperdynamic patients can better tolerate abrupt fluid and solute changes. b. It is the treatment of choice for patients with diminished renal perfusion who are unresponsive to diuretics. c. It is indicated for patients who require large-volume removal for severe uremia or critical acid–base imbalances. d. It is indicated for hemodynamically unstable patients, who are often intolerant of the abrupt fluid and solute changes that can occur with hemodialysis.

ANS: D

Continuous venovenous hemodialysis is indicated for patients who require large-volume removal for severe uremia or critical acid–base imbalances or for those who are resistant to diuretics.

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16. What is a continuous venovenous hemodialysis filter permeable to? a. Electrolytes b. Red blood cells c. Protein d. Lipids ANS: A

A continuous venovenous hemodialysis filter is permeable to solutes such as urea, creatinine, uric acid, sodium, potassium, ionized calcium, and drugs not bound by proteins.

17. A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C.

Her BUN level is elevated. She continues on vasopressor therapy. What other steps should be taken to protect the patient from inadequate organ perfusion? a. Increase net ultrafiltrate of fluid. b. Discontinue vasopressor support. c. Assess the patient for blood loss and hypotension. d. Notify the physician of access pressures.

ANS: C

The patient should be assessed for blood loss or response to blood products and medications. The nurse should use ordered vasopressor support and decrease the net ultrafiltrate to zero.

18. To control azotemia, the recommended nutritional intake of protein is a. .5 to 1.0 g/kg/day. b. 1.2 to 1.5 g/kg/day. c. 1.7 to 2.5 g/kg/day. d. 2.5

to 3.5 g/kg/day.

ANS: B

The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 grams/kg of protein per day to control azotemia (increased blood urea nitrogen level).

19. Which of the following diuretics maybe combined to work on different parts of the nephron? a. Loop and thiazide diuretics b. Loop and osmotic diuretics c. Osmotic and carbonic anhydrase inhibitor diuretics d. Thiazide and osmotic diuretics ANS: A

A thiazide diuretic such as chlorothiazide (Diuril) or metolazone (Zaroxolyn) may be administered and followed by a loop diuretic to take advantage of the fact that these medications work on different parts of the nephron. Sometimes a thiazide diuretic is added to a loop diuretic to compensate for the development of loop diuretic resistance.

20. What is the dose for low-dose dopamine? a. 1 to 2 mcg/kg/min b. 1 to 2 mg/kg/min c. 2 to 3 mcg/kg/min d. 2

to 3 mg/kg/min ANS: C

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Low-dose dopamine (2–3 mcg/kg/min), previously known as renal-dose dopamine, is frequently infused to stimulate blood flow to the kidney. Dopamine is effective in increasing urine output in the short term, but tolerance of the dopamine renal receptor to the medication is theorized to develop in the critically ill patients who are most at risk for acute kidney injury.

21. Laboratory results come back on a newly admitted patient. They are as follows: serum

BUN, 64 mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity, 1.002; and urine sodium, 96 mEq/L. The urine output has been 120 mL since admission 2 hours ago. These values are most consistent with which of the following diagnoses? a. Prerenal failure b. Postrenal failure c. Oliguric renal failure d. Acute kidney injury (AKI) ANS: D

Urinary sodium less than 10 mEq/L (low) suggests a prerenal condition. Urinary sodium greater than 40 mEq/L (in the presence of an elevated serum creatinine and the absence of a high salt load) suggests intrarenal damage has occurred. The urine output does not seem to suggest oliguria. The other options do not fit the data as presented.

22. A patient with renal failure reports all of the following during the medical history. Which

is most likely to have precipitated the patient’s renal failure?

Recent computed tomography of the brain with and without contrast A recent bout of congestive heart failure after an acute myocardial infarction Twice-daily prescription of Lasix 40 mg by mouth A recent bout of benign prostatic hypertrophy and transurethral resection of the prostate

a. b. c. d.

ANS: A

Intravenous contrast media can be nephrotoxic, especially with the patient’s preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media.

23.

An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is 88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral edema noted. Which of the following treatments would the physician most likely order? a. Lasix 40 mg intravenous push b. 0.9% normal saline at 125 mL/hr c. Dopamine 15 /kg/min d. Transfuse 1 U of packed red blood cells ANS: B

The patient’s hemodynamic parameters are most consistent with hypovolemia. The renal failure would then most probably be prerenal from inadequate blood flow. The treatment of choice for hypovolemia is fluid resuscitation. Important criteria when calculating fluid volume replacement include baseline metabolism, environmental temperature, and humidity. The rate of replacement depends on cardiopulmonary reserve, adequacy of kidney function, urine output, fluid balance, ongoing loss, and type of fluid replaced.

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24. A patient in acute renal failure presents with a potassium level of 6.9 mg/dL. He has had no

urine output in the past 4 hours despite urinary catheter insertion and Lasix 40 mg intravenous push. Vital signs are as follows: HR, 76 beats/min; respiratory rate, 18 breaths/min; and BP, 145/96 mm Hg. He is given 100 mL of 50% dextrose in water and 20 U of regular insulin intravenous push. A repeat potassium level 2 hours later shows a potassium level of 4.5 mg/dL. What order would now be expected? a. Sodium Kayexalate 15 g PO b. Nothing; this represents a normal potassium level c. Lasix 40 mg IVP d. 0.9% normal saline at 125 mL/hr ANS: A

This patient appears to be in acute anuric renal failure. The potassium was not eliminated from the body; it was simply shifted intracellularly. Soon the potassium will return to the bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is not expected to work in the presence of anuria. The patient’s vital signs do not support hypovolemia. In the presence of anuria, a large fluid infusion can precipitate congestive heart failure.

25. A patient with chronic renal failure receives hemodialysis treatments 3 days a week.

Every 2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells.

What is the probable reason for this patient’s frequent transfusion needs? a. Too much blood phlebotomized for tests b. Increased destruction of red blood cells because of the increased toxin levels c. Lack of production of erythropoietin to stimulate red blood cell formation d. Fluid retention causing hemodilution ANS: C

In chronic renal failure, the kidneys do not produce sufficient amounts of erythropoietin in response to normal stimuli such as anemia or hypotension. The other choices are not reasons for frequent blood transfusions in this patient.

26. Which of the following medications is considered a loop diuretic? a. Acetazolamide (Diamox) b. Furosemide (Lasix) c. Mannitol d. Metolazone (Zaroxolyn) ANS: B

Loop diuretics include furosemide (Lasix), bumetanide (Bumex), and torsemide (Torsemide). Furosemide is the most frequently used diuretic in critical care patients. It may be administered orally, as an intravenous (IV) bolus, or as a continuous IV infusion.

Diamox is a carbonic anhydrase inhibitor diuretic. Mannitol is an osmotic diuretic, and Zaroxolyn is a thiazide diuretic.

MULTIPLE RESPONSE 1. Which of the following conditions is associated between kidney failure and

respiratory failure? (Select all that apply.) a. ARDS

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b. c. d. e.

Lower GFR Increased urine output Decreased urine output Decreased blood flow to the kidneys

ANS: A, B, D, E

Mechanical ventilation for respiratory failure can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the glomerular filtration rate, and decreases urine output. Kidney failure increases inflammation, causes the lung vasculature to become more permeable, and contributes to the development of acute respiratory distress syndrome.

2. To prevent catheter-associated UTI (CAUTI), the nurse should (Select all that apply.) a. insert urinary catheters using aseptic techniques. b. change the urinary catheter daily. c. review the need for the urinary catheter daily and remove promptly. d. flush the urinary catheter q8 hours to maintain patency. e. avoid unnecessary use of indwelling urinary catheters.

ANS: A, C, E

The key components of CAUTI prevention are to avoid unnecessary use of urinary catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters, review the need for the urinary catheter daily, and remove the catheter promptly.

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Chapter 21: Gastrointestinal Clinical Assessment and Diagnostic Procedures Test Bank MULTIPLE CHOICE 1. When assessing the gastrointestinal system, the order of assessment progresses in which of

the following?

Inspection, palpation, percussion, auscultation b.

Palpation, percussion, inspection, auscultation c.

Inspection, d. auscultation, percussion, palpation Palpation, inspection, auscultation, percussion a.

ANS: C

To prevent stimulation of gastrointestinal activity, the order for the assessment should be inspection, auscultation, percussion, and palpation.

2. When assessing the abdomen, how long must the nurse listen to the abdomen to be able

to accurately chart that bowel sounds are absent? a. 30 seconds in each quadrant b. 1 minute c.

3 minutes d. 5 minutes ANS: D

Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush).

3. Which assessment technique is most useful in detecting abdominal pathologic

conditions? a. b. c. d.

Percussion Palpation Inspection Auscultation

ANS: B

Palpation is the assessment technique that is most useful in detecting abdominal pathologic conditions. Both light and deep palpation of each organ and quadrant should be completed. Deep palpation is most helpful in detecting abdominal masses. Areas in which the patient complains of tenderness should be palpated last.

4. Which of the following findings is considered an abnormal gastrointestinal

assessment finding?

Visible peristaltic waves Hyper-resonance of the intestine High-pitched gurgling sounds in the small intestine Dull sounds over the liver and spleen

a. b. c. d.

ANS: A

Visible pulsations or peristaltic waves are considered an abnormal assessment finding.

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5. Which of the following serum laboratory values is increased in acute pancreatitis? a. Bilirubin b. Amylase c. Lactate dehydrogenase d. Ammonia ANS: B

Serum amylase will rise with acute pancreatitis. The other values are affected by hepatocellular disease.

6. The best diagnostic test for the determination of upper gastrointestinal bleeding is a. endoscopic retrograde cholangiopancreatography (ERCP). b. colonoscopy. c. endoscopy. d. angiography.

ANS: C

Endoscopy is the procedure of choice for the diagnosis of upper gastrointestinal (GI) bleeding. Colonoscopy permits viewing of the lower GI tract from the rectum to the distal ileum, and it is used to evaluate sources of lower GI bleeding. Angiography is used as a diagnostic and a therapeutic procedure. Diagnostically, it is used to evaluate the status of the GI circulation. Endoscopic retrograde cholangiopancreatography (ERCP) enables viewing of the biliary and pancreatic ducts, and it is used in the evaluation of pancreatitis.

7. Upon auscultation, the nurse hears borborygmi. This is a change in the patient’s condition.

The nurse suspects the patient maybe experiencing a. a complete ileus. b. early intestinal obstruction. c. abnormality of blood flow. d. peritonitis.

ANS: B

Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by hunger, gastroenteritis, or early intestinal obstruction. Decreased (hypoactive) bowel sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality of blood flow.

8. Nursing management of the patient undergoing an angiogram includes a. keeping the patient flat for 24 hours. b. inserting a nasogastric tube before the procedure. c. administering tap water enemas until clear. d. checking the patient's pulse distal to the injection site every 15 minutes.

ANS: D

Postprocedural assessment involves monitoring vital signs, observing the injection site for bleeding, and assessing neurovascular integrity distal to the injection site every 15 minutes for the first 1 to 2 hours. Depending on how the puncture site is stabilized after the procedure, the patient may have to remain flat in bed for a specified length of time.

9. Which of the following diagnostic procedures is used to identify gallstones and

hepatic abscesses?

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a. b. c. d.

Ultrasonography Abdominal radiography Angiography Liver scan

ANS: A

Abdominal ultrasonography is useful in evaluating the status of the gallbladder and biliary system, the liver, the spleen, and the pancreas. It plays a key role in the diagnosis of many acute abdominal conditions, such as acute cholecystitis and biliary obstructions, because it is sensitive in detecting obstructive lesions, as well as ascites. Ultrasonography is used to identify gallstones and hepatic abscesses, candidiasis, and hematomas.

10. A 78-year-old patient was admitted to the critical care unit with cirrhosis of the liver.

In cirrhosis of the liver, which of the following laboratory values is expected to drop?

Albumin Total bilirubin Alkaline phosphatase Aspartate aminotransferase

a. b. c. d.

ANS: A

In a patient with cirrhosis, total bilirubin, alkaline phosphatase, aspartate aminotransferase, and alanine aminotransferase values all show elevation, but albumin values drop as a result of the catabolism.

11. Signs and symptoms of which condition include nausea, localized right lower quadrant

guarding and tenderness after 12 to 24 hours, fever, and an elevated white blood cell count? a. Appendicitis b. Hepatitis c. Cecal volvulus d. Perforated duodenal ulcer ANS: A

Signs and symptoms of appendicitis include anorexia, nausea, and vomiting; early vague epigastric, periumbilical, or generalized pain after 12 to 24 hours; RLQ at McBurney point; localized RLQ guarding and tenderness after 12 to 24 hours; a white blood cell count of 10,000/mm or left shift; and low-grade fever. Signs are highly variable.

12. A health care provider has ordered an MRI (magnetic resonance imaging) of the liver.

The nurse’s first action is to a. prepare the patient psychologically and physically for the procedure. b. monitor the patient’s response to the procedure. c. assess the patient after the procedure. d. inform the patient’s family of the results.

ANS: A

The nursing management of a patient undergoing a diagnostic procedure involves a variety of interventions. Nursing actions include preparing the patient psychologically and physically for the procedure, monitoring the patient’s responses to the procedure, and assessing the patient after the procedure. Preparing the patient includes teaching the patient about the procedure, answering any questions, and transporting and positioning the patient for the procedure.

13. Steatorrhea is determined by which laboratory study?

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a. b. c. d.

Gastric acid stimulation Urea breath test Culture and sensitivity Stool studies

ANS: D

Steatorrhea (an increase of fat in the stool) results from malabsorption or pancreatic insufficiency and is determined with stool studies. The result of the urea breath test is positive if the patient has a Helicobacter pylori infection. Gastric acid stimulation is used for the detection of duodenal ulcers, gastric atrophy, and gastric carcinoma.

14. Which radiographic test would be used to identify pseudocysts of the pancreas? a. Plain film radiography b. Abdominal ultrasonography c. CT of abdomen d. MRI of the abdomen ANS: C

CT (Computed tomography) detects mass lesions more than 2 cm in diameter and allows visualization and evaluation of many different aspects of gastrointestinal (GI) disease. It is particularly useful in identifying pancreatic pseudocysts, abdominal abscesses, biliary obstructions, and a variety of GI neoplastic lesions.

15. The patient has just returned from a liver biopsy. The patient should be positioned on the a. left side for 2 hours. b. right side for 2 hours. c. left side for 6 to 8 hours. d. right side for 6 to 8 hours.

ANS: B

After the procedure, the patient is positioned on the right side for 2 hours and kept on complete bed rest for the next 6 to 8 hours.

MULTIPLE RESPONSE 1. Identify anatomic structures that are found in the right upper quadrant. (Select all that

apply.) a. Duodenum b. Portion of the transverse colon c. Liver d. Stomach e. Cecum ANS: A, B, C

The right upper quadrant includes the liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portion of the right kidney, hepatic flexure of colon, and a portion of the ascending and transverse colon. The stomach is located in the left upper quadrant and the cecum is located in the right lower quadrant.

2. Identify anatomic structures that are found in the right lower quadrant. (Select all that

apply.) a. Sigmoid colon

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b. c. d. e.

Portion of the ascending colon Portion of the descending colon Distended bladder Enlarged uterus

ANS: B, D, E

The right lower quadrant includes the lower pole of the right kidney, cecum and appendix, portion of the ascending colon, bladder (if distended), ovary and salpinx, uterus (if enlarged), right spermatic cord, and right ureter. The sigmoid colon and portion of the descending colon are found in the left lower quadrant.

3. Identify anatomic structures that are found in the left upper quadrant. (Select all that apply.) a. Stomach b. Spleen c. Portion of the transverse and descending colon d. Head of the pancreas e. Body of the pancreas ANS: A, B, C, E

The left upper quadrant includes the left lobe of the liver, spleen, stomach, body of the pancreas, left adrenal gland, portion of the left kidney, splenic flexure of the colon, and portions of the transverse and descending colon. The head of the pancreas is found in the right upper quadrant.

4. Identify anatomic structures that are found in the left lower quadrant. (Select all that apply.) a. Distended uterus b. Cecum and appendix c. Left ureter d. Portion of the descending colon e. Sigmoid colon ANS: A, C, D, E

The left lower quadrant includes the lower pole of the left kidney, sigmoid colon, portion of the descending colon, bladder (if distended), ovary and salpinx, uterus (if distended), left spermatic cord, and left ureter. The cecum and appendix is found in the right lower quadrant.

5. Potential complications of an endoscopy include (Select all that apply.) a. perforation of the GI tract. b. hemorrhage. c.

oversedation. d.

constipation. e. aspiration.

ANS: A, B, C, E

Fiberoptic endoscopy may present risks for the patient. Although rare, potential complications include perforation of the gastrointestinal (GI) tract, hemorrhage, aspiration, vasovagal stimulation, and oversedation. Signs of perforation include abdominal pain and distention, GI bleeding, and fever.

6. Inspection of the GI system should include the (Select all that apply.) a. mouth.

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b. c. d. e.

esophagus. skin. bladder. abdomen.

ANS: A, C, E

Although assessment of the gastrointestinal system classically begins with inspection of the abdomen, the patient’s oral cavity also must be inspected to determine any unusual findings.

Abnormal findings of the mouth include temporomandibular joint tenderness, inflammation of gums, missing teeth, dental caries, ill-fitting dentures, and mouth odor. The skin should be observed for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and venous pattern.

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Chapter 22: Gastrointestinal Disorders and Therapeutic Management Test Bank MULTIPLE CHOICE 1. Which of the following disorders is the leading cause of upper GI hemorrhage? a. Stress ulcers b. Peptic ulcers c. Nonspecific erosive gastritis d. Esophageal varices ANS: B

Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastromucosal lining, is the leading cause of upper GI hemorrhage, accounting for approximately 21% of cases.

2. Esophagogastric varices are the result of a. portal hypertension resulting in diversion of blood from a high-pressure area

to a low-pressure area. b. superficial mucosal erosions as a result of increased stress levels. c. proulcer forces breaking down the mucosal resistance. d. inflammation and ulceration secondary to nonsteroidal anti-inflammatory drug use.

ANS: A

Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop as a result of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids.

Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

3. The patient at risk for GI hemorrhage should be monitored for which of the following

signs and symptoms?

Metabolic acidosis and hypovolemia Decreasing hemoglobin and hematocrit Hyperkalemia and hypernatremia Hematemesis and melena

a. b. c. d.

ANS: D

The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

4. A nursing priority for a patient with GI hemorrhage is a. positioning the patient in a high-Fowler position. b. airway protection. c. irrigating the nasogastric tube with iced saline.

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d. maintaining venous access so that fluids and blood can be administered.

ANS: D

Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of co- morbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

5. The physician orders gastric lavage to control GI bleeding. The nurse has inserted a large-

bore NG tube. What temperature and irrigating fluid would be used to obtain the best results? a. Warm NS or water b. Iced NS or water c. Room temperature NS or water d. Iced NS only ANS: C

Historically, iced saline was favored as a lavage irrigant. Research has shown, however, that low-temperature fluids shift the oxyhemoglobin dissociation curve to the left, decrease oxygen delivery to vital organs, and prolong bleeding time and prothrombin time.

Iced saline also may further aggravate bleeding; therefore, room temperature water or saline is the preferred irrigant for use in gastric lavage.

6. A patient with a 10-year history of alcoholism was admitted to the critical care unit with

the diagnosis of acute pancreatitis. The physiologic alteration that occurs in acute pancreatitis is a. uncontrolled hypoglycemia caused by an increased release of insulin. b. loss of storage capacity for senescent red blood cells. c. premature activation of inactive digestive enzymes, resulting in autodigestion. d. release of glycogen into the serum, resulting in hyperglycemia.

ANS: C

In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

7. A patient with a 10-year history of alcoholism was admitted to the critical care unit with

the diagnosis of acute pancreatitis. Based on the diagnosis, the patient is at risk for hypovolemic shock from plasma volume depletion. requires observation for hypoglycemia and hypercalcemia. should be started on enteral feedings after the nasogastric tube is placed. is placed on a fluid restriction to avoid the fluid sequestration.

a. b. c. d.

ANS: A

Because pancreatitis if often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

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8. A patient with a 10-year history of alcoholism was admitted to the critical care unit with

the diagnosis of acute pancreatitis. The patient is complaining of a pain in left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8.

To properly manage the patient’s pain, the priority of nursing interventions is to a. administer antiemetics around the clock. b. administer analgesics around the clock. c. educate the patient and family on lifestyle changes. d. teach relaxation techniques.

ANS: B

Pain management is a major priority in acute pancreatitis. Administration of around-theclock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee–chest position can also assist in pain control.

9. A patient with a 10-year history of alcoholism was admitted to the critical care unit with the

diagnosis of acute pancreatitis. The patient is preparing for discharge. Nursing intervention should include a. diabetes management. b. alcohol cessation program. c. frequency of hemoccult testing. d. frequency of PT and PTT testing.

ANS: B

As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.

10. Verification of feeding tube placement a. b. c. d.

includes auscultation for position. aspiration of stomach contents. x-ray study for confirmation. gastric pH measurement.

ANS: C

The traditional practice of confirming placement by auscultating air inserted through the tube over the epigastrium is not reliable and is not recommended. Aspiration of stomach contents and gastric pH measurement are also not recommended. If there is any doubt as to the tube’s position, a repeat radiograph should be obtained.

11. Which of the following medications is/are given to help control ammonia levels in a

patient with acute liver failure (ALF)? a. Insulin b. Vitamin K c. Lactulose d. Benzodiazepines ANS: C

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circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with ALF because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.

12. Esophagectomy is usually performed for a. cancer of the proximal esophagus and gastroesophageal junction. b. cancer of the distal esophagus and gastroesophageal junction. c. cancer of the pancreatic head. d. varices of the distal esophagus and gastroesophageal junction.

ANS: B

Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

13. Roux-en-Y gastric bypass is a. a restrictive type of bariatric surgery. b. a malabsorptive type of bariatric surgery. c. a combination of restrictive and malabsorption types of bariatric surgery. d. standard operation for pancreatic cancer.

ANS: C

Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.

14. Signs and symptoms of an anastomotic leak include a. pneumonia. b. subcutaneous emphysema. c. bleeding. d. atelectasis.

ANS: B

The clinical signs and symptoms of a leak can be subtle and often go unrecognized. They include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck. Upper gastrointestinal (GI) bleeding is an uncommon but life-threatening complication of GI surgery. Early bleeding usually occurs at the site of the anastomosis and can usually be treated through endoscopic intervention. The risk for pulmonary complications is substantial after GI surgery, and adverse respiratory events such as atelectasis and pneumonia are twice as likely to occur in the patient who is obese.

15. Which of the following nursing interventions after GI surgery would have the highest

priority of care?

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a. b. c. d.

Oxygenation Pain management Circulation Preventing infection

ANS: A

Nursing interventions in the postoperative period are focused first on promoting ventilation, adequate oxygenation, and preventing complications such as atelectasis and pneumonia. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Early ambulation is encouraged to reduce the risk of pulmonary embolus. Infection prevention with hand hygiene and antibiotics is important as well.

16. Which classification of medication is used to reduce volume and concentration of

gastric secretions?

Antacids Histamine2 (H2) antagonists Gastric mucosal agents Gastric proton pump inhibitors

a. b. c. d.

ANS: B

Histamine2 (H2) antagonists are used to reduce volume and concentration of gastric secretions. Antacids are used to buffer stomach acid and raise gastric ph. Gastric mucosal agents forms an ulcer-adherent complex with proteinaceous exudate. It covers the ulcer and protects against acid, pepsin, and bile salts. Gastric proton pump inhibitors inactivate acid or hydrogen acid pump, blocking secretion of hydrochloric acid by gastric parietal cells.

17. A patient has a Salem sump to lower intermittent suction. Nursing interventions a. b. c. d.

include prevention of esophageal erosion and stricture. prevention of dry mouth. prevention of ulceration of the nares. irrigating the tube every 4 hours or as ordered by the health care provider.

ANS: D

Interventions include irrigating the tube every 4 hours with normal saline, ensuring the blue air vent of the Salem sump is patent and maintained above the level of the patient’s stomach, and providing frequent mouth and nares care. Nursing management focuses on preventing complications common to this therapy, for example, ulceration and necrosis of the nares, esophageal reflux, esophagitis, esophageal erosion and stricture, gastric erosion, and dry mouth and parotitis from mouth breathing.

MULTIPLE RESPONSE 1. Which of the following is a potential cause for acute liver failure? (Select all that

apply.) a. Ischemia b. Hepatitis A, B, C, D, E, non-A, non-B, non-C c. Acetaminophen toxicity d.

Wilson e. disease Reye f. syndrome

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Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.

2. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which of

the following laboratory test results to be elevated? (Select all that apply.) a. Calcium b.

Serum c. amylase

Serum glucose d. Potassium e. WBC f. Serum triglycerides ANS: B, C, E, F

Calcium and potassium decrease with acute pancreatitis.

3. Which of the following are clinical manifestations of pancreatitis? (Select all that apply.) a. Epigastric and abdominal pain b. Nausea and vomiting c. Diaphoresis d. Jaundice e. Hyperactive bowel sounds f. Fever ANS: A, B, D, F

Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, GreyTurner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.

4. Which of the following interventions would you expect in the management of hepatic

failure?

(Select all that apply.) a. Benzodiazepines for agitation b. Pulse oximetry and serial arterial blood gas measurements c. Insulin drip for hyperglycemia and hyperkalemia d. Monitor electrolyte blood levels e. Assess for signs of cerebral edema ANS: B, D, E

The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood– brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation–perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.

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Chapter 23: Endocrine Clinical Assessment and Diagnostic Procedures Test Bank MULTIPLE CHOICE 1. Which of the following laboratory results is found in a patient with hyperglycemia? a. Insulin level of 25 /mL b. Absence of ketones in the urine c. Presence of ketones in the blood d. Serum osmolality of 270 mOsm/kg H2O ANS: C

In diabetic ketoacidosis, fat breakdown (lipolysis) occurs so rapidly that fat metabolism is incomplete, and the ketone bodies (acetone, -hydroxybutyric acid, and acetoacetic acid) accumulate in the blood (ketonemia) and are excreted in the urine (ketonuria). It is recommended that all patients with diabetes perform self-test or have their blood or urine tested for the presence of ketones during any alteration in level of consciousness or acute illness with elevated blood glucose.

2. A hydration assessment consists of checking a variety of parameters, including a. skin turgor. b. serum potassium level. c. capillary refill. d. serum protein level.

ANS: A

A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.

3. Glycosylated hemoglobin levels provide information about a. the average blood glucose level over the previous 3 to 4 months. b. blood glucose levels in comparison with serum hemoglobin. c. serial glucose readings after ingestion of a concentrated glucose solution. d. the difference between serum and urine glucose levels.

ANS: A

The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C), provides information about the average amount of glucose that has been present in the patient’s bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process known as glycosylation.

4. Which of the following laboratory studies or diagnostic procedures is most useful in

identifying central diabetes insipidus (DI)? a. Skull radiographs b. Serum glucose level

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c. Water deprivation test d. Antidiuretic hormone (ADH) stimulation test ANS: D

Serum antidiuretic hormone ADH levels are compared with the blood and urine osmolality to differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI). Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI. 5. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by

new-onset type 1 diabetes mellitus. Which of the following signs and symptoms obtained as part of the patient’s history might indicate the presence of hyperglycemia? a. Recent episodes of tachycardia and missed heart beats b. Decreased urine output accompanied by peripheral edema c. Periods of hyperactivity with weight gain d. Increased thirst and increased urinary output ANS: D

The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination patterns.

6. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by

new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor on the patient’s exhaled breath. This is a result of a. compensation for metabolic alkalosis. b. ketoacidosis. c. prior ingestion of high-calorie foods. d. decreased serum osmolality.

ANS: B

If ketoacidosis occurs, the patient’s breathing becomes deep and rapid (Kussmaul respirations), and the breath may have a fruity odor.

7. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused

by new-onset type 1 diabetes mellitus. The patient is complaining of headache and blurred vision.

The nurse knows that these are signs that may indicate a. kidney stones. b. diabetes insipidus. c. hypoglycemia. d. hyperglycemia.

ANS: D

Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.

8. The patient has a fasting glucose level of 150 mg/dL. The nurse knows this value is a. normal. b. diagnostic of diabetes, but it should be re-evaluated for accuracy.

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c. lower than what the nurse would expect in a patient receiving intravenous fluids. d. elevated, indicating diabetic ketoacidosis.

ANS: B

A normal fasting glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between 110 and 126 mg/dL identifies a person who is prediabetic. An FPG level of greater than 126 mg/dL (7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to make sure the result is accurate.

9. A normal HbA1c level for a normal person is a. less than 5.4%. b. less than 6.5%. c. between 5.4% and 6.5%. d. between 3% and 5.4%.

ANS: A

A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.

10. The patient weighed 62 kg on admission yesterday. Today the patient weighs 60 kg. The nurse knows

this reflects a fluid loss of a. 1 L. b. 2 L. c. 4 L. d. 10 L. ANS: B

Daily weight changes coincide with fluid retention and fluid loss. Sudden changes in weight could result from a change in fluid balance; 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1 kg, of weight gained or lost.

11. When preparing the patient for a serum ADH level, the nurse must withhold a. insulin and furosemide. b. morphine and carbamazepine. c. Lanoxin and potassium. d. heparin and beta-blockers.

ANS: B

To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum of 8 hours. Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.

12. The nurse knows that a serum osmolality of 378 mOsm/kg indicates a patient who is a. overhydrated. b. normal. c. dehydrated. d. hypokalemic.

ANS: C

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Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.

13. The nurse knows that the best test to differentiate between central and nephrogenic DI is a. the water deprivation test. b. serum osmolality. c. computed tomography scan. d. the ADH test.

ANS: D

The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI) (central) and nephrogenic (kidney) DI. In severe central DI, in which the pituitary is affected, the urine osmolality shows a significant increase (becomes more concentrated), which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test results in which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney dysfunction because the kidneys are no longer responsive to ADH. 14. The nurse knows that an abnormal response to the ADH test would be a. a slight increase in urine osmolality. b. a decrease in urine output. c. a decrease in serum osmolality. d. no change in urine osmolality.

ANS: D

If the urine osmolality remains unchanged after administering vasopressin, the target cells are no longer receptive to antidiuretic hormone.

15. When evaluating the patient for a pituitary tumor, attention on the computed tomography scan

should be focused on the a. frontal lobe. b. sella turcica. c. temporal lobe. d. anterior fossa.

ANS: B

The sella turcica at the base of the skull is the area to focus on to visualize the pituitary gland.

MULTIPLE RESPONSE 1. Which of the following findings would you expect to see in the patient with hyperglycemia?

(Select all that apply.) a. Anorexia b. Abdominal pain c. Bradycardia d. Fluid overload e. Change in level of consciousness f. Kussmaul respirations ANS: A, B, E, F

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More than likely the patient with hyperglycemia will be fluid volume depleted and tachycardic.

Chapter 24: Endocrine Disorders and Therapeutic Management Test Bank MULTIPLE CHOICE 1. A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis

(DKA) secondary to a. excess insulin administration. b. inadequate food intake. c. physiologic and psychologic stress. d. increased release of antidiuretic hormone (ADH).

ANS: C

Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.

2. The hallmark of hyperglycemic hyperosmolar syndrome (HHS) is a. hyperglycemia with low serum osmolality. b. severe hyperglycemia with minimal or absent ketosis. c. little or no ketosis in serum with rapidly escalating ketonuria. d. hyperglycemia and ketosis.

ANS: B

The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II diabetes.

3. The primary intervention for hyperglycemic hyperosmolar syndrome (HHS) is a. rapid rehydration. b. monitoring vital signs. c. high-dose intravenous (IV) insulin. d. hourly urine sugar and acetone testing.

ANS: A

The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS. 4. a. b. c. d.

Characteristics of diabetes insipidus (DI) are hyperglycemia and hyperosmolarity. hyperglycemia and peripheral edema. intense thirst and passage of excessively large quantities of dilute urine. peripheral edema and pulmonary crackles.

ANS: C

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The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.

5. Patients with central DI are treated with a. vasopressin. b. insulin. c. glucagon. d. propylthiouracil.

ANS: A

Patients with central DI who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH (vasopressin) or an ADH analog. The most commonly prescribed drug is the synthetic analog of ADH, desmopressin (DDAVP). DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or subcutaneously every 12 hours.

6. In the syndrome of inappropriate antidiuretic hormone (SIADH), the physiologic effect is a. massive diuresis, leading to hemoconcentration. b. dilutional hyponatremia, reducing sodium concentration to critically low levels. c. hypokalemia from massive diuresis. d. serum osmolality greater than 350 mOsm/kg.

ANS: B

Patients with SIADH have an excess of antidiuretic hormone secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia.

7. Which of the following nursing interventions should be initiated on all patients with SIADH? a. Placing the patient on an air mattress b. Forcing fluids c. Initiating seizure precautions d. Applying soft restraints ANS: C

The patient with SIADH has an excess of ADH secreted into the bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an inability to concentrate, mental confusion, apprehension, seizures, a decreased level of consciousness, coma, and death.

8. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit

with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). Which of the following symptoms is most suggestive of DKA? a. Irritability b. Excessive thirst c. Rapid weight gain d. Peripheral edema ANS: B

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DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise, headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of consciousness, can lead quickly to coma.

9. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit

with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis. Which of the following statements best describes the rationale for administrating potassium supplements with the patient’s insulin therapy? a. Potassium replaces losses incurred with diuresis. b. The patient has been in a long-term malnourished state. c. IV potassium renders the infused solution isotonic. d. Insulin drives the potassium back into the cells.

ANS: D

Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for patients with DKA who are receiving fluid resuscitation and insulin therapy.

10. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit

with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic ketoacidosis (DKA). The treatment of DKA involves a. extensive hydration. b. oral hypoglycemic agents. c. large doses of IV insulin. d. limiting food and fluids.

ANS: A

Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma glucose decline in response to insulin.

11. The most common problem in the patient with type 2 diabetes is a(n) a. lack of insulin production. b. imbalance between insulin production and use. c. overproduction of glucose. d. increased uptake of glucose in the cells.

ANS: B

Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.

12. A patient weighs 140 kg and is 60 in. tall. The patient’s blood sugar is being controlled by glipizide.

As the nurse discusses discharge instructions, the primary treatment goal with this type 2 diabetes patient would be a. signs of hypoglycemia.

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b. proper injection technique. c. weight loss. d. increased caloric intake.

ANS: C

This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients with type 2 diabetes.

13. A patient is admitted to the unit with extreme fatigue, vomiting, and headache. This patient has type 1

diabetes but has been on an insulin pump for 6 months. He states, “I know it could not be my diabetes because my pump gives me 24-hour control.” The nurse’s best response would be a. “You know a lot about your pump, and you are correct.” b. “You’re right. This is probably a virus.” c. “We’ll get an abdominal CT and see if your pancreas is inflamed.” d. “We’ll check your serum blood glucose and ketones.”

ANS: D

Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.

14. A patient who has type 2 diabetes is on the unit after aneurysm repair. His serum glucose levels have

been elevated for the past 2 days. He is concerned that he is becoming dependent on insulin. The best response for the nurse would be a. “This surgery may have damaged your pancreas. We will have to do more evaluation.” b. “Perhaps your diabetes was more serious from the beginning.” c. “You will need to discuss this with your physician.” d. “The stress on your body has temporarily increased your blood sugar levels.”

ANS: D

Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic gluconeogenesis.

15. The nurse knows that the dehydration associated with diabetic ketoacidosis results from a. increased serum osmolality and urea. b. decreased serum osmolality and hyperglycemia. c. ketones and potassium shifts. d. acute renal failure.

ANS: A

Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal.

16. The nurse knows that the dehydration in diabetic ketoacidosis stimulates catecholamine release,

which results in a. decreased glucose release. b. increased insulin release. c. decreased cardiac contractility.

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d. increased gluconeogenesis.

ANS: D

Dehydration stimulates catecholamine production in an effort to provide emergency support.

Catecholamine output stimulates further glycogenolysis, lipolysis, and gluconeogenesis, pouring glucose into the bloodstream.

17. a. b. c. d.

The major electrolyte disturbances that result from diuresis are low calcium and high phosphorus levels. low potassium and low sodium levels. high sodium and low phosphorus levels. low calcium and low potassium levels.

ANS: B

Serum sodium may be low as a result of the movement of water from the intracellular space into the extracellular (vascular) space. The serum potassium level is often normal; a low serum potassium level in diabetic ketoacidosis suggests that a significant potassium deficiency may be present.

18. The patient admitted in diabetic ketoacidosis has dry, cracked lips and is begging for

something to drink. The nurse’s best response would be to a. keep the patient NPO. b. allow the patient a cup of coffee. c. allow the patient water. d. allow the patient to drink anything he chooses.

ANS: C

The thirst sensation is the body’s attempt to correct the fluid deficit. Water is the best replacement.

19. A patient in diabetic ketoacidosis has the following arterial blood gasses: pH 7.25; pCO2 30 mm

Hg; HCO3 16. The patient has rapid, regular respirations. The nurse’s best response would be to a. ask the patient to breathe into a paper bag to retain CO2. b. administer sodium bicarbonate. c. administer insulin and fluids intravenously. d. prepare for intubation.

ANS: C

Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.

20. A patient in diabetic ketoacidosis is very lethargic and has a “funny” odor to his breath. The nurse

would suspect this to be a result of a. alcohol intoxication. b. hyperglycemia. c. hyperphosphatemia. d. acetone.

ANS: D

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Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a fall in serum pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis.

Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic “fruity” odor.

21. A patient in diabetic ketoacidosis is comatose with a temperature of 102.2° F. The nurse would

suspect a. head injury. b. infarct of the hypothalamus. c. infection. d. heat stroke.

ANS: C

A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.

22. A nondiabetic patient presents ketoacidosis. Reasons may include a. starvation and alcoholism. b. drug overdose. c. severe vomiting. d. hyperaldosteronism.

ANS: A

Other nondiabetic causes of ketoacidosis are starvation ketosis and alcoholic ketoacidosis.

23. As a patient with diabetic ketoacidosis receives insulin and fluids, the nurse knows careful

assessment must be given to which of the following electrolytes? a. Potassium b. Sodium c. Phosphorus d. Calcium ANS: A

Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.

24. The top priority in the initial treatment of diabetic ketoacidosis (DKA) is a. lowering the blood sugar. b. giving fluids. c. giving sodium bicarbonate to reverse the acidosis. d. determining the reason for the DKA. ANS: B

A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.

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25. The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis, the IV

line should be changed to a solution containing glucose when the a. patient becomes more alert. b. IV insulin has been infusing for 4 hours. c. blood glucose drops to 200 mg/dL. d. blood glucose drops to 100 mg/dL. ANS: C

When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.

26. The nurse knows that the patient with DKA will need a. subcutaneous insulin. b. IV insulin. c. subcutaneous and IV insulin. d. combination 70%/30% insulin.

ANS: C

The patient needs IV insulin for rapid onset but will also need subcutaneous insulin about 1 hour before the IV insulin is discontinued.

27. When a patient in diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects

a drop in the serum levels of a. sodium and potassium. b. potassium and phosphate. c. bicarbonate and calcium. d. sodium and phosphate.

ANS: B

Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is recommended.

28. To assist the nurse in evaluating the patient’s hydration status, assessment would include a. orthostatic hypotension and neck vein filling. b. pupil checks and Kernig sign. c.

Chvostek and Trousseau signs. d. S4

gallop and edema.

ANS: A

Assessment for orthostatic hypotension and neck vein filling is an important way to evaluate hydration status.

29. A patient with diabetic ketoacidosis has an insulin drip infusing, and the nurse has just administered

subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include a. Kussmaul respirations and flushed skin.

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b. irritability and paresthesia. c. abdominal cramps and nausea. d. hypotension and itching.

ANS: B

Irritability and paresthesia are seen in hypoglycemia.

30. A patient was admitted with diabetic ketoacidosis 1 hour ago and is on an insulin drip.

Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the electrocardiogram. The expected intervention would be to a. administer a lidocaine bolus. b. administer a lidocaine drip. c. synchronize cardioversion. d. evaluate electrolytes.

ANS: D

Hyperkalemia occurs with acidosis or with overaggressive administration of potassium replacement in patients with renal insufficiency. Severe hyperkalemia is demonstrated on the cardiac monitor by a large, peaked T wave; flattened P wave; and widened QRS complex.

31. A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of

hyperglycemic hyperosmolar syndrome (HHS) is made based on laboratory values of a. decreased serum glucose and increased serum ketones. b. increased urine ketones and decreased serum osmolality. c. increased serum osmolality and increased serum potassium. d. increased serum osmolality and increased serum glucose.

ANS: D

Laboratory findings are used to establish the definitive diagnosis of HHS. Plasma glucose levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.

32. An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum

ketones. Immediate attention must be given to a. clotting factors. b. rehydration. c. administration of insulin. d. sodium replacement.

ANS: B

The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.

33. A patient with hyperglycemic hyperosmolar syndrome (HHS) has a serum glucose level of

400 mg/dL and a serum sodium level of 138 mEq/L. The intravenous fluid of choice would be a. D5W. b. 0.45% NS. c.

0.9% NS. d. D5/NS.

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ANS: C

The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/hr, especially for patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure within normal range. Infusion volumes are adjusted according to the patient’s hydration state and sodium level.

34. The most common maintenance dose of intravenous insulin for a patient with hyperglycemic

hyperosmolar syndrome (HHS) would be a. 0.1 U/kg/hr. b. 1.0 U/kg/hr. c. 2.0 U/kg/hr. d. 5.0 U/kg/hr.

ANS: A

Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 units/hr for a person weighing 70 kg) should lower the plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If the measured glucose does not decrease by this amount, the insulin infusion rate may be doubled until the blood glucose is declining at a rate of 50 to 70 mg/dL per hour.

35. A patient is admitted with a long history of mental illness. Her husband states she has been drinking

up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse suspects a. central diabetes insipidus (DI). b. nephrogenic DI. c. psychogenic (dipsogenic) DI. d. iatrogenic DI. ANS: C

Psychogenic diabetes insipidus (DI) is a rare form of the disease that occurs with compulsive drinking of more than 5 L of water a day. Long-standing psychogenic DI closely mimics nephrogenic DI because the kidney tubules become less responsive to antidiuretic hormone as a result of prolonged conditioning to hypotonic urine.

36. A patient presenting with diabetes insipidus (DI) exhibits a. hyperosmolality and hypernatremia. b. hyperosmolality and hyponatremia. c. hypoosmolality and hypernatremia. d. hypo-

osmolality and hyponatremia.

ANS: A

In central DI, there is an inability to secrete an adequate amount of antidiuretic hormone (arginine vasopressin) in response to an osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine.

Hypernatremia is usually associated with serum hyperosmolality.

37. The onset of seizures in the patient with DI indicates a. increased potassium levels. b. hyperosmolality. c. severe dehydration. d. toxic ammonia levels.

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ANS: C

This excessive intake of water reduces the serum osmolality to a more normal level and prevents dehydration. In the person with decreased level of consciousness, the polyuria leads to severe hypernatremia, dehydration, decreased cerebral perfusion, seizures, loss of consciousness, and death.

38. A priority for patient education when discharged with long-term antidiuretic hormone

deficiency is a. daily intake and output. b. attention to thirst. c. a lowsodium diet. d. daily weights.

ANS: D

Daily weights on the same scale are an excellent assessment of fluid status. A weight gain or loss of 1 kg (2.2 lb) is equal to 1 L of fluid.

39. A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a

serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine specific gravity of 1.035. The nurse would suspect a. diuresis. b. DI. c. SIADH. d. hyperaldosteronism.

ANS: C

A decreased urine output, hyponatremia, hypoosmolality, and high urine specific gravity are classic signs of SIADH. Oat cell carcinoma is a precipitating factor for SIADH. 40. The patient at risk for developing SIADH may be taking a. adenosine (Adenocard). b. diltiazem (Cardizem). c. heparin sodium. d. acetaminophen.

ANS: D

Tylenol increases the release of ADH. 41. In evaluating the patient’s hyponatremia, the nurse understands the problem is a. increased cortisol release. b. decreased aldosterone release. c. increased glucocorticoid release. d. decreased glucagon release.

ANS: B

In SIADH, the increased levels of circulating ADH are unrelated to the serum sodium concentration. Aldosterone production from the adrenal glands is also suppressed.

42. After a patient has been diagnosed with SIADH, the nurse would expect the first line of

treatment to include a. fluid restriction.

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b. hypotonic intravenous fluid. c. D5W. d. fluid bolus.

ANS: A

Reduction in fluid intake is one component of the treatment plan for SIADH. 43. During the first 24 hours when the nurse administers hypertonic saline in a patient with

SIADH, the serum sodium should be raised no more than a. 5 mEq/day. b. 12 mEq/day. c. 20 mEq/day. d. 25 mEq/day.

ANS: B

One recommended regimen is an IV rate that provides sufficient sodium to raise serum sodium levels by up to 12 mEq/day for the first 24 hours (no more than 0.5 mEq each hour), with a total increase of 18 mEq/L in the initial 48 hours.

44. While a patient with SIADH is receiving hypertonic saline, the nurse assesses for signs that the

saline must be stopped. These signs would include a. decreased CVP and decreased PAP. b. bradycardia and thirst. c. hypotension and wheezing. d. hypertension and lung crackles.

ANS: D

Hypertension and lung crackles are signs of fluid overload. The hypertonic solution may pull fluid out of cells and tissues. Whereas weight gain signifies continual fluid retention, weight loss indicates loss of body fluid.

45. Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an

increased risk of developing a. type 1 diabetes. b. type 2 diabetes. c. DI. d. myxedema coma.

ANS: C

Any patient who has head trauma or resection of a pituitary tumor has an increased risk of developing DI. 46. The diagnosis of SIADH is made when which of the following conditions is present? a. Decreased ADH level and hyperkalemia b.

Decreased ADH level and hypernatremia c.

Increased ADH level and serum ketones d. Increased ADH level and low serum osmolality ANS: D

SIADH occurs when there are increased levels of ADH in the blood compared with a low serum osmolality.

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47. Decreased urine osmolality is a sign of a. hyperglycemia. b. diabetes insipidus. c. thyroid crisis. d. SIADH. ANS: B

Decreased urine osmolality is a sign of DI. MULTIPLE RESPONSE 1. The neuroendocrine stress response produces which of the following? (Select all that apply.) a. Elevated blood pressure b. Decreased gastric motility c. Tachycardia d. Heightened pain awareness e. Increased glucose ANS: A, B, C, E

The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the stomach, glucose is made available to the brain cells, and pain awareness is decreased.

2. A patient was admitted to the critical care unit with diabetic ketoacidosis (DKA). Glucose is

349 mg/dL, K+ is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you expect? (Select all that apply.) a. NS 1.5 L IV fluid bolus b. Insulin infusion at 5 units/hr c. Sodium bicarbonate 50 mmol IV push d. Vasopressin 10 units IM every 3 hr e. Potassium 20 mEq/L of IV fluid ANS: A, B, E

Dehydration is a common presenting issue in DKA, so the administration of fluids and insulin will help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is necessary.

Chapter 27: Hematologic Disorders and Oncologic Emergencies Test Bank MULTIPLE CHOICE 1. The intrinsic coagulation pathway is activated when a. local blood vessels constrict at the injury site. b. damaged endothelium comes into contact with circulating blood. c. tissue factor is released by injured cells. d. fibrinogen is converted to fibrin.

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ANS: B

The extrinsic pathway begins when vascular injury causes the release of tissue factor. The intrinsic pathway begins when damaged endothelium comes into contact with circulating blood. The two pathways converge when fibrinogen and prothrombin are converted to their active forms and a clot is established.

2. The most common cause of disseminated intravascular coagulation (DIC) is a. sepsis caused by gram-positive organisms. b. sepsis caused by gram-negative organisms. c. sickle cell

anemia. d. burns.

ANS: B

Although all of these answers can cause DIC, sepsis, particularly that caused by gram- negative organisms, can be identified as the culprit in as many as 20% of cases, making it the most common cause of DIC. 3. A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is

continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic blood pressure cuff. On his laboratory work, his platelets are normal, and his international normalized ratio is elevated. What other laboratory value would be most valuable in definitively diagnosing the patient’s condition? a. Fibrin split products b. D-Dimer level c. Bleeding time d. White blood cell count ANS: B

D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of coagulopathy.

4. A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is

continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic blood pressure cuff. On his laboratory work, his platelets are normal, and his international normalized ratio is elevated. The primary treatment goal for this patient is to a. maintain adequate organ perfusion. b. suppress antibody response that is destroying platelets. c. treat life-threatening metabolic disturbances. d. begin hypothermic therapy to prevent cerebral hemorrhage.

ANS: A

The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware of the conditions that commonly contribute to the development of DIC and treating them vigorously and without delay provide the best defense against this devastating condition. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are paramount to achieving a favorable outcome.

5. Sickle cell anemia is not prevalent in persons of which descent? a. West African

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b. Sole European c. Middle Eastern d. Asian or Pacific Islander ANS: D

This genetic trait is primarily found in people of West African descent. The disease has also been linked to persons of sole European or Middle Eastern ancestry; however, this is extremely rare. The disease is not prevalent in persons of Asian or Pacific Islander descent.

6. A patient is admitted into the critical care unit with symptoms of a low-grade fever, joint pain,

tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has a. ITP. b. heparin-induced thrombocytopenia. c. sickle cell anemia. d. DIC. ANS: C

A variety of clinical manifestations are associated with sickle cell anemia. The patient may present with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable spleen, and pretibial ulcers.

7. Type 2 heparin-induced thrombocytopenia is characterized by a. formation of thrombi, causing vessel occlusion. b. spontaneous epistaxis. c. elevated prothrombin times. d. massive peripheral ecchymoses.

ANS: A

Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for thrombosis than bleeding. Vessel occlusion can result in the need for limb amputation, stroke, acute myocardial infarction, and even death. The resultant formation of fibrin platelet– rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise to its more descriptive name: white clot syndrome.

8. Pulmonary embolism, a serious complication of HIT, is manifested by which of the following clinical

signs? a. Blanching of fingers and toes and loss of peripheral pulses b. Chest pain, pallor, and confusion c. Headache, impaired speech, and loss of motor function d. Dyspnea, pleuritic pain, and rales ANS: D

The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb indicate peripheral vascular thrombi. Neurologic signs and symptoms such as confusion, headache, and impaired speech can signal the onset of cerebral artery occlusion and stroke. Acute myocardial infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure. Thrombi in the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.

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9. The high-risk period for developing HIT is a. 5 to 10 hours after initiation of heparin. b. 5 to 14 hours after initiation of heparin. c. 5 to 14 days after initiation of heparin. d. 30 to 60 days after

initiation of heparin.

ANS: C

Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed every 2 or 3 days from day 4 to day 14. When a decrease in the platelet count is detected, heparin therapy should be discontinued immediately, and the patient should be tested for the presence of heparin antibodies.

10. Which of the following previous medical conditions would indicate a patient at risk for

developing HIT? a. Sepsis b. Deep vein thrombosis c. Cardiac arrest d. Pneumonia ANS: B

Ascertaining a medical history that includes previous heparin therapy, deep vein thrombosis, or cardiovascular surgery that included the use of cardiopulmonary bypass can alert the nurse to potential problems.

11. The primary mechanism in the development of tumor lysis syndrome is a. destruction of platelets by lymphocytic antibodies. b. destruction of malignant cells through radiation or chemotherapy. c. formation of heparin antibodies. d. damage to the endothelium.

ANS: B

The primary mechanism involved in the development of tumor lysis syndrome is the destruction of massive numbers of malignant cells, either by chemotherapy or radiation. This mass destruction results in the release of large amounts of potassium, phosphorus, and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.

12. Which of the following pathophysiologic events contributes to renal failure associated with tumor

lysis syndrome? a. Hypocalcemia b. Elevated white blood cell count c. Metabolic acidosis d. Crystallization of uric acid in the renal tubules ANS: D

When therapy is initiated, tumor cell destruction releases nucleic acids, which are metabolized into uric acid. Metabolic acidosis ensues, resulting in crystallization of the uric acid in the distal tubules of the kidneys and leading to obstruction of urine flow. Glomerular filtration rates drop as the kidneys are unable to clear the increasing amounts of uric acid.

Consequently, acute kidney injury eventually occurs.

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13. Which of the following would be appropriate for treating hypocalcemia? a. Calcium gluconate b. Insulin c. Sodium bicarbonate d. Dialysis ANS: A

Calcium gluconate is administered to treat hypocalcemia. Insulin and sodium bicarbonate treat hyperkalemia. Dialysis is the treatment for hyperuricemia.

14. Hospital-acquired anemia is an increasing problem in critically ill patients. Which of the

following nursing interventions can be most beneficial in preventing this problem? a. Administering fluids and inotropic agents to optimize blood pressure b. Using blood salvage devices c. Obtaining smaller blood samples through the use of pediatric blood tubes and pointof-care testing d. Decreasing afterload through the use of vasodilators ANS: C

Frequent blood draws in critically ill patients have been associated with the development of anemia.

Blood losses correspond to actual volume of samples and discards when drawing from venous access lines. Critical care nurses can be instrumental in significantly decreasing blood loss in this arena. The use of pediatric collection tubes and point-of-care testing are techniques that yield valid diagnostic results but require smaller amounts of blood.

15. Medication used to increase the level of fetal hemoglobin in the RBCs and reduce the

concentration of sickle hemoglobin is known as a. transfusion therapy. b. hydroxyurea. c. Kayexalate. d. oxygen.

ANS: B

Hydroxyurea is an oral agent that is a safe and effective treatment for children and adults who have sickle cell anemia. It works by increasing the level of fetal hemoglobin in the red blood cells, thereby reducing the concentration of sickle hemoglobin and sickling itself. Kayexalate is an oral or rectal medication to decrease potassium levels in the blood.

16. Hydroxyurea is increased by what dosage until the maximum of 35 mg/kg is reached? a. 5 mg/kg every 4 weeks b. 10 mg/kg every 8 weeks c. 5 mg/kg

every 12 weeks d. 15 mg/kg every 15 weeks ANS: C

The patient is usually started at a dose of 15 mg/kg by mouth once a day. The dose is increased by 5 mg/kg every 12 weeks until 35 mg/kg is reached as long as the patient’s blood count remains within an acceptable range.

17. Medical intervention to prevent metabolic imbalances associated with tumor lysis syndrome

includes

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a. b. c. d.

give Kayexalate for hypokalemia. keep urine pH below 7.0. fluid restriction. dietary restriction of potassium and phosphorus foods.

ANS: D

Electrolytes and arterial blood gases are closely monitored. Dietary restrictions of potassium and phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid formation and to increase renal clearance. These can be accomplished through the administration of sodium bicarbonate to increase the pH of the urine to above 7.0, which increases the solubility of uric acid, preventing subsequent crystallization. Allopurinol administration can also inhibit uric acid formation. Administration of intravenous fluids may be necessary early in the course of treatment if inadequate hydration exists. If potassium levels rise dangerously, Kayexalate (sodium polystyrene sulfonate) may be given orally, or if the patient is unable to tolerate oral medications because of nausea and vomiting, rectal instillation may be used.

18. Place these pathophysiologic mechanisms of DIC in the order in which they occur.

1. Activation of the fibrinolytic system 2. Breakdown of thrombi; spontaneous hemorrhage 3. Consumption of coagulation factors; failure of regulatory mechanisms 4. Endothelial damage; release of tissue factor 5. Thrombin formation; clots form along epithelial walls a. 4, 1, 5, 2, 3 b. 4, 1, 3, 2, 5 c. 5, 1, 2, 4, 3 d. 2, 3, 1, 5, 4 ANS: A

Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form, consuming coagulation factors. The fibrinolytic system is triggered to break down the clots, which leads to spontaneous hemorrhage.

MULTIPLE RESPONSE 1. Common findings in tumor lysis syndrome (TLS) include (Select all that apply.) a. increased calcium. b. decreased potassium. c. dysrhythmias. d. elevated blood urea nitrogen (BUN) and creatine. e. edema.

ANS: C, D, E

Common findings in TLS are as follows. Clinical: Weight gain, edema, diarrhea, lethargy, muscle cramps, nausea and vomiting, paresthesia, weakness, oliguria, uremia, seizures. Laboratory: Increased potassium, phosphorus, uric acid, BUN, and creatine; decreased calcium, creatinine clearance, pH, bicarbonate, and PaCO2. Diagnostic: Positive Chvostek and Trousseau signs, hyperactive deep tendon reflexes, dysrhythmias, and ECG changes.

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2. Which of the following nursing interventions would be used if a patient was put under bleeding

precautions? (Select all that apply.) a. Avoid injections as appropriate. b. Encourage the patient to eat foods high in calcium and vitamin C. c. Use a soft toothbrush or toothettes for oral care. d. Provide a therapeutic mattress and pad side rails. e. Use an electric razor for shaving.

ANS: A, C, D, E

Bleeding precautions include all of these options except encouraging the patient to eat foods high in calcium and vitamin C. Rather, patients should be instructed to increase intake of foods rich in vitamin K.

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Chapter 24: Trauma Urden: Priorities in Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. An unresponsive trauma patient has been admitted to the emergency

department. Which statement regarding opening the airway is accurate? a. Airway assessment must incorporate cervical spine immobilization. b. Hyperextension of the neck is the only acceptable technique. c. Flexion of the neck protects the patient from further injury. d. Airway patency takes priority over cervical spine immobilization.

ANS: A

Airway assessment must incorporate cervical spine immobilization. The patient’s head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway.

The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. A patient with severe traumatic brain injury has been admitted to the critical care unit.

What is one intervention to minimize secondary brain injury? a. Hyperventilate the patient to keep PCO2 less than 30. b. Restrict fluids to keep central venous pressure less than 6 cm H2O. GRADESMORE.COM c. Maintain the patient’s body temperature more than 37.5°C. d. Administer fluids to keep the mean arterial pressure greater than 60 mm Hg. ANS: D

Heart rate and blood pressure are continually monitored, with the goal of achieving MAP greater than 60 mm Hg (minimum) to ensure adequate perfusion to the brain. Secondary injury is the biochemical and cellular response to the initial trauma that can exacerbate the primary injury and cause additional damage and impairment in brain recovery. Secondary injury can be caused by ischemia, hypotension, hypercapnia, cerebral edema, or metabolic derangements.

Hyperventilation will decrease cerebral blood flow. Restricting fluids will contribute to hypovolemia and subsequently hypotension. Elevating the patient’s body temperature will increase the cerebral metabolic rate and contribute to cerebral ischemia.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Implementation TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 3. A patient has sustained an epidural hematoma after a 10-foot fall from a roof.

The nurse understands that an epidural hematoma is a condition that has which characteristic? a. Most often associated with middle meningeal artery lacerations

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b. Collection of blood between the dura mater and the arachnoid membrane c. Associated with a permanent loss of consciousness d. Signs and symptoms include bilateral pupil dilation

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ANS: A

Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs are most often associated with skull fractures and middle meningeal artery lacerations (two-thirds of patients). The classic clinical manifestations of EDH include brief loss of consciousness followed by a period of lucidity. Rapid deterioration in the level of consciousness should be anticipated, because arterial bleeding into the epidural space can occur quickly. The patient may complain of a severe, localized headache and may be sleepy. A dilated and fixed pupil on the same side as the impact area is a hallmark of EDH. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor

vehicle crash. The patient’s plan of care would involve which nursing action? a. Perform neurologic assessments once a shift. b. Obtain a computed tomography (CT) scan every day. c. Monitor blood pressure and temperature every hour. d. Initiate warming measures to keep temperature greater than 37.5°C. ANS: C

Severe DAI usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and excessive diaphoresis. Treatment of DAI includes support of vital functions. Neurologic assessment is performed every hour. DAI may not be visible on CT scan. Warming measures are generally not needed but cooling measure may be needed.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: AeDntEatSioMn ORE.COM ImG plR em

TOP: Trauma

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs

better than he can move his arms. The nurse suspects the patient may have which type of injury? a.

Posterior cord syndrome b. Brown- Séquard syndrome c. Diffuse axonal injury d. Central cord syndrome ANS: D

Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe

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prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma

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MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A patient has been admitted with a flail chest. What findings would the nurse

expect to observe supporting this diagnosis? a. Tracheal deviation toward the unaffected side b. Jugular venous distention c. Paradoxical respiratory movement d. Respiratory alkalosis ANS: C

Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail segment moves out.

PTS: 1 DIF: Cognitive Le el: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A patient has been admitted with a pulmonary contusion. Which finding will cause a

nurse to suspect that the patient’s condition is deteriorating? a. Increased bruising on the chest wall b. Increased need for pain medication c. The development of respiratory alkalosis d. Increased work of breathing

GRADESMOR E.COM

ANS: D

A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing management. Increased bruising and the need for pain medication are not signs of deterioration.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Evaluation TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A patient who was an unrestrained driver in a high-speed, head-on motor vehicle

collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Ruptured diaphragm ANS: A

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Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

PTS: 1 DIF: Cognitive Level: Evaluating OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A patient is admitted with a blunt cardiac injury (BCI) with no evidence of

rupture. The nursing management plan should include which intervention? a. Administer nitroglycerine for chest pain as needed. b. Monitor the patient for new onset dysrhythmias. c. Monitor serial biomarkers for evidence of further damage. d. Do not administer antidysrhythmic medications as they are ineffective.

ANS: B

The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such as troponin, offers very little diagnostic help for BCI. Medical management is aimed at preventing and treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of antidysrhythmic medications.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma G R A D E S M MSC: NCLEX: Physiological Integrity: ReduO ctR ioE n. ofCROisM k Potential 10. A patient is admitted with acute abdominal trauma. The patient has a positive

Focused Assessment with Sonography for Trauma (FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next? a. Emergency surgery b. Diagnostic peritoneal lavage (DPL) c. Computed tomography scan d. Intra-abdominal pressure monitoring ANS: A

Hemodynamically unstable patients with a positive FAST scan generally undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many trauma centers. CT scanning is the mainstay of diagnostic evaluation in the hemodynamically stable patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intra-abdominal hypertension.

PTS: 1 DIF: Cognitive L vel: Applying OBJ: Nursing Process Step: Planning TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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11. A patient is admitted to the ICU for observation of his grade II splenic laceration.

Which signs and symptoms suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock? a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr; skin that is pink, warm, and dry with capillary refill of 3 seconds b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr; pale, cool, clammy skin; confused c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr; pale, cool, dry skin; alert and oriented d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr; flushed, warm, diaphoretic skin; agitated and confused ANS: B

The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused.

Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs. Progressive deterioration may indicate the need for operative management.

PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A patient with multisystem trauma has been in the ICU for 6 days. The patient is still

intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient’s vital signs include: BP— 92/66 mm Hg; HR—118 beats/min; T—38.7°C; and CVP—5 mm Hg. What is the GRADESMORE.CO most likely cause of this hemodynamic picture? a. Septic shock b.

Hemorrhagic shock c.

Cardiogenic shock d.

Neurogenic shock ANS: A

The patient with multiple injuries is at risk for overwhelming infections and sepsis.

The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Older trauma patients have a higher mortality than younger trauma patients.

The nurse understands that this fact is probably related to what physiologic change? a. Deterioration of cerebral and motor skills

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b. Poor vision and hearing c. Diminished pain perception d. Limited physiologic reserve

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ANS: D

Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce further conflicting hemodynamic data. An older patient’s lack of physiologic reserve makes it imperative that early nutritional support is initiated.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The nurse is working on an organization-wide falls prevention project. The nurse

understands that the majority of falls accounting for traumatic injury occur in what population? a. Construction workers b. Adolescents c. Older adults d. Young adults ANS: C

Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps. Because many of the falls may be caused by an underlying medical condition (e.g., syncope, myocardial infarction, dysrhythmias), management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Trauma OdMaptation MSC: NCLEX: Physiological InG teR grA itD y:EPS hyMsiO olR oE gic.aC lA 15. A patient with multisystem trauma has been in the critical care unit for 2 days. The

patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication? a. Hypovolemic shock b. Acute kidney injury c. Venous thromboembolism d. Malnutrition ANS: C

Patients with major trauma are at very high risk for VTE. Factors that form the basis of VTE pathophysiology are common in trauma, including endothelial injury (as a result of trauma), hypercoagulopathy (as a result of trauma-induced coagulopathy), and blood stasis (as a result of immobility). The patient should have already been treated for hypovolemic shock. While the patient is at risk for acute kidney injury and malnutrition but not from immobility.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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16. A nurse and a new graduate nurse are discussing the secondary survey of the trauma

patient.

The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information? a. Check circulatory status. b. Check electrolyte profile. c.

Insert a urinary catheter. d. Obtain patient history.

ANS: D

During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output are not adequate. Circulatory status is part of the primary survey.

PTS: 1 DIF: Cognitive Le el: Applying OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 17. A nurse and a nursing student are discussing management of the trauma patient.

The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information? a.

Used to assess respiratory status b. Used to assess circulatory status c.

Used to assess pain status d. Used to assess level of consciousness GRADESMORE.COM ANS: D

The AVPU method can be used to quickly describe the patient’s level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Health Promotion and Maintenance 18. A trauma patient’s condition has deteriorated. The nurse observes changes in the

patient’s condition including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication? a. Cardiac tamponade b. Hemothorax

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c. Open pneumothorax d. Ruptured diaphragm ANS: B

Assessment findings for patients with a hemothorax include hypovolemic shock.

Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

PTS: 1

DIF: Cognitive Level: Analyzing

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OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted

a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure? a. Thoracotomy b. Pericardiocentesis c. Splenectomy d. Pneumonectomy ANS: A

Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.

PTS: 1 DIF: Cognitive L vel: Applying OBJ: Nursing Process Step: Planning TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 20. The nurse understands that certain trauma patients are at risk for developing fat

embolism syndrome. Which type of trauma is this complication usually associated with? a. Liver trauma b. Kidney trauma c. Orthopedic trauma d. Spinal cord trauma

GRADESMORE.COM

ANS: C

Fat embolism syndrome can occur as a complication of orthopedic trauma.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. Major trauma patients are at high risk of developing deep venous thrombosis and

pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply.) a. Blood stasis b. Hypernatremia c. Injury to the intimal surface of the vessel d. Hyperosmolarity e. Hypercoagulopathy f. Immobility ANS: A, C, E, F

The factors that form the basis of venous thromboembolism pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy.

Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.

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PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Diagnosis TOP: Trauma MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A patient has been admitted with muscle trauma and crush injuries. The nurse

understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply.) a. Dark tea–color urine b. Decreased urine output c. Decreased oxygen saturation d. Diminished pulses e. Increased serum creatine kinase level ANS: A, B, E

Circulating myoglobin can lead to the development of acute kidney injury by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea–colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored.

Decreased oxygen saturation and diminished pulses are not associated with rhabdomyolysis.

PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

GtRwAitDhEexStM 3. The nurse is caring for a patien enOsiRvE e. traCuOmMa to the lower extremities. The nurse understands that patient is at risk for compartment syndrome. Which findings would the nurse expect to observe as evidence of this complication? (Select all that apply.) a. Paresthesia b. Decreased pulses c. Pain in the affected extremity d. Swelling in the affected extremity e. Decreases capillary refill ANS: A, C, D

Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresthesia, and pain of the affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.

PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. The nurse is caring for a patient with blunt abdominal trauma. The nurse

understands that patient is at risk for abdominal compartment syndrome. Which

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findings would the nurse expect to observe as evidence of this complication?

(Select all that apply.) a. Decreased cardiac output

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b. c. d. e.

Increased peak pulmonary pressures Decreased urine output Hypoxemia Bradycardia

ANS: A, B, C, D

Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased peak pulmonary pressures, decreased urine output, and hypoxemia.

PTS: 1 DIF: Cognitive Le el: Analyzing OBJ: Nursing Process Step: Assessment TOP: Trauma MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 5. Patients immobilized because of spinal trauma are at a high risk for contractures. The

nursing management plan for these patients should include which preventive measures? (Select all that apply.) a. Consultation by PT and OT early in the treatment of the patient b. Turning and repositioning the patient every 2 hours as ordered by the practitioner c. Range of motion exercises 1 month after the spine has been stabilized d. Removal of splints every 4 hours and at bedtime e. Hand splints for patients with paraplegia f. Hand and foot splints for patients with quadriplegia ANS: A, B, F

Physical therapy and occupational therapy personnel should be consulted early in the patient’s course. Range of motion exercises are initiated as soon as the spine has been stabilized. Foot drop splints should be appliedGoR nA adDmEiS ssM ioO nRtoEp.rC evOenMt contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

TOP: Trauma

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Chapter 25: Kidney Clinical Assessment and Diagnostic Procedures Urden: Critical Care Nursing, 9th EditionEdition MULTIPLE CHOICE 1. A patient was admitted with multiple trauma who has been volume resuscitated. The nurse

suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse’s suspicion? a. Venous filling of the hand veins greater than 5 seconds b. Distended neck veins in the supine position c. Presence of orthostatic hypotension d. Presence of a third heart sound ANS: D

Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 622

2. Loss of albumin from the vascular space may result in which condition? a. Peripheral edema b. Extra heart sounds c.

Hypertension d. Hyponatremia ANS: A

Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased albumin level can occur as a result of proteincalorie malnutrition, which occurs in many critically ill patients in whom available stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the interstitial space.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 627

3. A patient was admitted with acute heart failure who has been receiving diuretic therapy.

The nurse suspects the patient is hypovolemic. What auscultatory parameter would confirm the nurse’s suspicion? a. Hypertension b. Third or fourth heart sound c. Orthostatic hypotension d. Vascular bruit ANS: C

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A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs because a sufficient preload is not immediately available when the patient changes position.

The heart rate increases in an attempt to maintain cardiac output and circulation.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 622

4. Percussion of kidneys is usually done to assess what parameter? a. Size and shape of the kidneys b. Presence of pain in the renal area c. Presence of a fluid wave d. Patient’s overall fluid status ANS: B

Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 623

5. In a patient with a distended abdomen, differentiating ascites from solid bowel contents

is accomplished by performing what assessment? a. Auscultation of bowel sounds b. Palpation of the liver margin c. Measuring

abdominal girth d. Eliciting a fluid wave ANS: D

Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the opposite flank produces a wave in the accumulated fluid that can be felt under the hands.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 623

6. A patient has been admitted with acute kidney injury. The nurse knows the most

important consideration for evaluating the patient’s fluid status is what parameter? a. Daily weights b. Urine and serum osmolality c. Intake and output d. Hemoglobin and hematocrit levels ANS: A

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One of the most important assessments of kidney and fluid status is the patient’s weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 623

7. A patient has been admitted in acute heart failure. Which parameter would indicate to

the nurse that the patient is fluid overloaded? a. Central venous pressure of 4 mm Hg b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg c. Cardiac index of 2.5 L/min/m2 d. Mean arterial pressure of 40 mm Hg ANS: B

The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume deficit, PAOP is low.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 624

8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release

of what substance? a. Ketones b. Glucagon c. Antidiuretic hormone d. Potassium ANS: C

When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules.

This expands the vascular space, returns the serum osmolality level back to normal, and results in more concentrated urine and an elevated urine osmolality level.

PTS: 1 DIF: Cognitive Level: Remembering OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 626

9. A patient was admitted with acute kidney failure. Which urinalysis value reflects a

decreased ability of the kidneys to concentrate urine? pH of 5.0 Specific gravity of 1.000 No casts Urine sodium of 140 mEq/24 h

a. b. c. d.

ANS: B

Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 627

10. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient

reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main cause of ascites is what condition? a. Hypervolemia b. Dehydration c. Volume overload d. Liver damage ANS: C

Individuals with kidney failure may have ascites caused by volume overload, which forces fluid into the abdomen because of increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess. Severe ascites in persons with compromised liver function may result from decreased plasma proteins. The ascites occurs because the increased vascular pressure associated with liver dysfunction forces fluid and plasma proteins from the vascular space into the interstitial space and abdominal cavity.

Although the individual may exhibit marked edema, the intravascular space is volume depleted, and the patient is hypovolemic.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 623

11. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient

reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder? a.

Kidney–ureter–bladder (KUB) b.

Intravenous pyelography (IVP) c. Renal ultrasonography (ECHO) d.

Renal angiography ANS: B

Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder. Kidney–ureter–bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests.

In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.

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PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 630|Table 25-4

12. A patient is admitted with renal failure. The patient’s weight upon admission was 176 lb,

and the next day it is 184 lb. What is the approximate amount of fluid retained with this weight gain? a. 800 mL b.

2200 mL c. 3600 mL d.

8000 mL ANS: C

One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 L; 3.6 L is equal to 3600 mL. PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 624

13. When calculating the anion gap, what is the predominant cation? a. Sodium b. Potassium c. Chloride d. Bicarbonate ANS: A

The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant anion.

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Intervention TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 626

14. A patient was admitted with acute heart failure a few days ago. Today the patient’s urine

has a specific gravity of 1.040. What could be the potential cause for this value?

Volume overload Volume deficit Acidosis Urine ketones

a. b. c. d.

ANS: B

Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI).

Possible causes for decreased values include volume overload and interrenal AKI. PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 628|Table 25-3

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15. A patient was admitted with heart failure. The nurse is assessing the patient for peripheral

edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse note in the medical record? a. +1 pitting b. edema +2 pitting edema c. +3 pitting edema d. +4 pitting edema ANS: C

The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 seconds); +3 = 6-mm depth (lasting up to 60 seconds); and +4 = 8-mm depth (lasting longer than 60 seconds).

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 622|Table 25-1

16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that

the patient has developed what problem? a.

Glycosuria b.

Proteinuria c.

Myoglobin d. Uremia ANS: D

A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of protein in the urine. Myoglobin is the presence of red blood cells in the urine.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 620

17. A patient has been on complete bed rest for 3 days. The practitioner has left orders to get

the patient out of bed for meals. The patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing what problem? a.

Orthostatic b. hypertension Orthostatic hypotension c.

Hypervolemia d. Electrolyte imbalance ANS: B

Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness.

Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 622

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MULTIPLE RESPONSE 1. What causes the presence of myoglobin in urine? (Select all that

apply.) a. Bleeding b. Traumatic damage to the skeletal muscle c.

Asthmatic attack d.

Rhabdomyolysis e. Cocaine abuse ANS: A, B, D, E

Although a few red blood cells (RBCs) in the urine are normal, discernibly bloody urine usually indicates bleeding within the urinary tract or kidney trauma. The presence of myoglobin can make the urine appear red. Microscopic examination of the urine fails to reveal RBCs, with myoglobin being present instead. Myoglobin in the urine may result from skeletal muscle damage (eg, traumatic crush injury) or rhabdomyolysis.

Rhabdomyolysis may develop in patients admitted to a critical care unit for many reasons, including traumatic injury, cocaine abuse, status epilepticus, heat prostration, or collapse during intense physical exercise (eg, running a marathon race on a hot day).

PTS: 1 DIF: Cognitive Level: Understanding OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 629

2. Which findings may be present in the patient with significant fluid volume overload?

(Select all that apply.) a. S3 or S4 may develop. b. Distention of the hand veins will disappear if the hand is elevated. c. When testing the quality of skin turgor, the skin will not return to the

normal position for several seconds. d. Tachycardia with hypotension may be present. e. Dependent edema may be present.

ANS: A, E

A gallop and dependent edema are indicative of fluid excess; the other signs are indicative of fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Analyzing OBJ: Nursing Process Step: Assessment TOP: Renal Clinical Assessment and Diagnostic Procedures MSC: NCLEX: Physiologic Integrity

REF: p. 625|Box 25-3

3. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient

reports that over the past few weeks, his urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse would expect to see elevated values in which laboratory results? (Select all that apply.) a. Blood urea nitrogen (BUN) b. Creatinine c. Glucose d. Hemoglobin and hematocrit e. Protein ANS: A, B, D Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most often in persons with kidney failure resulting from impaired excretion. Decreased hematocrit value can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney failure, anemia may occur early in the disease.

PTS: 1 DIF: Cognitive Level: Applying OBJ: Nursing Process Step: Assessment TOP: Renal MSC: NCLEX: Physiologic Integrity

REF: p. 625|p. 627

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Chapter 26: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Test Bank MULTIPLE CHOICE 1. Shock syndrome can best be described as a a. physiologic state resulting in hypotension and tachycardia. b. generalized systemic response to inadequate tissue perfusion. c. degenerative condition leading to death. d. condition occurring with hypovolemia that results in irreversible hypotension.

ANS: B

Shock is a complex pathophysiologic process that often results in multiple organ dysfunction syndrome and death. All types of shock eventually result in ineffective tissue perfusion and the development of acute circulatory failure.

2. Hypovolemic shock that results from an internal shifting of fluid from the intravascular

space to the extravascular space is known as absolute hypovolemia. distributive hypovolemia. relative hypovolemia. compensatory hypovolemia.

a. b. c. d.

ANS: C

Hypovolemia results in a loss of circulating fluid volume. A decrease in circulating volume leads to a decrease in venous return, which results in a decrease in end-diastolic volume or preload.

3. The nursing measure that can best enhance large volumes of fluid replacement

in hypovolemic shock is insertion of a large-diameter peripheral intravenous catheter. positioning the patient in the Trendelenburg position. forcing at least 240 mL of fluid each hour. administering intravenous lines under pressure.

a. b. c. d.

ANS: A

Measures to facilitate the administration of volume replacement include insertion of large- bore peripheral intravenous catheters; rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders above the chest.

4. The main cause of cardiogenic shock is a. an inability of the heart to pump blood forward. b. hypovolemia, resulting in decreased stroke volume. c. disruption of the conduction system when re-entry phenomenon occurs. d. an inability of the heart to respond to inotropic agents.

ANS: A

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Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.

5. Which of the following hemodynamic parameters supports the diagnosis of

cardiogenic shock? a. Increased right atrial pressure b. Decreased pulmonary artery wedge pressure c. Increased cardiac output d. Decreased cardiac index ANS: D

Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.

6. With anaphylactic shock, which mechanism results in a decreased cardiac output? a. Peripheral vasodilation b. Increased cardiac output c. Decreased alveolar ventilation d. Fluid retention resulting in congestive heart failure ANS: A

Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.

7. Which of the following drugs promotes bronchodilation and vasoconstriction? a. SoluMedrol b.

Gentamicin c.

Atropine d. Epinephrine ANS: D

Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of biochemical mediators.

8. The patients at highest risk for neurogenic shock are those who have had a. a stroke. b. a spinal cord injury. c. Guillain-Barré syndrome. d. a craniotomy.

ANS: B

The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.

9. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary

catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the following hemodynamic values would you expect to find? a. Cardiac output of 8 L/min Downloaded by: giftonwenna | gonwenn819@student.glendale.edu Distribution of this document is illegal

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b. Right atrial pressure of 17 mm Hg c. Pulmonary artery wedge pressure of 23 mm Hg d. Systemic vascular resistance of 1100 ANS: A

Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.

10. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary

catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic mechanism that results in septic shock? a. Bacterial toxins lead to vasodilation. b. Increased white blood cells are released to fight invading bacteria. c. Microorganisms invade organs such as the kidneys and heart. d. An increase of white blood cells leads to decreased red blood cell production and anemia.

ANS: A

The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.

11. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary

catheter was inserted. Complete blood cell count results have revealed escalating white blood cell counts. The patient is transferred to the critical care unit when her condition deteriorates. Septic shock is diagnosed. The medical management of the patient’s condition is aimed toward a. limiting fluids to minimize the possibility of congestive heart failure. b. finding and eradicating the cause of infection. c. discontinuing invasive monitoring as a possible cause of sepsis. d. administering vasodilator substances to increase blood flow to vital organs.

ANS: B

Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.

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12. Signs of hypovolemia in the trauma patient include a. distended neck veins. b. a decreased level of consciousness. c. bounding radial and pedal pulses. d. a widening pulse pressure.

ANS: B

Signs of underperfusion include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.

13. Which medications are not effective in the immediate treatment of acute anaphylaxis? a. Epinephrine b. Vasopressors c. Diphenhydramine (Benadryl) IV d. Corticosteroids ANS: D

Epinephrine is the first-line treatment of choice for anaphylaxis and should be administered when initial signs and symptoms occur. Several medications are used as second-line adjunctive therapy. Inhaled -adrenergic agents are used to treat bronchospasm unresponsive to epinephrine. Diphenhydramine (Benadryl) given 1 to 2 mg/kg (25?0–50 mg) by a slow intravenous line is used to block histamine response.

Ranitidine, given in conjunction with diphenhydramine at a dose of 1 mg/kg intravenously over 10 to 15 minutes, has been found helpful. Corticosteroids are not effective in the immediate treatment of acute anaphylaxis but may be given with the goal of preventing a prolonged or delayed reaction.

14. A vasoconstrictor used to treat shock is a. adrenaline. b. Nipride. c. Dobutrex. d. adenosine.

ANS: A

Adrenaline is a vasoconstrictor, Nipride is a vasodilator, Dobutrex is an inotrope, and adenosine is an antidysrhythmic.

15. Which of the following clinical manifestations is not suggestive of systemic

inflammatory response syndrome (SIRS)?

Temperature of 37.5° C Heart rate of 95 beats/min Respiratory rate of 24 breath/min White blood cell (WBC) count of 15,000 cells/mm3

a. b. c. d.

ANS: A

SIRS occurs when two or more of four clinical manifestations are present in the patient at high risk. These manifestations are temperature less than 36° C or greater than 38° C, heart rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or PaCO2 less than 32 mm Hg, or WBC greater than 12,000 cells/mm3 or less than 4000 cells/mm3 or greater than 10% immature (band forms).

16. When SIRS is the result of infection, it is called

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a. b. c. d.

inflammation. anaphylaxis. sepsis. pneumonia.

ANS: C

When SIRS is the result of infection, the term sepsis is used.

17. The difference between primary and secondary multiple organ dysfunction syndrome

(MODS) is that primary MODS is the result of a. widespread systemic inflammation that results in dysfunction of organs

not involved in the initial insult. b. direct organ injury. c. disorganization of the immune system response. d. widespread disruption of the coagulation system.

ANS: B

Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is directly attributed to the insult itself.

18. The gastrointestinal system is a common target organ for MODS related to a. anorexia. b. limited or absent food ingestion. c. disruption of the mucosal barrier from hypoperfusion. d. a decrease in hydrochloric acid secretion.

ANS: C

With microcirculatory failure to the gastrointestinal tract, the gut’s barrier function may be lost, which leads to bacterial translocation, sustained inflammation, endogenous endotoxemia, and MODS. 19. Clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult.

Which symptom below is indicative of hepatic insufficiency?

Elevated serum creatinine Decreased bilirubin Jaundice Decreased serum transaminase

a. b. c. d.

ANS: C

Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult.

Jaundice and transient elevations in serum transaminase and bilirubin levels occur.

Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of bilirubin from hemoglobin catabolism.

20. A patient is admitted to the intensive care unit after she develops disseminated

intravascular coagulation (DIC) after a vaginal delivery. DIC is known to occur in patients with retained placental fragments. What is the result of DIC? a. Hypersensitive response to an antigen, resulting in anaphylaxis

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b. Depletion of clotting factors and excessive fibrinolysis, resulting in

simultaneous microvascular clotting and hemorrhage c. Vasodilatation, resulting in hypotension d. Septic shock, resulting in vasodilation and decreased perfusion ANS: B

DIC results simultaneously in microvascular clotting and hemorrhage in organ systems, leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the intrinsic or extrinsic coagulation pathways.

21. Laboratory values for DIC show abnormalities in a. liver function tests. b. tests for renal function. c. platelet counts. d. blood glucose levels.

ANS: C

Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of DIC. 22. Which medication is not recommended in the treatment of shock-related lactic acidosis? a. Glucose b. Sodium bicarbonate c. Vasoconstrictor d. Large quantity of crystalloids fluids ANS: B

Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis.

Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic vascular resistance and improving the patient’s blood pressure level. Crystalloids are balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.

23. The most common site for sepsis and septic shock is a. the respiratory system. b. the gastrointestinal system. c. the genitourinary system. d. the circulatory system.

ANS: A

The respiratory system is the most common site of infection producing severe sepsis and septic shock followed by the genitourinary and gastrointestinal systems.

24. Profound weight loss in patients with SIRS or MODS is the result of a. hypometabolism. b.

hypermetabolism. c. hyperglycemia. d. intolerance to enteral feedings.

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ANS: B

Hypermetabolism in SIRS or MODS results in profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity.

Enteral nutrition may exert a physiologic effect that downregulates the systemic immune response and reduces oxidate stress.

25. One theory suggests that organ dysfunction in MODS occurs in a sequential or progressive

pattern. Place the following organs in the order in which they are affected: 1. Bone marrow 2. Cardiac 3. Gut 4. Kidneys 5. Liver 6. Lungs a. 6, 5, 2, 1, 3, 4 b. 5, 4, 6, 1, 2, 3 c. 6, 5, 3, 4, 2, 1 d. 6, 3, 4, 5, 2, 1 ANS: C

Organ dysfunction may occur in a sequential or progressive pattern. Organ dysfunction may begin in the lungs, the most commonly affected major organ, and progress to the liver, gut, and kidneys. Cardiac and bone marrow dysfunction may follow. Neurologic and autonomic system impairment may occur and propagate the progression of organ failure, which is associated with illness severity and mortality. Organs may fail simultaneously; for example, kidney dysfunction may occur concurrently with hepatic dysfunction. After the initial insult and resuscitation, patients develop persistent hypermetabolism, a metabolic consequence of sustained systemic inflammation and physiologic stress followed closely by pulmonary dysfunction, manifested as acute respiratory distress syndrome.

MULTIPLE RESPONSE 1. The key to treatment of septic shock is finding the cause of the infection. Which of the

following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.) a. Blood cultures x 2 b. Wound cultures c. Urine cultures d. Sputum cultures e. CBC with differential ANS: A, B, C, D

A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.

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2. Which of the following historical findings would indicate a high risk for latex allergy?

(Select all that apply.)

Allergic reaction to anesthetics Eczema of the hands Congenital urologic disorder Asthma Health care worker

a. b. c. d. e.

ANS: A, B, C, E

Prevention of anaphylactic shock is one of the primary responsibilities of nurses in critical care areas. Preventive measures include the identification of patients at risk and cautious assessment of each patient’s response to the administration of medications, blood, and blood products. A complete and accurate history of each patient’s allergies is an essential component of preventive nursing care. In addition to a list of the allergies, a detailed description of the type of response for each one should be obtained.

3. Evidence-based guidelines for the treatment of septic shock include which of the following?

(Select all that apply.)

Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater Low-dose dopamine for renal protection High-dose corticosteroids Administration of activated protein C Achieve central venous oxygen saturation of 70% or more

a. b. c. d. e.

ANS: A, D, E

There is no evidence to support the use of dopamine; low-dose steroids are part of the sepsis management bundle.

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