Test Bank for Introduction to Critical Care Nursing 8th Edition by Mary Lou-Sole, Klein & Moseley

TEST BANK

TEST BANK

PART I: FUNDAMENTAL CONCEPTS Chapter:1. Overview of Critical Care Nursing Chapter:2. Patient and Family Response to the Critical Care Experience Chapter:3. Ethical and Legal Issues in Critical Care Nursing Chapter:4. Palliative and End-of-Life Care Chapter:5. Organ Donation

PART II: TOOLS FOR THE CRITICAL CARE NURSE Chapter:6. Comfort and Sedation Chapter:7. Nutritional Therapy Chapter:8. Dysrhythmia Interpretation and Management Chapter:9. Hemodynamic Monitoring Chapter:10. Ventilatory Assistance Chapter:11. Rapid Response Teams and Code Management

PART III: NURSING CARE DURING CRITICAL ILLNESS Chapter:12. Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Chapter:13. Cardiovascular Alterations Chapter:14. Nervous System Alterations Chapter:15. Acute Respiratory Failure Chapter:16. Acute Kidney Injury Chapter:17. Hematological and Immune Disorders Chapter:18. Gastrointestinal Alterations Chapter:19. Endocrine Alterations Chapter:20. Trauma and Surgical Management Chapter:21. Burns

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Sole: Introduction to Critical Care Nursing,8E

Chapter 01: Overview of Critical Care Nursing Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Which of the following professional organizations best supports critical care nursing practice? a. American Association of Critical-Care Nurses b. American Heart Association c. American Nurses Association d. Society of Critical Care Medicine ANS: A

The American Association of Critical-Care Nurses is the specialty organization that supports and represents critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical care team under the direction of an intensivist.

DIF: Cognitive Level: Knowledge OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is

interested in certification. Which credential would be most applicable for her to seek? a. ACNPC b. CCNS c. CCRN d. PCCN ANS: C

The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or step-down unit settings.

DIF: Cognitive Level: Application OBJ: Explain certification options for critical care nurses.

MSC: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process Step: N/A

3. What is the main purpose of certification for critical care nursing? a. To assure the consumer that critical nurses will not make a mistake. b. To help prepare the critical care nurse for graduate school. c. To assist in promoting magnet status for a facility. d. To validate a nurse’s knowledge of critical care nursing.

ANS: D

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Sole: Introduction to Critical Care Nursing,8E

Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification.

DIF: Cognitive Level: Analysis OBJ: Explain certification options for critical care nurses.

MSC: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process Step: N/A

4. What is the focus of the synergy model of practice? a. Allowing unrestricted visiting for the patient 24 hours each day. b. Providing holistic and alternative therapies. c. Considering the needs of patients and their families, which drives nursing

competency. d. Addressing the patients’ needs for energy and support.

ANS: C

The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient’s and family’s needs and application of alternative therapies if desired by the patient, but that is not the primary focus of the model.

DIF: Cognitive Level: Application OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 5. The family of your critically ill patient tells you that they have not spoken with the physician

in over 24 hours and they have some questions that they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members ANS: C

Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration.

DIF: Cognitive Level: Analysis OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 6. The AACN Standards for Acute and Critical Care Nursing Practice uses what framework to

guide critical care nursing practice? a. Evidence-based practice

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Sole: Introduction to Critical Care Nursing,8E

b. Healthy work environment c. National Patient Safety Goals d. Nursing process ANS: D

The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in the Standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN Standards.

DIF: Cognitive Level: Understand OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 7. The charge nurse is responsible for making the patient assignments on the critical care unit.

She assigns the experienced, certified nurse to care for the acutely ill patient diagnosed with sepsis who also requires continuous renal replacement therapy and mechanical ventilation.

She assigns the nurse with less than 1 year of experience to two patients who are more stable.

This assignment reflects implementation of what guiding framework? a. Crew resource management model b. National Patient Safety Goals c. Quality and Safety Education for Nurses (QSEN) model d. Synergy model of practice ANS: D

This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts related to team training, National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education to undergraduate and graduate nursing students to learn quality and safety concepts.

DIF: Cognitive Level: Analysis OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 8. The vision of the American Association of Critical-Care Nurses is a healthcare system driven

by achieving what goal? a. Maintaining a healthy work environment. b. Providing care from a multiprofessional team under the direction of a critical care physician. c. Effectively meeting the needs of critically ill patients and families. d. Creating respectful, healing, and humane environments.

ANS: C

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Sole: Introduction to Critical Care Nursing,8E

The AACN vision is a healthcare system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization’s vision. The SCCM promotes care from a multiprofessional team under the direction of a critical care physician.

DIF: Cognitive Level: Knowledge OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 9. What is the most important outcome of effective communication? a. Demonstrating caring practices to family members. b. Ensuring that patient teaching is provided c. Meeting the diversity needs of patients. d. Reducing patient errors.

ANS: D

Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, be used for patient/family teaching, and address diversity needs; however, the main outcome of effective communication is patient safety.

DIF: Cognitive Level: Analysis OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 10. The nurse is caring for a critically ill patient whose urine output has been low for 2

consecutive hours. After a thorough patient assessment, you call the primary care provider with the following report.

Dr. Smith, I’m calling about Mrs. P., your 65-year-old patient in CCU 10. Her urine output for the past 2 hours totaled only 40 mL. She arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour. Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her BUN and creatinine levels have been stable and in normal range.

Her abdominal dressing is dry with no indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the information the nurse gives about the patient’s history and vital signs is appropriate for what part of the model? a. Situation b. Background c. Assessment d. Recommendation ANS: B

The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse’s assessment, and the suggestion for fluids is the recommendation.

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DIF: Cognitive Level: Understand OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment 11. The family members of a critically ill, 90-year-old patient bring in a copy of the patient’s

living will to the hospital, which identifies the patient’s wishes regarding health care. The nurse discusses the contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Professional Performance? a. Acquires and maintains current knowledge of practice b. Acts ethically on the behalf of the patient and family c. Considers factors related to safe patient care d. Uses clinical inquiry and integrates research findings in practice ANS: B

Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.

DIF: Cognitive Level: Analysis OBJ: Describe standards of care and performance for critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 12. Which of the following assists the critical care nurse in ensuring that care is appropriate and

based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals ANS: A

Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidencebased practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practices.

DIF: Cognitive Level: Analysis OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 13. Comparing the patient’s current (home) medications with those ordered during hospitalization

and communicating a complete list of medications to the next care provider when the patient is transferred within an organization or to another setting are strategies toward best achieving what patient related goal? a. Improving accuracy of patient identification. b. Preventing errors related to look-alike and sound-alike medications. c. Reconciling medications across the continuum of care. d. Reducing harms associated with administration of anticoagulants.

ANS: C

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Sole: Introduction to Critical Care Nursing,8E

These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, not medication reconciliation. Reducing harms associated with administration of anticoagulants is another National Patient Safety Goal.

DIF: Cognitive Level: Comprehension OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 14. As part of nursing management of a critically ill patient, orders are written to keep the head of

the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often referred to using what term? a. Bundle of care. b. Clinical practice guideline. c. Patient safety goal. d. Quality improvement initiative.

ANS: A

A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals.

DIF: Cognitive Level: Analysis OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 15. A nurse who works in an intermediate care unit has experienced high nursing turnover. The

nurse manager is often considered to be an autocratic leader by staff members and that leadership style is contributing to turnover. The nurse asks to be involved in developing new guidelines to prevent pressure ulcers in the patient population. The nurse manager suggests that the nurse has not yet had enough experience to be on the prevention task force. This situation and setting is an example of what form of ineffective leadership? a. Creating a barrier to inter-staff communication. b. Supporting a work environment that is unhealthy. c. Displaying ineffective decision making. d. Demonstrating nursing practice that is not evidence-based.

ANS: B

These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership.

It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment.

DIF: Cognitive Level: Analysis

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Sole: Introduction to Critical Care Nursing,8E

OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 16. Which of the following statements describes the core concept of the synergy model of

practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence care. d. Unique needs of patients and their families influence nursing competencies.

ANS: D

The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration.

DIF: Cognitive Level: Application OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. A nurse who plans care based on the patient’s gender, ethnicity, spirituality, and lifestyle is

said to demonstrate what focus? a. Becoming a moral advocate. b. Facilitating all forms of learning. c. Responding to diversity. d. Using effective clinical judgment.

ANS: C

Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well.

DIF: Cognitive Level: Comprehension OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of healthcare-acquired infection.

ANS: A, C, D

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All except for eliminating use of restraints are current National Patient Safety Goals.

Hospitals have policies regarding use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal.

DIF: Cognitive Level: Knowledge OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is (are) official journal(s) of the American Association of Critical-

Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly ANS: A, C

American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics and Critical Care Nursing Quarterly are not AACN publications.

DIF: Cognitive Level: Knowledge OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 3. What were identified as the first critical care units? (Select all that apply.) a. Burn units. b. Coronary care units c. Recovery rooms. d. Neonatal intensive care units. e. High-risk OB units.

ANS: B, C

Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, high risk OB and neonatal intensive care units were established as specialty units evolved.

DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A

OBJ: Define critical care nursing.

MSC: NCLEX: Safe and Effective Care Environment

4. Which of the following nursing activities demonstrates implementation of the AACN

Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of CriticalCare Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit’s nurse practice council d. Posting an article from Critical Care Nurse on management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia ANS: A, B, C, D, E

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Sole: Introduction to Critical Care Nursing,8E

All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services— Collaborates with the healthcare team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other healthcare providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

DIF: Cognitive Level: Analysis OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 5. Which scenarios contribute to effective handoff communication at change of shift? (Select all

that apply.) a. The nephrology consultant physician is making rounds and asks the nurse to provide an update on the patient’s status and assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurse’s station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. Both the off-going and the oncoming nurses conduct a standardized report at the patient’s bedside and review key assessment findings. e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

ANS: C, D

A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurse’s station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse.

Likewise, noise in the nurse’s station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.

DIF: Cognitive Level: Analysis OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment 6. Which strategy is important to addressing issues associated with the aging workforce? (Select

all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians that are available to assist with patient care, such as turning the patient d. Developing a staffing model that accurately reflects the unit’s needs. e. Remodeling patient care rooms to include devices to assist in patient lifting ANS: A, C, D

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Sole: Introduction to Critical Care Nursing,8E

Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including non-licensed assistive personnel, to help with nursing and non-nursing tasks is helpful. Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.

DIF: Cognitive Level: Analysis OBJ: Identify current trends and issues in critical care nursing.

MSC: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process Step: N/A

7. Which of the following strategies will assist in creating a healthy work environment for the

critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication ANS: A, D, E

Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, and if done without nursing input, could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly not needed.

DIF: Cognitive Level: Analysis OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment

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Sole: Introduction to Critical Care Nursing,8E

Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free. Certification does not prepare one for graduate school; however, achieving certification demonstrates motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses; however, that is not the purpose of certification.

DIF: Cognitive Level: Remember/Knowledge REF: p. 6 OBJ: Explain certification options for critical care nurses.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. The synergy model of practice focuses on a. allowing unrestricted visiting for the patient 24 hours a day. b. holistic and alternative therapies. c. the needs of patients and their families, which drive nursing competency. d. patients’ needs for energy and support.

ANS: C

The synergy model of practice states that the needs of patients and families influence and drive competencies of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patient’s and family’s needs and the application of alternative therapies if desired by the patient, but that is not the primary focus of the model.

DIF: Cognitive Level: Remember/Knowledge REF: p. 6 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs CategoN ryU: R SSafIN e Ga nTdB E. Cf O feM ct i v e Care Environment 5. The family of your critically ill patient tells you that they have not spoken with the physician

in over 24 hours and that they have some questions they want clarified. During morning rounds, you convey this concern to the attending intensivist and arrange a meeting with the family at 4:00 PM. Which competency of critical care nursing does this represent? a. Advocacy and moral agency in solving ethical issues b. Clinical judgment and clinical reasoning skills c. Collaboration with patients, families, and team members d. Facilitation of learning for patients, families, and team members ANS: C

Although one might consider that all of these competencies are being addressed, communication and collaboration with the family and physician best exemplify the competency of collaboration.

DIF: Cognitive Level: Analyze/Analysis REF: p. 6 | Fig 1-3 | Box 1-1 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to

guide critical care nursing practice? a. Evidence-based practice

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b. Healthy work environment c. National Patient Safety Goals d. Nursing process ANS: D

The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care, implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not included in its standards. The Joint Commission has established National Patient Safety Goals, but these are not the AACN standards.

DIF: Cognitive Level: Remember/Knowledge REF: p. 6 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 7. The charge nurse is responsible for making the patient assignments on the critical care unit.

An experienced, certified nurse is assigned to care for the acutely ill patient with sepsis who also requires continuous renal replacement therapy and mechanical ventilation. The nurse with less than 1 year of experience is assigned to two patients who are more stable. This assignment reflects implementation of the a. crew resource management model. b. National Patient Safety Goals. c. Quality and Safety Education for Nurses (QSEN) model. d. synergy model of practice.

ANS: D

This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the nurse competencies are matched to the patient characteristics. Crew resource management concepts are related to team training; National Patient Safety Goals are specified by The Joint Commission to promote safe care but do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted education of undergraduate and graduate nursing students on quality and safety concepts.

DIF: Cognitive Level: Analyze/Analysis REF: p. 6 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 8. The vision of the American Association of Critical-Care Nurses is a health care system driven

by a. b. c. d.

a healthy work environment. care from a multiprofessional team under the direction of a critical care physician. the needs of critically ill patients and families. respectful, healing, and humane environments.

ANS: C

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The AACN vision is a health care system driven by the needs of critically ill patients and families where critical care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work environment as well as respectful and healing environments, but that is not the organization’s vision. The Society of Critical Care Medicine (SCCM) promotes care from a multiprofessional team under the direction of a critical care physician.

DIF: Cognitive Level: Remember/Knowledge REF: p. 5 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 9. The most important outcome of effective communication is to a. demonstrate caring practices to family members. b. ensure that patient teaching is done. c. meet the diversity needs of patients. d. reduce patient errors.

ANS: D

Many errors are directly attributed to faulty communication. Effective communication has been identified as an essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication may demonstrate caring practices, address diversity needs, and be used for patient/family teaching; however, the main outcome of effective communication is patient safety.

DIF: Cognitive Level: Remember/Knowledge REF: p. 9 OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive

hours. After a thorough patient assessment, you call the intensivist with report. Which information do you convey regarding background? a. Urine output of 40 mL/2 hours b. Current vital signs and history of aortic aneurysm repair 4 hours ago c. A statement that the patient is possibly hypovolemic d. A request for IV fluids ANS: B

The history and vital signs are part of the background. Information regarding the low urine output is the situation. Information regarding possible hypovolemia is part of the nurse’s assessment, and the suggestion for fluids is the recommendation.

DIF: Cognitive Level: Analyze/Analysis REF: p. 9 OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Integrated Process: Communication MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 11. The family members of a critically ill patient bring a copy of the patient’s living will to the

hospital, which identifies the patient’s wishes regarding health care. You discuss contents of the living will with the patient’s physician. This is an example of implementation of which of the AACN Standards of Professional Performance?

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a. b. c. d.

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Acquires and maintains current knowledge of practice Acts ethically on the behalf of the patient and family Considers factors related to safe patient care Uses clinical inquiry and integrates research findings in practice

ANS: B

Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.

DIF: Cognitive Level: Analyze/Analysis REF: p. 6 | Box 1-2 OBJ: Describe standards of care and performance for critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 12. Which of the following assists the critical care nurse in ensuring that care is appropriate and

based on research? a. Clinical practice guidelines b. Computerized physician order entry c. Consulting with advanced practice nurses d. Implementing Joint Commission National Patient Safety Goals ANS: A

Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research. Some physician order entry pathways, but not all, are based on research recommendations. Some advanced practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are recommendations to reduce errors using evidence-based practiNcUesR. SINGTB.COM DIF: Cognitive Level: Analyze/Analysis REF: p. 8 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 13. Comparing the patient’s current (home) medications with those ordered during hospitalization

and communicating a complete list of medications to the next provider when the patient is transferred within an organization or to another setting are strategies to: a. improve accuracy of patient identification. b. prevent errors related to look-alike and sound-alike medications. c. reconcile medications across the continuum of care. d. reduce harms associated with the administration of anticoagulants.

ANS: C

These are steps recommended in the National Patient Safety Goals to reconcile medications across the continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal. Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, but is not related to transferring the patient between settings. Reducing harms associated with the administration of anticoagulants is another National Patient Safety Goal.

DIF: Cognitive Level: Understand/Comprehension REF: p. 7 | Box 1-3 OBJ: Describe quality and safety initiatives related to critical care nursing.

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TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 14. As part of nursing management of a critically ill patient, orders are written to keep the head of

the bed elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is often called a a. bundle of care. b. clinical practice guideline. c. patient safety goal. d. quality improvement initiative.

ANS: A

A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines and are monitored for compliance as part of quality improvement initiatives. At some point, these may become part of patient safety goals.

DIF: Cognitive Level: Remember/Knowledge REF: p. 7 | Box 1-3 OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 15. You work in an intermediate care unit and have asked to be involved in developing new

guidelines to prevent pressure ulcers in your patient population. The nurse manager tells you that you do not yet have enough experience to be on the prevention task force and that your ideas will be rejected by others. T Nh iUs RsSi tI uNaGt iToBn. Ci sO aMn example of a. a barrier to handoff communication. b. a work environment that is unhealthy. c. ineffective decision making. d. nursing practice that is not evidence-based.

ANS: B

These are examples of an unhealthy work environment. A healthy work environment values communication, collaboration, and effective decision making. It also has authentic leadership.

It is not an example of handoff communication, which is communication that occurs to transition patient care from one staff member to another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidence-based practice, but your influence in the unit is limited by the unhealthy work environment.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 8-9 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 16. Which of the following statements describes the core concept of the synergy model of

practice? a. All nurses must be certified in order to have the synergy model implemented. b. Family members must be included in daily interdisciplinary rounds. c. Nurses and physicians must work collaboratively and synergistically to influence

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care. d. Unique needs of patients and their families influence nursing competencies.

ANS: D

The synergy model of practice is care based on the unique needs and characteristics of the patient and family members. Although critical care certification is based on the synergy model, the model does not specifically address certification. Inclusion of family members into the daily rounds is an example of implementation of the synergy model. With the focus on patients and family members with nurse interaction, the synergy model does not address physician collaboration.

DIF: Cognitive Level: Apply/Application REF: p. 6 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 17. A nurse who plans care based on the patient’s gender, ethnicity, spirituality, and lifestyle is

said to a. be a moral advocate. b. facilitate learning. c. respond to diversity. d. use clinical judgment.

ANS: C

Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning. Clinical judgment uses other factors as well.

DIF: Cognitive Level: Understand/Comprehension REF: p. 5 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. Which of the following is a National Patient Safety Goal? (Select all that apply.) a. Accurately identify patients. b. Eliminate the use of patient restraints. c. Reconcile medications across the continuum of care. d. Reduce risks of health care–acquired infection. e. Reduce costs associated with hospitalization.

ANS: A, C, D

All except for eliminating the use of restraints and reducing costs are current National Patient Safety Goals. Hospitals have policies regarding the use of restraints and are attempting to reduce the use of restraints; however, this is not a National Patient Safety Goal. Many facilities are actively working on cost reduction, but this is not a National Patient Safety Goal either.

DIF: Cognitive Level: Remember/Knowledge REF: p. 7 | Box 1-3 OBJ: Describe quality and safety initiatives related to critical care nursing.

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TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 2. Which of the following is (are) official journal(s) of the American Association of

Critical-Care Nurses? (Select all that apply.) a. American Journal of Critical Care b. Critical Care Clinics of North America c. Critical Care Nurse d. Critical Care Nursing Quarterly e. Critical Care Nursing Management ANS: A, C

American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care Clinics, Critical Care Nursing Quarterly, and Critical Care Nursing Management are not AACN publications.

DIF: Cognitive Level: Remember/Knowledge REF: p. 5 OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 3. The first critical care units were (Select all that apply.) a. burn units. b. coronary care units. c. recovery rooms. d. neonatal intensive care units. e. high-risk OB units.

ANS: B, C

Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn, neonatal intensive care, and high-risk OB units were established as specialty units evolved.

DIF: Cognitive Level: Remember/Knowledge REF: p. 3 OBJ: Define critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. Which of the following nursing activities demonstrates implementation of the AACN

Standards of Professional Performance? (Select all that apply.) a. Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in which a continuing education program on sepsis is being taught b. Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient and family c. Participating on the unit’s nurse practice council d. Posting an article from Critical Care Nurse on the management of venous thromboembolism for your colleagues to read e. Using evidence-based strategies to prevent ventilator-associated pneumonia ANS: A, B, C, D, E

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All answers are correct. Attending a program to learn about sepsis—Acquires and maintains current knowledge and competency in patient care. Collaborating with pastoral services— Collaborates with the health care team to provide care in a healing, humane, and caring environment. Posting information for others—Contributes to the professional development of peers and other health care providers. Nurse practice council—Provides leadership in the practice setting. Evidence-based practices—Uses clinical inquiry in practice.

DIF: Cognitive Level: Remember/Knowledge REF: p. 4 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. Which scenarios contribute to effective handoff communication at change of shift? (Select all

that apply.) a. The nephrology consultant physician is making rounds and asks you for an update on the patient’s status and to assist in placing a central line for hemodialysis. b. The noise level is high because twice as many staff members are present and everyone is giving report in the nurses’ station. c. The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient transfers. d. You and the oncoming nurse conduct a standardized report at the patient’s bedside and review key assessment findings. e. The off-going nurse is giving the patient medications at the same time as giving handoff report to the oncoming nurse.

ANS: C, D

A reporting tool and bedside report improve handoff communication by ensuring standardized communication and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs at the nurses’ station during a change of shift. The nephrologist has created an interruption that can impede handoff with the next nurse.

Likewise, noise in the nurses’ station can cause distractions that can impair concentration and listening. Giving medications at the same time as handoff report could lead to serious errors both in medication administration and in the report itself.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 9-10 OBJ: Describe quality and safety initiatives related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 6. Which strategy is important in addressing issues associated with the aging workforce? (Select

all that apply.) a. Allowing nurses to work flexible shift durations b. Encouraging older nurses to transfer to an outpatient setting that is less stressful c. Hiring nurse technicians who are available to assist with patient care, such as turning the patient d. Remodeling patient care rooms to include devices to assist in patient lifting e. Developing a staffing model that accurately reflects the unit’s needs.

ANS: A, C, D

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Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce. Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding; therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate staffing, including both registered nurses and nonlicensed assistive personnel to help with nursing and nonnursing tasks, is helpful.

Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the unit loses the expertise of this group.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 16-17 OBJ: Identify current trends and issues in critical care nursing. TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 7. Which of the following strategies will assist in creating a healthy work environment for the

critical care nurse? (Select all that apply.) a. Celebrating improved outcomes from a nurse-driven protocol with a pizza party b. Implementing a medication safety program designed by pharmacists c. Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio d. Offering quarterly joint nurse-physician workshops to discuss unit issues e. Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff communication ANS: A, D, E

Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work environment. Implementing a medication safety program enhances patient safety, but if done without nursing input, it could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse competencies, not have predetermined ratios that are unrealistic and possibly unneededN . URSINGTB.COM DIF: Cognitive Level: Apply/Application REF: pp. 8-9 OBJ: Describe standards of professional practice for critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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Chapter 02: Patient and Family Response to the Critical Care Experience Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Family members have a need for information. Which interventions best assist in meeting this

need? a. Handing family members a pamphlet that explains all of the critical care equipment b. Providing a daily update of the patient’s progress and facilitating communication with the intensivist c. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist d. Writing down a list of all new medications and doses and giving the list to family members during visitation ANS: B

The nurse can give a status report related to the patient’s condition and current treatment plan as well as ensure that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like. Pamphlets are helpful; however, the nurse should also explain the equipment that is at this patient’s bedside and not assume that everyone can read and understand written material. Limiting the information to that provided by the physician is unnecessary and will not meet the family’s information needs. Most family members are concerned about the patient’s general condition and treatment plan. They do not want or need a detailed list of medications, doses, or other treatments.

DIF: Cognitive Level: Apply/Application REF: p. 23 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 2. The nurse is a member of a committee to design a critical care unit in a new building. Which

design trend would best facilitate family-centered care? a. Ensure that the patient’s room is large enough and has adequate space for a sleeper sofa and storage for family members’ personal belongings. b. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing. c. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea. d. Provide access to a scenic garden for meditation.

ANS: A

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New unit design trends to promote family-centered care include patient rooms that provide a larger family space and comfortable furniture and storage to promote open visitation, including overnight stays in the patient’s room. Ready access to diagnostic testing, including portable equipment, is an important trend; however, the purpose for this is to prevent the need for transport, not to foster family-centered care. A waiting room in close proximity to the unit with amenities is a nice feature; however, it does not need to be large if adequate space is incorporated into the patient’s room. A scenic garden for meditation may assist in reducing family members’ stress, but proximity to the patient is the greatest need.

DIF: Cognitive Level: Apply/Application REF: p. 19 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Psychosocial Integrity 3. The nurse is caring for a patient who sustained a head injury and is unresponsive to painful

stimuli. Which intervention is most appropriate while bathing the patient? a. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure. b. Because the patient is unconscious, complete care as quickly and quietly as possible. c. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there. d. Turn the television on to the evening news so that you and the patient can be updated to current events.

ANS: C

Although unconscious, many p a t i eNnUt Rs ScIaNnGhTeBar.C,OuM nderstand, and respond to stimuli. Therefore, it is important to converse with the patient and reorient her to the environment. Some, but not all, family members may want to get involved in direct care; it is not known if this individual is a willing participant, and talking about who’s who in the family is inappropriate while providing direct care to the patient. Although the patient is unconscious, communication and simple conversations remain important interventions. Use of the television to provide sensory input that the patient regularly enjoys is a nursing intervention, but turning on the news for the sake of the nurse is not appropriate.

DIF: Cognitive Level: Apply/Application REF: p. 20 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 4. Sleep often is disrupted for critically ill patients. Which nursing intervention is most

appropriate to promote sleep and rest? a. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals. b. Encourage family members to talk with the patient whenever they are present in the room. c. Keep the television on to provide white noise and distraction. d. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

ANS: A

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Planning care to promote periods of uninterrupted rest is important. Consulting with the pharmacist to adjust a medication schedule is an excellent example of this intervention. It is important for family members to communicate with the patient; however, rest periods must be scheduled. Family members can be present in the room while remaining quiet during these scheduled times. The television may be useful if it is part of the patient’s normal routine for sleep; however, it does not consistently provide white noise or distraction. Lights should be dimmed during scheduled rest periods and at night to facilitate sleep and rest.

DIF: Cognitive Level: Apply/Application REF: p. 20 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity—Basic Care and Comfort 5. Family assessment is essential to meet family needs. Which of the following must be assessed

first to assist the nurse in providing family-centered care? a. Assessment of patient and family’s developmental stages and needs b. Description of the patient’s home environment c. Identification of immediate family, extended family, and decision makers d. Observation and assessment of how family members function with each other ANS: C

Assessment of the family structure is the first step and is essential before specific interventions can be designed. It identifies immediate family, extended family, and decision makers in the family. Structural assessment also includes ethnicity and religion. The developmental assessment is done after the structural assessment and includes the developmental stages of the patient and family. Functional assessment is also important to assess how family members f u nc t Ni oUnRwS Ii Nt hGeTaBc. hC Oo M t h e r ; however, it is not done first.

Assessment of the home environment is important when identifying discharge planning needs.

DIF: Cognitive Level: Apply/Application REF: p. 21 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 6. Critical illness often results in family conflicts. Which scenario is most likely to result in the

greatest conflict? a. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s boyfriend for causing the accident. b. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year. c. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his health care proxy in a written advance directive. d. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment

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of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is “committing suicide.”

ANS: B

Each of these situations may result in family conflict. The situation with the unmarried 36-year-old male without a written advance directive results in his distant parents being legally responsible for his health care decisions. Because of his long-standing commitment with his partner and lack of recent contact with his parents, this scenario is likely to cause the most conflict. The parents may make decisions based on their wishes, as they may not be knowledgeable of the patient’s wishes. The supportive parents of the college student may create conflict with the boyfriend, but the parents’ ongoing friendship and shared values will assist in reducing conflict. The male admitted for bypass surgery, although in a same-sex relationship, has clearly identified whom he wants to make health care decisions for him. The elderly female may have conflict with her son; however, she is capable of making her own decisions and has a written advance directive to support her decisions.

DIF: Cognitive Level: Analyze/Analysis REF: p. 22 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 7. Which nursing interventions would best support the family of a critically ill patient? a. Encourage family members to stay all night in case the patient needs them. b. Give a condition update each morning and whenever changes occur. c. Limit visitation from children into the critical care unit. d. Provide beverages and snacks in the wa itin g room.

N UR SING T B .C O M

ANS: B

The need for information is one of the highest identified by family members of critically ill patients. A planned condition update helps the family know what to expect. New room designs provide space for family members to spend the night if desired; however, if the patient is stable, family members should be encouraged to sleep at home to ensure that they are well rested and can support the patient. Restriction of children in the critical care unit is not supported by research evidence. Child visitation should be individualized based on the needs and wishes of the patient and family. Beverages and snacks are important but not as important as information.

DIF: Cognitive Level: Analyze/Analysis REF: p. 23 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 8. Which intervention is appropriate to assist the patient in coping with admission to the critical

care unit? a. Allowing unrestricted visiting by several family members at one time b. Explaining all procedures in easy-to-understand terms c. Providing back massage and mouth care d. Turning down the alarm volume on the cardiac monitor ANS: B

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Communication and explanations of procedures are priority interventions to help patients cope with admission. Comfort is an important intervention but not the priority. Noise control is an important intervention but not the priority. Open visitation is recommended; however, the number of family members may need to be limited to promote rest and sleep.

DIF: Cognitive Level: Analyze/Analysis REF: p. 20 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient

to: a. b. c. d.

anxiety. pain. powerlessness. sensory overload.

ANS: D

Constant noise is a source of sensory overload. Pain and lack of information contribute to anxiety. Noise does not cause physical pain. Lack of involvement in care causes powerlessness.

DIF: Cognitive Level: Remember/Knowledge REF: p. 18 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 10. Which of the following statementsN U a bRoSuIN t fGaTmBi.lCyOaMssessment is false? a. Assessment of structure (who comprises the family) is the last step in assessment. b. Interaction among family members is assessed. c. It is important to assess communication among family members to understand

roles. d. Ongoing assessment is important, because family functioning may change during

the course of illness.

ANS: A

Assessment of structure should be done first so that the nurse can identify such things as who comprises the family and who assumes leadership and decision-making responsibilities. This assessment also assists in identifying which individuals are most important to the patient and how many people may be seeking information. Family member interaction must be assessed, so this answer is true. Family member communication must be assessed, so this answer is true. Ongoing assessment of family is necessary as functions may change, so this answer is true.

DIF: Cognitive Level: Remember/Knowledge REF: p. 21 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 11. Which intervention about visitation in the critical care unit is true? a. The majority of critical care nurses implement restricted visiting hours to allow the

patient to rest.

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b. Children should never be permitted to visit a critically ill family member. c. Visitation that is individualized to the needs of patients and family members is

ideal. d. Visiting hours should always be unrestricted.

ANS: C

Visiting should be based on the needs of patients and their families. There may be times when visiting needs to be limited (e.g., to allow the patient to rest); however, it is important to individualize visitation. Sometimes it is appropriate for children to visit; research has not found child visitation to be harmful to either the patient or the child. Visiting should be adjusted to patient needs.

DIF: Cognitive Level: Remember/Knowledge REF: p. 24 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 12. Elderly patients who require critical care treatment are at risk for increased mortality,

functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life? a. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower. b. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but n eed edNdUi Ru rSeI Nti cG TmBe. CdiOcM ati o ns adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other. c. A 90-year-old man admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the “social butterfly” at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF. d. An 84-year-old woman who had stents placed to treat coronary artery occlusion.

She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure.

ANS: A

Although he is younger, the 70-year-old with the complicated critical care course, limited social support, and a transfer to a long-term acute care facility is at greatest risk for decreased quality of life and functional decline. He will continue to need high-level nursing care and support for rehabilitation. The other cases are examples of individuals with shorter hospital stays, uncomplicated courses, and social support systems.

DIF: Cognitive Level: Analyze/Analysis REF: p. 21 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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13. Patients often have recollections of the critical care experience. Which is likely to be the most

common recollection of patients who required endotracheal intubation and mechanical ventilation? a. Difficulty in communicating b. Inability to get comfortable c. Pain d. Sleep disruption ANS: A

Although the patient may recall all of these potential experiences, recollection of difficult communication is most likely secondary to the endotracheal tube placement.

DIF: Cognitive Level: Analyze/Analysis REF: p. 20 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Psychosocial Integrity 14. Many critically ill patients experience anxiety. The nurse can reduce anxiety with which

approach? a. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. b. Explain the unit routine. c. Explain procedures before and while you are doing them. d. Suction Mr. J.’s endotracheal tube immediately when he starts to cough.

ANS: C

Anxiety is reduced when procedures are explained before completing them and when the O .ML i m i t i ng visitation has not been nurse continues to talk to the patieNnUt Rd Su IrNi nGgT tBh. eCm demonstrated by research to benefit patients. Explaining the unit routine is important but is not as specific to the patient as explaining a procedure right before doing it. Providing physical care is vital to critically ill patients, but may or may not reduce anxiety.

DIF: Cognitive Level: Analyze/Analysis REF: p. 20 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 15. The intensive care nurse is working on a committee to reduce noise in the unit. Which

recommendation should the nurse propose first? a. Change telephones to blinking lights instead of audible ringtones. b. Invest in call lights that page the nursing staff instead of beeping. c. Recommend that nurses turn off cardiac monitors on stable patients. d. Soundproof the pneumatic tube system.

ANS: D

The pneumatic tube system is extremely loud at 88dB[A] and should be the first proposal as it will have the biggest impact on noise on the unit. Call light systems typically ring at the 48–63 dB[A] range and are also a significant cause of noise, but not as much as the pneumatic tube system. Telephones are also noisy, ringing at 60–67 dB[A]. Nurses should never shut off monitor alarms as this is a patient safety issue.

DIF: Cognitive Level: Apply/Application

REF: p. 19

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OBJ: Discuss how to safely reduce the noise level on the unit floor.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment—Management of Care 16. The nurse is assigned to care for a patient who is a non–native English speaker. What is the

best way to communicate with the patient and family to provide updates and explain procedures? a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use. b. Contact the hospital’s interpreter service for someone to translate. c. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit. d. Use the patient’s 8-year-old child who is fluent in both English and the native language to translate for you.

ANS: B

The best approach when communicating with someone whose primary language is not English is to use the interpreter services of the agency. These individuals are trained and knowledgeable. If the nurse conducted a search on the computer, he or she would not know if the information retrieved was valid, nor would the nurse know if the patient or family can read in their native language. Although one of the residents might be fluent in the language, you do not know his or her abilities to translate. In addition, the resident’s availability is likely to be limited. Although the child might be able to translate, the nurse cannot ensure that the child is translating health care concepts correctly.

DIF: Cognitive Level: Analyze/Analysis REF: p. 22 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

N U R S I N GTB. COM TOP: Nursing Process Step: Implem e n ta ti o n MSC: NCLEX Client Needs Category: Psychosocial Integrity 17. Family assessment can be challenging, and each nurse may obtain additional information

regarding family structure and dynamics. What is the best way to share this information from shift to shift? a. Create an informal family information sheet that is kept on the bedside clipboard.

That way, everyone can review it quickly when needed. b. Develop a standardized reporting form for family information that is incorporated into the patient’s medical record and updated as needed. c. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues. d. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

ANS: B

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A standardized method for gathering data about family structure and function and recording it in an official document is the best approach. This strategy ensures that data are collected and kept in the medical record. Data are also easily retrievable by anyone who needs to know this information. Informal documentation is often kept to assist in follow-up and change-of-shift reporting; however, this strategy is not recommended, as data collected are likely to vary and not be part of a permanent record. Although the charge nurse often has some information regarding families, the primary responsibility for assessment and follow-up belongs to the bedside nurse. Family information should be shared at change of shift using a standardized format, not “try to remember to discuss….”

DIF: Cognitive Level: Analyze/Analysis REF: p. 22 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 18. The spouse of a patient who is hospitalized in the critical care unit following resuscitation for

a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, “I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay.” The nurse recognizes that this response most likely is due to the spouse’s a. desire to pursue a lawsuit if the assignment is not changed. b. inability to participate in the husband’s care. c. lack of prior experience in a critical care setting. d. sense of loss of control of the situation.

ANS: D

Demanding behaviors often o c c u rNwUhReSnI Nt hGeT Bf a. CmOi lMy member has a sense of loss of control or has had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this scenario. No information is provided regarding whether the family member is participating in care or not. It is unknown whether the spouse had a prior negative experience.

DIF: Cognitive Level: Analyze/Analysis REF: p. 22 OBJ: Discuss the impact of critical care hospitalization on the patient and family.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Psychosocial Integrity 19. Open visitation policies are expected by many professional organizations. Which statement

reflects adherence to current recommendations? a. Allow animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program. b. Allow family visitation throughout the day except at change of shift and during rounds. c. Determine, in collaboration with the patient and family, who can visit and when.

Facilitate open visitation policies. d. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

ANS: C

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Open visitation is considered best practice. Limiting visitation is not supported by research.

Facilities should develop visitation schedules in collaboration with the patient and family.

Animals do not need to be limited to therapy animals. Many patients benefit from the presence of personal pets brought to the unit according to hospital policy. Although many units restrict visitation during report and rounds for confidentiality, family-centered facilities will encourage family participation during report and rounds. Children should not be banned arbitrarily from the unit or have hours limited.

DIF: Cognitive Level: Remember/Knowledge REF: p. 24 OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 20. The VALUE mnemonic is a helpful strategy to enhance communication with family members

of critically ill patients. Which of the following statements describes a VALUE strategy? a. View the family as guests on the unit. b. Acknowledge family emotions. c. Learn as much as you can about family structure and function. d. Use a trained interpreter if the family does not speak English.

ANS: B

The VALUE mnemonic includes the following: V—Value what the family tells you.

A—Acknowledge family emotions.

L—Listen to the family members.

U—Understand the patient as a person.

E—Elicit (ask) questions of famil N y UmReSm rsB. .COM INbGeT DIF: Cognitive Level: Remember/Knowledge REF: p. 25 OBJ: Describe common family needs and family-centered nursing interventions.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 21. Changing visitation policies can be challenging. The nurse manager recognizes which of the

following as an effective strategy for promoting changes in practice? a. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation. b. Discuss the pros and cons of open visitation at the next staff meeting. c. Invite the nurses with the most experience to develop a revised policy. d. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

ANS: D

Changes in policy are most effective through willing champions as part of a unit-based, staff-led practice council. Discussion of evidence-based findings is important, but it is not logical to expect every nurse to read a research article and share findings. Discussion of pros and cons at a staff meeting is likely to be prolonged and based on opinion rather than evidence. Nurses with the most experience are not necessarily the ones to develop a new policy. They may be the least likely to change; therefore, it is important to solicit volunteers from all staff members, not just the experienced ones.

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DIF: Cognitive Level: Apply/Application REF: p. 25 OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity MULTIPLE RESPONSE 1. Nursing strategies to help families cope with the stress of critical illness include: (Select all

that apply.) a. asking the family to leave during the morning bath to promote the patient’s privacy. b. encouraging family members to make notes of questions they have for the physician during family rounds. c. if possible, providing continuity of nursing care. d. providing a daily update of the patient’s condition to the family spokesperson. e. ensuring that a waiting room stocked with snacks is nearby.

ANS: B, C, D

Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent staff members assists in reducing stress. Communicating daily updates of the patient’s condition meets the family’s need for information. Family members often want to assist with simple activities of patient care, so limiting participation is the exception to this list. A comfortable waiting room is necessary; however, it may or may not impact the family’s stress level.

DIF: Cognitive Level: Apply/Application REF: pp. 23-24 OBJ: Describe common family n e e N d sUaRnSdI Nf aGmTi Bl y. C- cOenMtered nursing interventions.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 2. Family presence is encouraged during resuscitation and invasive procedures. Which findings

about this practice have been reported in the literature? (Select all that apply.) a. Families benefit by witnessing that everything possible was done. b. Families report reduced anxiety and fear about what is being done to the patient. c. Presence encourages family members to seek litigation for improper care. d. Presence reduces nurses’ involvement in explaining things to the family. e. Families report that staff conversations during this time were distressing.

ANS: A, B

Families benefit from witnessing procedures and resuscitation. The presence of family members removes doubt about the patient’s condition, allows them to witness that everything was done, and decreases anxiety about what is occurring. Increased litigation has not been associated with family presence. Policies and procedures are needed to facilitate family presence. A facilitator is needed, and it may initially require more nursing involvement. It does not eliminate nurses’ responsibility for communicating with the family. The literature does not report that families have reported feelings of distress over staff conversations during these times.

DIF: Cognitive Level: Remember/Knowledge REF: p. 26 OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.

TOP: Integrated Process: Caring

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MSC: NCLEX Client Needs Category: Psychosocial Integrity 3. Noise in the critical care unit can have negative effects on the patient. Which of the following

interventions assists in reducing noise levels in the critical care setting? (Select all that apply.) a. Ask the family to bring in the patient’s iPod or other device with favorite music. b. Invite a volunteer harpist to play on the unit on a regular basis. c. Remodel the unit to have two-patient rooms to facilitate nursing care. d. Remodel the unit to install acoustical ceiling tiles. e. Turn the volume of equipment alarms as low as they can be adjusted, and “off” if possible.

ANS: A, B, D

A personal device with favorite music and headphones can be helpful in reducing ambient unit noise. Music therapy programs, such as harpists, can provide soothing sedative music that is often comforting to both patients and family members. Acoustical tiles help to reduce noise in the critical care setting and should be included in remodeling plans as well as new unit construction. Multiple patients in a single room would increase noise levels and contribute to an increased risk of infection. Alarms on critical equipment must never be turned off. The volume should be loud enough that the alarm can be heard by the nurse if outside the room.

The lowest setting may not be loud enough, depending on the unit layout and patient assignment.

DIF: Cognitive Level: Apply/Application REF: p. 19 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity N U R S I N G T B .CO M

4. It is important for critically ill p a t i e n t s t o f e e l s a fe . Which nursing strategies help the patient to

feel safe in the critical care setting? (Select all that apply.) a. Allow family members to remain at the bedside. b. Consult with the charge nurse before making any patient care decisions. c. Provide informal conversation by discussing your plans for after work. d. Respond promptly to call bells or other communication for assistance. e. Inform the patient that you have cared for many similar patients.

ANS: A, D

Patients feel safe when nurses exhibit technical competence, meet their needs, and provide reorientation. Family member presence may also contribute to feeling safe. Consulting with the charge nurse before making decisions may be interpreted as incompetence or insecurity.

The nurse’s personal activities should never be discussed with patients. Simply informing the patient that you have cared for many similar patients may or may not cause the patient to feel safer; the patient may feel this is condescending.

DIF: Cognitive Level: Apply/Application REF: p. 23 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 5. The critical care environment is often stressful to a critically ill patient. Identify stressors that

are common. (Select all that apply.) a. Alarms that sound from various devices

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Bright fluorescent lighting Lack of day-night cues Sounds from the mechanical ventilator Visiting hours tailored to meet individual needs

ANS: A, B, C, D

Adjustment of visiting hours to meet the needs of patients and families assists in reducing the stress of critical illness. All other responses are environmental stressors that may increase anxiety or affect sleep.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 19-20 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 6. To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can

(Select all that apply.) a. ask the nurses on the intermediate care unit to give the family a tour of the new unit. b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer. c. ensure that the patient will be located near the nurses’ station in the new unit. d. invite the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer. e. help the patient and family focus on the positive meaning of a transfer.

ANS: A, D, E

Patients often have stress when thN eyUR arSeINmGoTvBe.dCOfrM om the safety of the critical care unit.

Introducing the patient and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation stress. Encouraging the patient and family to see the transfer as a positive sign of healing might lessen the stress they feel. Although the patient and his family may feel safer in a room near the nurses’ station, bed placement is determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and once the physician has determined that the patient no longer meets critical care admission requirements, it is essential that transfers be made as soon as a bed on the intermediate care unit is available.

DIF: Cognitive Level: Apply/Application REF: p. 20 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 7. The critical care environment is stressful to the patient. Which interventions assist in reducing

this stress? (Select all that apply.) a. Adjust lighting to promote normal sleep-wake cycles. b. Provide clocks, calendars, and personal photos in the patient’s room. c. Talk to the patient about other patients you are caring for on the unit. d. Tell the patient the day and time when you are providing routine nursing interventions. e. Allow unlimited visitation tailored to the patient’s individual needs.

ANS: A, B, E

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Manipulation of the environment, such as the adjustment of lighting, is helpful in promoting sleep and rest. Clocks, calendars, photos, and other personal items promote orientation and personalize the environment; telling the patient the day and time and other current events assists in maintaining the patient’s orientation. Allowing visitation that best meets the patient’s needs will reduce stress as the patient’s support systems are present. Conversations about other patients are private and should take place away from other patients.

DIF: Cognitive Level: Apply/Application REF: pp. 22-24 OBJ: Describe stressors in the critical care environment and strategies to reduce them.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity

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Chapter 03: Ethical and Legal Issues in Critical Care Nursing Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Ideally, an advance directive should be developed by the a. family if the patient is in critical condition. b. patient as part of the hospital admission process. c. patient before hospitalization. d. patient’s health care surrogate.

ANS: C

Advance directives should be made and signed while a person is in good health and in a state of mind to make decisions about what should happen if he or she becomes incapacitated (e.g., during a critical illness). Families help to make decisions based on written advance directives, but families are not responsible for developing them for the patient. Developing advance directives during the admission process is not feasible, and the patient may not be capable of making an advance directive. The surrogate or proxy is one who has been already designated by a person to make health care decisions based on written advance directives.

DIF: Cognitive Level: Remember/Knowledge REF: p. 36 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 2. A critically ill patient has a living will in the chart. The patient’s condition has deteriorated, NURSINGTB.COM

but the spouse wants “everything done,” regardless of the patient’s wishes. Which ethical principle is the spouse violating? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence ANS: A

Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own health and future. The spouse is violating the patient’s autonomy in decision making. Beneficence consists of actions intended to benefit the patients or others.

Justice means being fair. Nonmaleficence is the duty to prevent harm.

DIF: Cognitive Level: Analyze/Analysis REF: p. 31 | Box 3-1 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 3. Which statement regarding ethical concepts is true? a. A living will is the same as a health care proxy. b. A signed donor card ensures that organ donation will occur in the event of brain

death. c. A surrogate is a competent adult designated by a person to make health care

decisions in the event the person is incapacitated.

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d. A persistent vegetative state is the same as brain death in most states.

ANS: C

A surrogate is a competent adult designated by a person to make health care decisions if that person becomes incapacitated. A living will is a witnessed document that states a person’s wishes regarding life-prolonging procedures, whereas a health care proxy is a person authorized by state statute to make health care decisions. In many states, consent by family members or health care proxy is required for organ donation even if an individual has a signed donor card. A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact; brain death is cessation of brain function.

DIF: Cognitive Level: Remember/Knowledge REF: p. 34 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. Which of the following statements about resuscitation is true? a. Family members should never be present during resuscitation. b. It is not necessary for a physician to write “do not resuscitate” orders in the chart if

a patient has a health care surrogate. c. “Slow codes” are ethical and should be considered in futile situations if advanced

directives are unavailable. d. Withholding “extraordinary” resuscitation is legal and ethical if specified in

advance directives and physician orders.

ANS: D

Withholding resuscitation and o t hNe rU cRaSrIeN iGs Tl Be g. CaOl M a n d ethical if based on the patient’s wishes.

Formal orders should be written that specify what is to be done if a patient suffers a cardiopulmonary arrest. Family presence during resuscitation and invasive procedures should be encouraged. A written order for “do not resuscitate” must be documented in the medical record. The decision to write the order is made in collaboration with the health care surrogate.

“Slow codes” sometimes occur in the clinical setting while attempts are made to contact the health care surrogate or proxy; however, they are neither legal nor ethical. Specific written orders determine what is to be done for resuscitation efforts.

DIF: Cognitive Level: Remember/Knowledge REF: p. 36 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to

respond to medical treatment. The intensivist in charge of the patient conducts a conference to explain that treatment options have been exhausted and to suggest that the patient be given a “do not resuscitate” status. This scenario illustrates the concept of a. brain death. b. futility. c. incompetence. d. life-prolonging procedures.

ANS: B

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This is the definition of futility. Brain death is cessation of brain function and is not described in this scenario. Incompetence (in this chapter) is when a patient is unable to make decisions regarding health care treatment. A life-prolonging procedure is one that sustains, restores, or supplants a spontaneous vital function.

DIF: Cognitive Level: Remember/Knowledge REF: p. 36 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 6. The nurse is caring for a patient admitted with a traumatic brain injury following a motor

vehicle crash. Several weeks later, the patient is still ventilator dependent and unresponsive to stimulation but occasionally takes a spontaneous breath. The physician explains to the family that the patient has severe neurological impairment and is not expected to recover consciousness. The nurse recognizes that this patient is a. an organ donor. b. brain dead. c. in a persistent vegetative state. d. terminally ill.

ANS: C

A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the environment. The patient is not brain dead, as evidenced by occasionally taking a spontaneous breath. Because the patient is not brain dead, he or she cannot be an organ donor at this time. Treatment of this condition may be considered futile; however, this coNnUdRitSioINnGwToBu.CldOM not be defined as terminally ill.

DIF: Cognitive Level: Analyze/Analysis REF: p. 38 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 7. A nurse caring for a patient with neurological impairment often must use painful stimuli to

elicit the patient’s response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical principle of a. beneficence. b. fidelity. c. nonmaleficence. d. veracity.

ANS: C

Nonmaleficence means not to intentionally harm others. The nurse does need to determine the patient’s response to painful stimulation but does so in a way that is ethical. Beneficence demonstrates actions intended to benefit the patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others. Veracity is the obligation to tell the truth.

DIF: Cognitive Level: Analyze/Analysis REF: p. 31 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 8. Which of the following organizations requires a mechanism for addressing ethical issues? a. American Association of Critical-Care Nurses b. American Hospital Association c. Society of Critical Care Medicine d. The Joint Commission ANS: D

The Joint Commission requires that a formal mechanism be in place to address patients’ ethical concerns. The other organizations do not address formal ethics committees.

DIF: Cognitive Level: Remember/Knowledge REF: p. 32 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 9. The nurse is caring for a patient who is not responding to medical treatment. The intensivist

holds a conference with the family, and a decision is made to withdraw life support. The nurse’s religious beliefs are not in agreement with the withdrawal of life support. However, the nurse assists with the process to avoid confronting the charge nurse. Afterward the nurse feels guilty for “killing the patient.” This scenario is likely to cause a. abandonment. b. family stress. c. moral distress. d. negligence.

ANS: C

Moral distress occurs when the nurse acts in a manner contrary to personal or professional values. Abandonment is defined as the unilateral severance of a professional relationship while a patient is still in need of health care. Family stress would not be impacted in this situation if the nurse responded appropriately during the procedure. Negligence is failure to act according to the standard of care.

DIF: Cognitive Level: Understand/Comprehension REF: p. 32 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 10. The nurse is caring for a patient who has been declared brain dead. The patient is considered a

potential organ donor. To proceed with donation, the nurse understands that a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the health care proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved.

ANS: B

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After brain death has been determined, the organs must be perfused to maintain viability.

Therefore, the patient remains on life support even though he or she is legally dead. A signed donor card indicates the individual’s wishes; however, most organ procurement agencies require family consent even if a donor card has been signed. In most states, the health care surrogate or proxy is required to give consent for organ donation. After brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be removed in the operating room.

DIF: Cognitive Level: Remember/Knowledge REF: p. 38 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 11. The nurse is caring for a patient who is declared brain dead and is an organ donor. The

following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead.

1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline.

What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810 ANS: B

The time of death is when brain dea oTnB fi.rCmOeMd and documented in the chart, even though NUth RSisINcG the patient’s heart is still beating. Organs are retrieved after brain death has been documented.

DIF: Cognitive Level: Analyze/Analysis REF: p. 38 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 12. The nurse is caring for a critically ill patient on mechanical ventilation. The physician

identifies the need for a bronchoscopy, which requires informed consent. For the physician to obtain consent from the patient, the patient must be able to a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English.

ANS: B

Informed consent requires that a person know what is to be done and have the competence to make an informed decision. Most critically ill patients do not have this capacity; however, an assessment should be made to determine the patient’s capacity. Some patients on mechanical ventilation are able to give written consent. Reading and writing in English are not requirements for informed consent.

DIF: Cognitive Level: Remember/Knowledge REF: p. 33 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 13. The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and

shows a potentially lethal rhythm. The patient has no pulse. The patient does not have a “do not resuscitate” order written on the chart. What is the appropriate nursing action? a. Contact the attending physician immediately to determine if CPR should be initiated. b. Contact the family immediately to determine if they want CPR to be started. c. Give emergency medications but withhold intubation. d. Initiate CPR and call a code.

ANS: D

Because no orders have been written, it is imperative that a code be called. In this example, decisions regarding resuscitation status should be determined as soon as possible before a code event. The physician and family should be contacted immediately to determine treatment options, but CPR is not withheld. It is not appropriate to conduct a “partial” code by giving medications only.

DIF: Cognitive Level: Analyze/Analysis REF: p. 36 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 14. When addressing an ethical dilemma, contextual, physiological, and personal factors of the

situation must be considered. Which of the following is an example of a personal factor? a. The hospital has a policy that everyone must have an advance directive on the chart. b. The patient has lost 20 pounds in the past month and is fatigued all the time. c. The patient has told you what quality of life means and his or her wishes. d. The physician considers care to be futile in a given situation.

ANS: C

Personal factors include competence, stated wishes, goals and hopes, definition of quality of life, and family relationships. Hospital policy is a contextual factor. Weight loss and fatigue are physiological factors. The physician’s belief is a contextual factor.

DIF: Cognitive Level: Analyze/Analysis REF: p. 31 | Fig 3-1 OBJ: Apply the components of a systematic, ethical decision-making model.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 15. A specific request made by a competent person that directs medical care related to

life-prolonging procedures in the event that person loses capacity to make decisions is called a a. “do not resuscitate” order. b. health care proxy. c. informed consent. d. living will.

ANS: D

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A living will is a formal advance directive that directs medical care related to life-prolonging procedures when a person does not have the capacity to make decisions regarding health care and treatment. A “do not resuscitate” order is a legal medical order prohibiting resuscitation measures in the event of clinical death. A health care proxy is an individual designated by the person to make decisions if incapacitated. Informed consent involves decisions regarding treatments and procedures following explanation of risks and benefits.

DIF: Cognitive Level: Remember/Knowledge REF: p. 35 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 16. The American Nurses Credential Center Magnet Recognition Program supports many actions

to ensure that nurses are engaged and empowered to participate in ethical decision making.

Which of the following would assist nurses in being involved in research studies? a. Education on protection of human subjects b. Participation of staff nurses on ethics committees c. Written descriptions of how nurses participate in ethics programs d. Written policies and procedures related to response to ethical issues ANS: A

Completion of education related to human subject protection assists nurses in research. Ethics committees, ethics programs, and policies address ethics issues rather than prepare nurses for research.

DIF: Cognitive Level: Understand/Comprehension REF: p. 32 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 17. The critical care nurse wants a better understanding of when to initiate an ethics consult. After

attending an educational program, the nurse understands that the following situation would require an ethics consultation: a. Conflict has occurred between the physician and family regarding treatment decisions. A family conference is held, and the family and physician agree to a treatment plan that includes aggressive treatment for 24 hours followed by reevaluation. b. Family members disagree as to a patient’s course of treatment. The patient has designated a health care proxy and has a written advance directive. c. Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the operating room. He was successfully resuscitated, but now is not responding to treatment. He has a written advance directive, and his wife is present. d. Patient with multiple trauma and is not responding to treatment. No family members are known, and the health care team is debating if care is futile.

ANS: D

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In the case of a seriously ill patient who is incapacitated and does not have a surrogate, an ethics consultation is warranted. While care does not have to be provided in the case of futility, disagreements may lead to the need for a consult to resolve the dilemma. The conflict has been resolved in the case of the family and physician agreeing on a course of treatment for 24 hours followed by reevaluation. Although family members disagree, if a patient has a written advance directive and a designated health care proxy, an ethics consultation is unwarranted; the patient’s wishes are clearly known. The cardiac surgery patient has a written directive to guide his treatment.

DIF: Cognitive Level: Analyze/Analysis REF: p. 33 | Box 3-3 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 18. The nurse knows that which of the following statements about organ donation is true? a. Anyone who is comfortable approaching the family should discuss the option of

organ donation. b. Brain death determination is required before organs can be retrieved for transplant. c. Donation of selected organs after cardiac death is ethically acceptable. d. Family members should consider the withdrawal of life support so that the patient

can become an organ donor.

ANS: C

Donation of selected organs after cardiac death is ethically and legally appropriate. Specific policies and procedures for donation after cardiac death facilitate this procedure. Only designated requesters who are knowledgeable and trained in organ donation should approach the family to discuss donation. O rNg aUnRsS cI Na nG TbBe . Cr eOt rMi e ve d not only after brain death but also after cardiac death. The decision to withdraw life support should be made separately from the decision to donate organs.

DIF: Cognitive Level: Remember/Knowledge REF: p. 38 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment MULTIPLE RESPONSE 1. Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma

may exist include which of the following? (Select all that apply.) a. Family members are confused about what is happening to the patient. b. Family members are in conflict as to the best treatment options. They disagree with one another and cannot come to consensus. c. The family asks that the patient not be told of treatment plans. d. The patient’s condition has changed dramatically for the worse and is not responding to conventional treatment. e. The physician is considering the use of a medication that is not approved to treat the patient’s condition.

ANS: A, B, C, D, E

All of these are potential signs of an ethical dilemma.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 30 OBJ: Apply the components of a systematic, ethical decision-making model.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 2. The nurse is caring for a patient whose condition has deteriorated and who is not responding

to standard treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal of treatment versus aggressive treatment. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.) a. Burden versus benefit b. Family’s wishes c. Patient’s wishes d. Potential outcomes of treatment options e. Cost savings of withdrawing treatment ANS: A, C, D

According to the ethical decision-making process, decisions should be made in light of the patient’s wishes (autonomy), burden versus benefit (beneficence), other relevant principles, and potential outcomes of various options. The patient’s wishes may differ from those of the family. Costs should not be considered; rather health care resources should be distributed in a way that ensures justice.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 30-31 |Fig 3-12 OBJ: Apply the components of a systematic, ethical decision-making model.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 3. The nurse utilizes which of the following strategies when encountering an ethical dilemma in

practice? (Select all that apply.) a. Change-of-shift report updates b. Ethics consultation services c. Formal multiprofessional ethics committees d. Pastoral care services e. Social work consultation ANS: B, C

Formal mechanisms such as multiprofessional ethics committees or referral services are strategies to address ethical issues. Nurse-to-nurse communication can help share information from shift to shift, but it is not the best way to address ethical issues. Pastoral care representatives may serve on an ethics committee; however, their primary role is to support the spiritual needs of the patient and family. A social worker may be very beneficial, but is not at the level of a multiprofessional committee.

DIF: Cognitive Level: Apply/Application REF: p. 32 | p. 36 OBJ: Discuss ethical principles and legal concepts related to critical care nursing.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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4. The nurse is caring for a patient with severe neurological impairment following a massive

stroke. The physician has ordered tests to determine brain death. The nurse understands that criteria for brain death include (Select all that apply.) a. absence of cerebral blood flow. b. absence of brainstem reflexes on neurological examination. c. Cheyne-Stokes respirations. d. flat electroencephalogram. e. responding only to painful stimuli.

ANS: A, B, D

Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat electroencephalograph. The presence of Cheyne-Stokes respirations and the response to pain would indicate some brain function.

DIF: Cognitive Level: Remember/Knowledge REF: p. 38 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. The nurse is caring for an 80-year-old patient who has been treated for gastrointestinal

bleeding. The family has agreed to withhold additional treatment. The patient has a written advance directive specifying requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that several orders may be written to comply with this request, including which of the following? (Select all that apply.) a. “Do not resuscitate.” b. Change antibiotic to a less expensive medication. c. Discontinue tube feeding. d. Stop any further blood transfusions. e. Water boluses every 4 hours with tube feeding.

ANS: A, D, E

A DNR order would be appropriate given the family’s decision, as would prohibiting further transfusions. Giving water boluses is compatible with the patient’s wishes, but stopping the feeding is not. Changing antibiotics may or may not be appropriate, but the cost of treatment is not related to the withholding of further care.

DIF: Cognitive Level: Analyze/Analysis REF: p. 35 OBJ: Discuss ethical and legal issues that arise in the critical care setting.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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Chapter 04: End-of-Life Care and Palliative Care in Critical Care Settings Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and

agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most appropriate nursing intervention to control agitation? a. Administer fentanyl (Duragesic) 25 mg IV bolus. b. Administer lorazepam (Ativan) 1 mg IV now. c. Increase the rate of the morphine infusion by 50%. d. Request an order for a paralytic agent.

ANS: B

Lorazepam (Ativan) 1 mg IV is an appropriate drug dose for a patient who is experiencing agitation during withdrawal of life support. Because it is ordered but not yet given, the nurse should give this drug now. Fentanyl treats pain and morphine controls pain. Paralytic agents are not warranted.

DIF: Cognitive Level: Apply/Application REF: p. 46 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity N U RS IN G T B .C O M

2. A 75-year-old patient, who s u f fe r e d a m a s s i v e s t r oke 3 weeks ago, has been unresponsive and

has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didn’t want what was being done. After holding a family conference with the spouse, the medical team concurs, and the feeding tube is not placed. This situation is an example of a. euthanasia. b. palliative care. c. withdrawal of life support. d. withholding life support.

ANS: D

Because the tube feeding had not been yet placed in the care of this patient, this scenario is an example of withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life support involves the discontinuation of previously established therapies in a terminally ill patient.

DIF: Cognitive Level: Remember/Knowledge REF: p. 43 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes

and Risks of Treatment (SUPPORT)? a. Clear communication is typical in the relationships between most patients and health care providers. b. Critical care units often meet the needs of dying patients and their families. c. Disparities exist between patients’ care preferences and the actual care provided. d. Pain and suffering of patients at end of life is well controlled in the hospital.

ANS: C

Disparities and lack of communication are common in the relationships between patients and health care providers. Critical care units are often poorly equipped to meet the needs of dying patients. The SUPPORT study demonstrated that pain and suffering are widespread in hospitals.

DIF: Cognitive Level: Remember/Knowledge REF: p. 40 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. A statement that provides a legally recognized description of an individual’s desires regarding

care at the end of life is a (an) a. advance directive. b. guardianship ad litem. c. health care proxy. d. power of attorney.

ANS: A

Legally recognized documents that provide guidance on an individual’s end-of-life choices are advance directives. Advance directives include living wills, durable powers of attorney for health care, and health care surrogate designations. A guardianship ad litem is a parent who files legal action on the behalf of a child. A health care proxy is an individual who is legally designated through statute to make decisions for an incapacitated person. A power of attorney is an individual who is, through filing of legal papers, authorized to act on the behalf of an incapacitated person in legal matters.

DIF: Cognitive Level: Understand/Comprehension REF: p. 47 OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. A patient with metastatic lung carcinoma has been unresponsive to chemotherapy. The

medical team has determined that there are no additional treatments available that will prolong life or improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutritional support. This is an example of which end-of-life concept? a. Medical futility b. Palliative care c. Terminal weaning d. Withdrawal of treatment ANS: A

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Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patient’s health status. Palliative care focuses on symptom relief and is not limited to the dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment refers to the removal of established therapies in a terminally ill patient.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 6. Designated health care surrogates should base health care decisions on a. personal beliefs and values. b. recommendations of family members and friends. c. recommendations of the physician and health care team. d. wishes previously expressed by the patient.

ANS: D

Health care surrogates attempt to have decisions match the wishes of the patient. Although suggestions of family and friends may provide insight into patient desires, actual decisions should be based upon known patient wishes. The physician and health care team may provide recommendations, but decisions should be based on the patient’s wishes.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Describe ethical and legal concerns related to end-of-life care.

B.oCcO Mentation TOP: Integrated Process: CommuniN caUtiRoSnIN anGdTD um MSC: NCLEX Client Needs Category: Psychosocial Integrity 7. Which statement made by a staff nurse identifying guidelines for palliative care would need to

be corrected? a. Basic nursing care is a critical element in palliative care management. b. Common conditions that require palliative management are nausea, agitation, and sleep disturbance. c. Palliative care practices are reserved for the dying client. d. Palliative care practices relieve symptoms that negatively affect the quality of life of a patient.

ANS: C

The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient. Palliative care is an integral part of every injured or ill patient's care. Basic nursing care, including repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all commonly require palliative care techniques.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 8. Which statement is true regarding the impact of culture on end-of-life decision making?

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a. Cultural beliefs should not take precedence over health care team decisions. b. It is easy and common to assess cultural beliefs affecting end-of-life care in the

intensive care unit. c. Culture and religious beliefs may affect end-of-life decision making. d. Perspectives regarding end-of-life care are similar between and within religious

groups.

ANS: C

Religious doctrines and cultural beliefs have profound impact on end-of-life decisions.

Patient and family culture and preferences in end-of-life care should guide treatment and not be overruled by the wishes of medical personnel. It is difficult to assess end-of-life desires in the intensive care unit due to many constraints, and nurses need to become more proficient at this. Language barriers make it even more difficult and time consuming, but nurses should strive to respect the patient’s and family’s wishes. Perspectives on end-of-life care vary within and between religious groups.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss cultural considerations in end-of-life care.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity

REF: p. 48

9. The most critical element of effective early end-of-life decision making is a. control of distressing symptoms, such as nausea, anxiety, and pain. b. effective communication among the patient, family, and health care team

throughout the course of the illness. c. organizational support of palliative care principles. d. the relocation of the dying p at i e n t f r o m t h e c r i t i c a l care unit to a lower level of N U R S I N GT B . C O M care.

ANS: B

The failure of clinicians, family members, and patients to openly discuss prognoses, end-of-life wishes, and preferences contributes to care conflicts such as in the Schiavo case.

Early discussion of end-of-life wishes is required to promote positive outcomes for the patient and family; such discussions actually should predate illness. Even though symptom control is a significant dimension of palliative care, it is not involved in initial end-of-life decision making. Adequate staffing and facility policies that support the dying patient are critical but should not impact family decision making. The patient should be cared for in an environment that best supports the needs of the patient and family. Even though organizational support of palliative principles is important, it should not drive individual decision making.

DIF: Cognitive Level: Remember/Knowledge REF: p. 42 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Psychosocial Integrity 10. A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate

palliative management of this symptom includes: a. administration of midazolam (Versed). b. administration of morphine.

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c. an increase in the amount of oxygen being delivered to the patient. d. aggressive use of inotropic and vasoactive medications to improve heart function.

ANS: B

Morphine is an excellent agent to control the symptom of dyspnea. Midazolam is used for anxiety. An increase in oxygen or aggressive use of medications to improve the patient’s heart function is inappropriate in this case.

DIF: Cognitive Level: Apply/Application REF: p. 46 | Fig 4-2 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 11. Which statement is consistent with societal views of dying in the United States? a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of

care. c. People die of distinct, complex illness for which a cure is always possible. d. The purpose of the health care system is to prevent disease and treat symptoms.

ANS: A

Death is viewed as a failure by society and health care providers, a view that results in aggressive management of disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible. There is a commonly held belief that the health care system exists to treat illness, disease, and injury and to “save” lives.

DIF: Cognitive Level: U nd e r s t a nd / NCUo m R Sp IrNe hGeTnBs i. oCnO M REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 12. Which nursing intervention would need to be corrected on a care plan for a patient in order to

be consistent with the principles of effective end-of-life care? a. Control of distressing symptoms such as dyspnea, nausea, and pain through the use of pharmacological and nonpharmacological interventions b. Limitation of visitation to reduce the emotional distress experienced by family members c. Patient and family education on anticipated patient responses to withdrawal of therapy d. Provision of spiritual care resources as desired by the patient and family ANS: B

Active involvement of family is a critical dimension of end-of-life care. Family members should have access to the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective end-of-life care practices.

Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and family through provision of spiritual resources and bereavement care is a critical element of end-of-life care.

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DIF: Cognitive Level: Apply/Application REF: p. 47 | Box 4-4 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 13. In which of the following situations would a health care surrogate or proxy assume the

end-of-life decision-making role for a patient? a. When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms b. When a dying patient who is competent requests to withdraw treatment against the wishes of the family c. When a dying patient who is competent requests to continue treatment against the recommendations of the health care team d. When a dying patient who is competent is receiving prn treatment for pain and anxiety ANS: A

A patient who requires heavy sedation, such as IV infusions of pain medications or anxiolytic medications, would not be competent to make health care decisions. A health care proxy or surrogate would be required in this situation. A patient who is deemed competent by the medical team may be responsible for health care decisions even if these are not consistent with family beliefs. A surrogate would not assume decision-making responsibilities in this situation. A health care team member who cannot support decisions would be responsible for finding an alternative care provider who could support the patient's wishes.

DIF: Cognitive Level: Analyze/Analysis REF: p. 40 OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: EvaluaN tioUnRSINGTB.COM MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 14. Which statement is true regarding the effects of caring for dying patients on nurses? a. Attendance at funerals is inappropriate and will only create additional stress in

nurses who are already at risk for burnout. b. Caring for dying patients is an expected part of nursing and will not affect the

emotional health of the nurse if he or she maintains a professional approach with each patient and family. c. Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs. d. Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses.

ANS: D

Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when the care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations.

Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict

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resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Psychosocial Integrity 15. The family is considering the withdrawal of life-sustaining measures from the patient. The

nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following? a. Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products. b. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits. c. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents. d. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.

ANS: A

Any treatment that is used to sustain life, including nutrition, fluids, antibiotics, blood products, and respiratory support, may be withdrawn in consultation with the patient and/or surrogate provided that the patient has been deemed terminal or persistently vegetative. Any dose of anxiolytics or analgesics may be used to relieve suffering, although these may have the potential to hasten death. Life-sustaining treatment should not be withdrawn while the patient is receiving paralytic treatments. Death occurs as a consequence of the underlying disease, and the goal of care is to relieve suffering, not to hasten death.

DIF: Cognitive Level: Analyze/Analysis REF: p. 44 OBJ: Describe ethical and legal concerns related to end-of-life care.

N URSINGTB.COM TOP: Nursing Process Step: Plannin g MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 16. The patient’s spouse is terrified by the prospect of removing life-sustaining treatments from

the patient and asks why anyone would do that. The nurse explains, a. “It is to save you money so that you won’t have such a large financial burden.” b. “It will preserve limited resources for the hospital so that other patients may benefit from them.” c. “It is to discontinue treatments that are not helping your loved one and that may be very uncomfortable.” d. “We have done all we can for your loved one, and any more treatment would be futile.”

ANS: C

The goal of withdrawal of life-sustaining treatments is to remove treatments that are not beneficial and that may be uncomfortable.

DIF: Cognitive Level: Understand/Comprehension REF: p. 43 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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17. All of the patient’s children are distressed by the possibility of removing life-support

treatments from their mother. The child who is most upset tells the nurse, “This is the same as killing her! I thought you were supposed to help her!” The nurse explains to the family, a. “This is a process of allowing your mother to die naturally after the injuries that she sustained in a serious accident.” b. “The hospital would never allow us to do that kind of thing.” c. “Let’s talk about this calmly, and I will explain why assisted suicide is appropriate in this case.” d. “She’s lived a long and productive life.”

ANS: A

Forgoing life-sustaining treatments is not the same as active euthanasia or assisted suicide.

Killing is an action causing another’s death, whereas allowing dying is avoiding any intervention that interferes with a natural death following illness or trauma. Telling the family that the hospital would not allow this, or asking the family to talk calmly belittles their feelings and does not provide useful information.

DIF: Cognitive Level: Apply/Application REF: p. 43 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Psychosocial Integrity 18. To prevent any unwanted resuscitation after life-sustaining treatments have been withdrawn,

the nurse should ensure that: a. “do not resuscitate” (DNR) orders are written before the discontinuation of the treatments. b. the family is not allowed to visit until the death occurs. c. DNR orders are written as soon as possible after the discontinuation of the

treatments. d. the change-of-shift report includes the information that the patient is not to be resuscitated.

ANS: A

DNR orders should be written before withdrawal of life support; this will prevent any unfortunate errors in unwanted resuscitation during the time period between initiation of withdrawal and the actual death.

DIF: Cognitive Level: Apply/Application REF: p. 44 OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 19. The patient’s spouse is very upset because his loved one, who is near death, has dyspnea and

restlessness. The nurse explains that there are some ways to decrease this discomfort, including: a. respiratory therapy treatments. b. opioid medications given as needed. c. incentive spirometry. d. increased hydration.

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ANS: B

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).

DIF: Cognitive Level: Apply/Application REF: p. 46 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Communication and Documentation MSC: NCLEX Client Needs Category: Physiological Integrity 20. The patient’s spouse tells the nurse that there is no point in continuing to visit at the bedside

because the patient is unresponsive. The best response by the nurse is a. “You’re right. Your loved one is not aware of anything now.” b. “This seems to be very difficult for you.” c. “I’ll call you if she starts responding again.” d. “Why don’t you check to see if any other family member would like to visit?”

ANS: B

The most therapeutic response by the nurse is to acknowledge the distress of the spouse.

DIF: Cognitive Level: Apply/Application REF: p. 47 | Box 4-4 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Psychosocial Integrity 21. Which of the following statements about palliative care is accurate? a. Withholding and withdrawing life-sustaining treatment are distinctly different in

the eyes of the legal community. b. Reducing distressing symptomNsUiRs St hI Ne GpTr Bim. CaOr yMg oal of palliative care. c. Only the patient can determine what constitutes palliative care for him or her. d. Withdrawing life-sustaining treatments is considered euthanasia in most states.

ANS: B

The goal of palliative care is to reduce the distressing symptoms many patients experience due to serious illnesses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Select interventions that may be included during “terminal weaning” include which of the

following? (Select all that apply.) a. Complete extubation following ventilator withdrawal b. Discontinuation of artificial ventilation but maintenance of the artificial airway c. Discontinuation of anxiolytic and pain medications d. Titration of ventilator support based upon blood gas determinations e. Titration of ventilator support to minimal levels based upon patient assessment of comfort

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ANS: A, B, E

“Terminal weaning” may include titration of ventilator support to minimal levels, removal of the ventilator with maintenance of the artificial airway, and complete extubation. Pain and anxiolytic medications may be required to control dyspnea and anxiety that may accompany ventilator withdrawal. Blood gas determinations would be used in therapeutic ventilator management.

DIF: Cognitive Level: Remember/Knowledge REF: p. 44 | p. 46 | Fig 4-2 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which therapeutic interventions may be withdrawn or withheld from the terminally ill client?

(Select all that apply.) a. Antibiotics b. Dialysis c. Nutrition d. Pain medications e. Simple nursing interventions such as repositioning and hygiene ANS: A, B, C

Any treatment that is life sustaining may be withheld from a terminally ill patient during the end of life. These treatments include nutrition, dialysis, fluids, antibiotics, respiratory support, therapeutic medications, and blood products. Any dose of analgesic or anxiolytic medication may be used to prevent suffering and should not be withdrawn.

Dignity should be maintained during the course of dying. This would include ongoing provision of basic nursing care and comfort.

DIF: Cognitive Level: Analyze/Analysis REF: p. 43 OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Which interventions can the nurse use to facilitate communication with patients and families

who are in the process of making decisions regarding end-of-life care options? (Select all that apply.) a. Communication of uniform messages from all health care team members b. An integrated plan of care that is developed collaboratively by the patient, family, and health care team c. Facilitation of continuity of care through accurate shift-to-shift and transfer reports d. Limitation of time for families to express feelings in order to control family grief e. Reassuring the patient and family that they will not be abandoned as the goals of care shift from aggressive treatment to comfort care ANS: A, B, C, E

Effective and consistent communication among the patient, family, and health care team members is required to promote positive outcomes during end-of-life care.

Family members should be provided ample time to express feelings in order to improve the level of satisfaction and prevent dysfunctional bereavement patterns.

DIF:

Cognitive Level: Apply/Application

REF: pp. 42-43

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OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 4. Palliation may include (Select all that apply.) a. relieving pain. b. relieving nausea. c. psychological support. d. withdrawing life-support interventions. e. withholding tube feedings.

ANS: A, B, C

Palliation includes the relief of symptoms that may have a negative effect on the family or the patient.

DIF: Cognitive Level: Remember/Knowledge REF: p. 41 OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and health care providers.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 5. When providing palliative care, the nurse must keep in mind that the family may include

which of the following? (Select all that apply.) a. Unmarried life partners of same sex b. Unmarried life partners of opposite sex c. Roommates d. Close friends e. Parents ANS: A, B, C, D, E

The definition of family varies and may include unmarried life partners of the same or opposite sex, close friends, and other close individuals who have no legal relationship with the patient. The patient gets to define who will be regarded as “family.”

DIF: Cognitive Level: Remember/Knowledge REF: p. 47 OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Integrated Process: Caring MSC: NCLEX Client Needs Category: Psychosocial Integrity

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Chapter 05: Comfort and Sedation Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Nociceptors differ from other nerve receptors in the body in that they: a. adapt very little to continual pain response. b. inhibit the infiltration of neutrophils and eosinophils. c. play no role in the inflammatory response. d. transmit only the thermal stimuli.

ANS: A

Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve receptors in the body in that they adapt very little to the pain response. The body continues to experience pain until the stimulus is discontinued or therapy is initiated.

This is a protective mechanism so that the body tissues being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss the physiology of pain and anxiety.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 54

2. A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating

the ventilator well and has not required any sedation. On assessment, the nurse notes the N U R SI N G TB . CO M patient is tachycardic and hyperten s iv e w i th a n in creased respiratory rate of 28 breaths/min.

The patient has been suctioned recently via the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse’s commands. The nurse should: a. assess the patient’s level of pain. b. decrease the ventilator rate. c. provide sedation as ordered. d. suction the patient again.

ANS: A

Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain and need for pain medication. Decreasing the ventilator rate will not help in this situation. Providing sedation may calm the patient but will not solve the problem if the physiological changes are from pain. The patient has just been suctioned and the airway is clear. There is no need to suction again.

DIF: Cognitive Level: Analyze/Analysis REF: p. 55 OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit

signs of anxiety, the nurse’s first priority is to a. administer antianxiety medications as ordered.

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b. administer pain medication as ordered. c. identify and treat the underlying cause. d. reassess the patient hourly to determine whether symptoms resolve on their own.

ANS: C

When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs. Treatment is not initiated until assessment is completed.

Medication may not be needed if the underlying cause can be resolved.

DIF: Cognitive Level: Apply/Application REF: p. 70 | Table 5-11 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or

Patient State Index (PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI monitors are simpler to use because they a. can be used only on heavily sedated patients. b. can be used only on pediatric patients. c. provide raw EEG data and a numeric value. d. require only five leads.

ANS: C

The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the numeric value. A single electrode is placed across the patient’s forehead and is attached to a monitor. These monitors can be used in both children and adults and in patients with varying levels of sedation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 60 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. The nurse is caring for a patient who requires administration of a neuromuscular blocking

agent to facilitate ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide: a. antianxiety effects. b. complete analgesia. c. high levels of sedation. d. no sedation or analgesia.

ANS: D

Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties.

Patients who receive NMBs must also receive sedatives and pain medication.

DIF: Cognitive Level: Remember/Knowledge REF: p. 72 OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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6. The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target

level of paralysis? a. Glasgow Coma Scale score of 3 b. Train-of-four yields two twitches c. Bispectral index of 60 d. CAM-ICU positive ANS: B

A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The bispectral index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.

DIF: Cognitive Level: Remember/Knowledge REF: p. 73 OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is concerned that the patient will pull out the endotracheal tube. As part of the

nursing management, the nurse obtains an order for a. arm binders or splints. b. a higher dosage of lorazepam. c. propofol. d. soft wrist restraints.

ANS: D

The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe are appropriate. I f NpUo Rs sSi IbNl Ge , TtBh .eC tOuMb e or device causing irritation should be removed, but if that is not possible, the nurse must prevent the patient from pulling it out.

Restraints are associated with an increased incidence of agitation and delirium. Therefore, restraints should not be used unless as a last resort for combative patients. The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor adding propofol is indicated and would be likely to prolong mechanical ventilation.

DIF: Cognitive Level: Apply/Application REF: p. 61 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 8. The primary mode of action for neuromuscular blocking agents used in the management of

some ventilated patients is a. analgesia. b. anticonvulsant therapy. c. paralysis. d. sedation.

ANS: C

These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation.

They do not have anticonvulsant properties.

DIF: Cognitive Level: Remember/Knowledge REF: p. 72 OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. The most important nursing intervention for patients who receive neuromuscular blocking

agents is to a. administer sedatives in conjunction with the neuromuscular blocking agents. b. assess neurological status every 30 minutes. c. avoid interaction with the patient, because he or she won't be able to hear. d. restrain the patient to avoid self-extubation.

ANS: A

Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed, restraining devices may not be needed.

DIF: Cognitive Level: Apply/Application REF: p. 72 OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. The best way to monitor agitation and effectiveness of treating it in the critically ill patient is

to use a/the: a. Confusion Assessment Method (CAM-ICU). b. FACES assessment tool. c. Glasgow Coma Scale. d. Richmond Agitation Sedation Scale.

ANS: D

Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.

DIF: Cognitive Level: Remember/Knowledge REF: p. 59 | Table 5-5 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The

nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? a. Creatinine: 3.1 mg/dL b. Platelet count 350,000 billion/L c. White blood count 13, 550 mm3 d. ALT 25 U/L ANS: A

Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values such as shown here.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 71 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale.

The nurse recognizes a. brow lowering b. eyelid closing c. grimacing d. relaxed facial expression

as indicating the greatest level of pain.

ANS: C

The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.

DIF: Cognitive Level: Understand/Comprehension REF: p. 58 | Table 5-3 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse wishes to assess the quality of a patient’s pain. Which of the following questions is

appropriate to obtain this assessment if the patient is able to give a verbal response? a. “Is the pain constant or intermittent?” b. “Is the pain sharp, dull, or crushing?” c. “What makes the pain better? Worse?” d. “When did the pain start?”

ANS: B

If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other responses relate to continuous or intermittent presence, what provides relief, and duration.

DIF: Cognitive Level: Understand/Comprehension REF: p. 56 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool. Which

of the following assessments would indicate the greatest likelihood of pain and need for nursing intervention? a. Absence of vocal sounds b. Fighting the ventilator c. Moving legs in bed d. Relaxed muscles in upper extremities ANS: B

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Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator, and could indicate pain or anxiety. Absence of vocal sounds (e.g., no crying) and relaxed muscles do not indicate pain and are not given a point value. The patient may be moving the legs as a method of range of motion, not necessarily in response to pain. The patient needs to be assessed for restlessness if the movement is excessive.

DIF: Cognitive Level: Apply/Application REF: p. 59 | Table 5-4 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. The nurse is caring for four patients on the progressive care unit. Which patient is at greatest

risk for developing delirium? a. 36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol withdrawal protocol. b. 54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking c. 86-year-old from nursing home with dementia, postoperative from colon resection, still being mechanically ventilated d. 95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid ANS: C

From this list, the 86-year-old postoperative nursing home resident is at greatest risk due to advanced age, cognitive impairment, and some degree of respiratory failure. The 96-year-old has been provided eyeglasses and a hearing aid, which will decrease the risk of delirium.

Smoking is a possible risk for d e l iNr iUuRmS.I NT Gh eT B3. 6C-OyM e ar-old is receiving medications as part of an alcohol withdrawal protocol, which should decrease the risk for delirium.

DIF: Cognitive Level: Analyze/Analysis REF: p. 61 | Table 5-8 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 16. The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions

toward keeping the patient: a. comfortable. b. nourished. c. safe. d. sedated.

ANS: C

The greatest priority in managing delirium is to keep the patient safe. Sedation may contribute to the development of delirium. Comfort and nutrition are important, but they are not priorities.

DIF: Cognitive Level: Understand/Comprehension REF: p. 61 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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17. The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an

extended period. Which of the following nursing interventions would improve the patient’s well-being and reduce anxiety the most? a. Arrange for the patient’s dog to be brought into the unit (per protocol). b. Provide aromatherapy with scents such as lavender that are known to help anxiety. c. Secure the harpist to come and play soothing music for an hour every afternoon. d. Wheel the patient out near the unit aquarium to observe the tropical fish.

ANS: A

Nonpharmacological approaches are helpful in reducing stress and anxiety, and each of these activities has the potential for improving the patient’s well-being. The patient is likely to benefit most from the presence of his or her own dog rather than the other activities, however; if unit protocol does not allow the patient’s own dog, the nurse should investigate the use of therapy animals or the other options.

DIF: Cognitive Level: Apply/Application REF: p. 64 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Psychological Integrity 18. The nurse recognizes that which patient is likely to benefit most from patient-controlled

analgesia (PCA)? a. Patient with a C4 fracture and quadriplegia b. Patient with a femur fracture and closed head injury c. Postoperative patient who had elective bariatric surgery d. Postoperative cardiac surgery patient with mild dementia ANS: C

The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA as this patient should be awake, cognitively intact, and will have the acute pain related to the surgical procedure. The quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may not understand how to operate the pump. Likewise, the patient with the closed head injury may not be cognitively intact.

DIF: Cognitive Level: Analyze/Analysis REF: p. 71 | Box 5-6 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse

understands that the best way to administer such drugs is to: a. administer around the clock, rather than as needed, to ensure constant sedation. b. administer the medications through the feeding tube to prevent complications. c. give the highest allowable dose for the greatest effect. d. titrate to a predefined endpoint using a standard sedation scale.

ANS: D

The best approach for administering benzodiazepines (and all sedatives) is to administer and titrate to a desired endpoint using a standard sedation scale. Administering around the clock as well as giving the highest allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect, most benzodiazepines are given intravenously.

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DIF: Cognitive Level: Apply/Application REF: p. 72 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 20. The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative

patient. Which statement by the nurse indicates understanding of management of this patient? a. “Alcohol withdrawal is common; we see it all of the time in the trauma unit.” b. “There is no way to assess for alcohol withdrawal.” c. “This patient will require less pain medication.” d. “We have initiated the alcohol withdrawal protocol.”

ANS: D

The most important treatment of alcohol withdrawal syndrome is prevention. Many units have protocols that are initiated early to prevent the syndrome. Alcohol withdrawal syndrome is common; however, this statement does not indicate knowledge of management. The patient experiencing alcohol withdrawal may exhibit a variety of symptoms, such as disorientation, agitation, and tachycardia. Patients with substance abuse require increased dosages of pain medications.

DIF: Cognitive Level: Understand/Comprehension REF: p. 74 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and prevent delirium.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of

critically ill patients include: (Select all that apply.) a. anaerobic exercise. b. art therapy. c. guided imagery. d. music therapy. e. animal therapy.

ANS: C, D, E

Guided imagery is a powerful technique for controlling pain and anxiety, especially that associated with painful procedures. Similar to guided imagery, a music therapy program offers patients a diversionary technique for pain and anxiety relief. Likewise animal therapy has many benefits for the critically ill patient. Anaerobic exercise is not a nonpharmacological approach for managing pain and anxiety. Most critically ill patients are not able to participate in art therapy.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 62-64 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which of the following statements regarding pain and anxiety are true? (Select all that apply.) a. Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or

fearful withdrawal.

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b. Critically ill patients often experience anxiety, but they rarely experience pain. c. Pain and anxiety are often interrelated and may be difficult to differentiate because

their physiological and behavioral manifestations are similar. d. Pain is defined by each patient; it is whatever the person experiencing the pain

says it is. e. While anxiety is unpleasant, it does not contribute to mortality or morbidity of the

critically ill patient.

ANS: A, C, D

Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and anxiety are often interrelated. Critically ill patients commonly have both pain and anxiety.

Anxiety does increase both morbidity and mortality in critically ill patients, especially those with cardiovascular disease.

DIF: Cognitive Level: Understand/Comprehension REF: p. 53 OBJ: Define pain and anxiety.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 3. Which of the following factors predispose the critically ill patient to pain and anxiety? (Select

all that apply.) a. Inability to communicate b. Invasive procedures c. Monitoring devices d. Nursing care e. Preexisting conditions ANS: A, B, C, D, E

All of these factors predispose theNpUaRtiSeInNt GtoT Bp.aCiOn Mor anxiety.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 53-54 OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Choose the items that are common to both pain and anxiety. (Select all that apply.) a. Cyclical exacerbation of one another b. Require good nursing assessment for proper treatment c. Response only to real phenomena d. Subjective in nature e. Perception may be influenced by prior experience ANS: A, B, D, E

Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle that often requires good nursing assessment to manage the precipitating problem and break the cycle. Anxiety is a response to a real or perceived fear. Pain is a response to real or “phantom” phenomenon but always involves transmission of nerve impulses. Both relate to the patient’s perceptions of pain and fear. Previous experiences of both pain and/or anxiety can influence the patient’s perception of both. Anxiety is a response to real or perceived fear, and pain is a response to a real or “phantom” phenomenon.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54 OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. Anxiety differs from pain in that: (Select all that apply.) a. it is confined to neurological processes in the brain. b. it is linked to reward and punishment centers in the limbic system. c. it is subjective. d. there is no actual tissue injury. e. it can be increased by noise and light.

ANS: A, B, D, E

Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of the brain. It is totally neurological and does not involve tissue injury. Like pain, it is a subjective phenomenon. Noise, light, and other stimuli can increase the intensity of anxiety.

Both anxiety and pain are subjective in nature.

DIF: Cognitive Level: Understand/Comprehension OBJ: Discuss the physiology of pain and anxiety.

TOP: Nursing Process Step: Assessment

REF: pp. 53-55

6. Factors in the critical care unit that may predispose the client to increased pain and anxiety

include: (Select all that apply.) a. an endotracheal tube. b. frequent vital signs. c. monitor alarms. d. room temperature. e. hostile environment.

ANS: A, B, C, D, E

Anxiety is likely to result from loss of control, the inability to communicate, continuous noise and lighting, excessive stimulation (including repeated vital sign measurements), lack of mobility, and uncomfortable room temperatures. Increased anxiety levels often lead to increased pain perception. Environments that are perceived as hostile also contribute.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54 OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. In the healthy individual, pain and anxiety: (Select all that apply.) a. activate the sympathetic nervous system (SNS). b. decrease stress levels. c. help remove one from harm. d. increase performance levels. e. limit sympathetic nervous system activity.

ANS: A, C, D

In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance levels or to remove one from potential harm. The “fight or flight” response occurs in response to pain and/or anxiety and involves the activation of the sympathetic nervous system. Pain and anxiety, however, can induce significant stress. The SNS is activated, not limited, by pain and/or anxiety.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 55 OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is caring for a patient who is intubated and on a ventilator following extensive

abdominal surgery. Although the patient is responsive, the nurse is not able to read the patient’s lips as the patient attempts to mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use when assessing the patient’s pain level? (Select all that apply.) a. The FACES scale b. Pain Intensity Scale c. The PQRST method d. The Visual Analogue Scale e. The CAM tool ANS: A, D

The PQRST method and the Pain Intensity Scale require verbalization and/or writing to communicate pain level. The FACES scale and the Visual Analogue Scale can be used by simply having the patient point to the appropriate place. Because of this, they are the easiest to use with children, people with language barriers, and intubated patients. The CAM tool is used to assess delirium.

DIF: Cognitive Level: Apply/Application REF: pp. 57-58 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 9. In the critically ill patient, an incomplete assessment and/or management of pain or anxiety

may be hampered by which of the following? (Select all that apply.) a. Administration of neuromuscular blocking agents b. Delirium c. Effective nurse communication and assessment skills d. Nonverbal patients e. Ventilated patient ANS: A, B, D

Delirium appears in approximately 80% of patients in the intensive care unit. Delirium is characterized by changing mental status, inattention, disorganized thinking, and altered levels of consciousness. Patients in the intensive care unit may not be able to verbalize because of the presence of an artificial airway, sedative medication, neuromuscular blocking agents, or brain injury. Effective nurse-to-patient communication and assessment skills would facilitate assessment of pain and anxiety. There are tools and assessment methods to assess pain in ventilated patients.

DIF: Cognitive Level: Understand/Comprehension REF: p. 56 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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10. Which of the following are accepted nonpharmacological approaches to managing pain and/or

anxiety in critically ill patients? (Select all that apply.) a. Environmental manipulation b. Explanations of monitoring equipment c. Guided imagery d. Music therapy e. Provision of personal items ANS: A, B, C, D, E

Manipulating the environment so that it appears less hostile helps decrease anxiety, as does continually reorienting the patient. Focus techniques such as guided imagery and music therapy can create a state of relaxation. Personal items can reduce anxiety and provide a pleasant distraction.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 61-64 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a postoperative patient in the critical care unit. The physician has

ordered patient-controlled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.) a. is a safe and effective method for administering analgesia. b. has potentially fewer side effects than other routes of analgesic administration. c. is an ideal method to provide most critically ill patients some control over their treatment. d. provides good quality analgesi a .

N U RSINGTB.COM e. does not work well without family assistance.

ANS: A, B, D

PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side effects than other routes. PCA management is rarely appropriate for critically ill patients because most patients are unable to depress the button, or they are too ill to manage their pain effectively. If the patient is cognitively intact, family assistance is not needed to use this modality and is not advisable; the patient needs to be able to push the button.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 69-70 OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort and reduce anxiety.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 12. A patient requires pancuronium as part of treatment of refractive increased intracranial

pressure. The nursing care for this patient includes: (Select all that apply.) a. administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient’s feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c. ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care, oral care, and skin care. e. ensuring good nutrition with frequent feedings throughout the day.

ANS: A, C, D

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Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate. Feeding the patient on an NMB orally is not possible.

DIF: Cognitive Level: Analyze/Analysis REF: p. 73 OBJ: Discuss assessment and management challenges in subsets of critically ill patients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is assessing the critically ill patient for delirium. The nurse recognizes which

characteristics that indicate hyperactive delirium? (Select all that apply.) a. Agitation b. Apathy c. Biting d. Hitting e. Restlessness ANS: A, C, D, E

All except for apathy are characteristics of hyperactive delirium. Apathy is seen in hypoactive cases.

DIF: Cognitive Level: Understand/Comprehension REF: p. 59 | Table 5-4 OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.

TOP: Nursing Process Step: Assess N mUenRtSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 06: Nutritional Support Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. A patient is having complications from abdominal surgery and remains NPO. Because enteral

tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy? a. Aspiration pneumonia and sepsis b. Sepsis and fluid and electrolyte imbalances c. Fluid overload and pulmonary edema d. Hypoglycemia and renal insufficiency ANS: B

Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NURSINGTB.COM

2. A patient is being ventilated and has been started on enteral feedings with a nasogastric

small-bore feeding tube. What is the primary reason the nurse must frequently assess tube placement? a. To assess for paralytic ileus b. To maintain the patency of the feeding tube c. To monitor for skin breakdown on the nose d. To prevent aspiration of the feedings ANS: D

Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin breakdown on the nose.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85 | Table 6-4 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter

insertion? a. Basilic vein b. Femoral vein c. Radial artery

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d. Subclavian vein ANS: D

Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein. Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 80

4. A patient has been admitted to the critical care unit after a stroke. After “failing” a swallow

study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step? a. Administer medications. b. Cap off and wait 24 hours before starting feedings. c. Obtain a chest radiograph. d. Start the tube feeding.

ANS: C

Correct placement must be verified by radiograph before use of the tube for either feeding or administering medications. There is no reason to cap the tube and wait; once placement is verified, the tube can be used.

DIF: Cognitive Level: Apply/Application OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: PlanninNgURSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 86 | Table 6-4

5. A critically ill patient has a nonhealing wound and malnutrition. Which component of

nutritional supplementation is most important for this patient to receive? a. Arginine b. Omega-3 fatty acids c. Branched-chain amino acids d. Vitamin A ANS: D

Vitamin A is vital for wound healing. Arginine is also important in wound healing but is more important for trauma and septic patients, as are omega-3 fatty acids. Branched-chain amino acids are very important for stressed patients who have liver dysfunction or ARDS. DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 82 | Table 6-1

6. A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry

out which intervention to minimize aspiration risk? a. Add blue dye to the formula. b. Assess the residual every hour. c. Elevate the head of the bed 30 degrees.

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d. Provide feedings via continuous infusion.

ANS: C

The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize aspiration.

DIF: Cognitive Level: Apply/Application OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 86 | Table 6-4

7. A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky

green fluid. What action by the nurse takes priority? a. Notify the provider. b. Assess the patient’s lungs and oxygen saturation. c. Stop the tube feeding. d. Slow the rate of the infusion.

ANS: C

Nausea and vomiting are signs of tube feeding intolerance. The nurse should first stop the feeding. Then the nurse can assess for other signs of intolerance and aspiration. After a complete assessment, the nurse would notify the provider.

DIF: Cognitive Level: Apply/Application REF: p. 85 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 8. A patient is receiving enteral feedings and reports fullness and abdominal discomfort. What

action by the nurse is best? a. Connect the feeding tube to suction. b. Continue the tube feeding. c. Decrease the tube feeding. d. Assess the patient’s gastric residual.

ANS: D

The patient may not be tolerating the tube feeding. The nurse should assess the gastric residual and hold the feeding if it is greater than 500 mL. The other actions are not warranted; the nurse needs further information before proceeding.

DIF: Cognitive Level: Apply/Application REF: pp. 85-86 | Table 6-4 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. In addition to residual stomach volume, what other evidence suggests feeding intolerance? a. Abdominal distension b. Absence of tympany on percussion c. Active bowel sounds d. Elevated blood glucose by fingerstick ANS: A

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Abdominal distension is expected if the feedings are not being absorbed. Tympany occurs along with distension.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss methods for evaluating nutritional status.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 85-86 | Table 6-4

10. Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A

stool specimen is collected to check for which possible cause? a. Clostridium difficile b. Escherichia coli c. Occult blood d. Ova and parasites ANS: A

Patients receiving enteral nutrition who develop diarrhea are evaluated for antibioticassociated causes, including Clostridium difficile.

DIF: Cognitive Level: Remember/Knowledge REF: p. 86 | Table 6-4 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed

possible interventions for this patient. Which intervention needs correction before finalizing the plan of care? a. Change the intravenous tubingNeUvReSrIyN2G4TB h.oCuOrsM. b. Infuse antibiotics through the intravenous line. c. Monitor the blood glucose every 6 hours. d. Monitor the fluid and electrolyte balance.

ANS: B

Medications should not be infused through the IV line infusing parenteral nutrition. The other actions are correct.

DIF: Cognitive Level: Apply/Application OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 85

12. In evaluating a patient’s nutrition, the nurse would monitor which blood test as the most

sensitive indicator of protein synthesis and catabolism? a. Albumin b. BUN c. Prealbumin d. Triglycerides ANS: C

Prealbumin is the most sensitive indicator of protein synthesis and catabolism.

DIF:

Cognitive Level: Remember/Knowledge

REF: p. 87 Laboratory Alert Box

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OBJ: Discuss methods for evaluating nutritional status.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 13. A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The

nurse recognizes which drug as having the potential for causing drug-nutrient reactions? a. Aspirin b. Enoxaparin c. Ibuprofen d. Phenytoin ANS: D

Bioavailability of phenytoin is reduced when administered with enteral feedings. The other drugs do not have significant drug-nutrient interactions.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 85

14. Which statement is true about normal function of the gastrointestinal (GI) tract? a. Failure of the tight junctions allows bacteria to invade the GI tract. b. The gut lacks protective mechanisms; thus, infection is always a concern. c. Water is reabsorbed at the beginning of the colon. d. Without nutritional stimulation, mucosal villi atrophy.

ANS: D

Mucosal villi replenish every 3 to N4UdRaSyI sN; GwTiBth. CoOutMnutritional stimulation, they atrophy. The other statements are false.

DIF: Cognitive Level: Remember/Knowledge REF: p. 77 OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. An important nutritional consideration in the elderly population is a. a decrease in protein requirements. b. an increase in caloric requirements with age. c. the potential for drug-nutrient interaction related to polypharmacy. d. the presence of other diseases that decrease caloric needs.

ANS: C

Patients taking multiple medications have a greater potential for drug-nutrient interactions; older adults may be taking multiple medications.

DIF: Cognitive Level: Remember/Knowledge REF: p. 79 OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 16. Objective data designating that the nutrition goals are not being met include a. hyperglycemia, normovolemia, and increased protein level.

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b. overhydration, hypoglycemia, and weight gain. c. weight gain, inconsistent glucose, and normovolemia. d. weight loss, elevated glucose, and dehydration.

ANS: D

When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and either overhydration or dehydration.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 87

17. A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit

on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate? a. Elemental protein formula b. Fiber-added formula c. High medium–chain triglyceride formula d. Lactose-free formula ANS: B

Added fiber helps to control blood glucose and reduce hyperlipidemia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 83 OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 18. Select the physiological reasoning behind enteral therapy as the preferred source of nutritional

therapy. a. Gut overgrowth increases. b. Gastroparesis increases. c. Bacterial translocation is initiated. d. Gut mucosa is preserved.

ANS: D

Enteral feedings prevent bacterial overgrowth and potential bacterial translocation from the gastrointestinal tract and preserve the gut mucosa.

DIF: Cognitive Level: Remember/Knowledge REF: p. 81 OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse identifies which patient at greatest risk for malabsorption of protein? a. The patient with gallbladder obstruction b. The patient with ileitis c. The patient with distal colon resection d. The patient with jejunal tumor ANS: B

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The ileum is where protein is broken down and absorbed; the patient with ileitis would be at greatest risk for protein malabsorption.

DIF: Cognitive Level: Remember/Knowledge REF: p. 78 OBJ: Review the anatomy and physiology related to utilization of nutrients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 20. The best nursing approach to prevent feeding tube obstruction is to a. dilute the feeding to make it flow more easily. b. flush the tube every 4 hours with 20 to 30 mL of tap water. c. pass a stylet daily to keep the tubing clear. d. use a larger bore tube where possible.

ANS: B

Flushing the tubing every 4 hours helps prevent obstruction. Diluting tube feedings can cause water intoxication. Stylets are never used to clear a tube, and the smallest bore possible should be used for best tolerance.

DIF: Cognitive Level: Apply/Application OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 84

21. Patients experiencing severe physiological stress increase their nutritional requirements to: a. 20 kcal/kg/day. b. 30 kcal/kg/day. c. 35 kcal/kg/day. d. 50 kcal/kg/day.

ANS: C

Severely stressed individuals require 35 kcal/kg/day; 50 kcal/kg/day exceeds caloric needs. A total of 20 kcal/kg/day is less than normal caloric requirements. A total of 30 kcal/kg/day is the caloric requirement for a moderately stressed individual.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Table 6-2

22. Malnutrition contributes to infection risk by a. hampering normal gastrointestinal motility. b. impairing immune function. c. increasing blood glucose. d. increasing drug interactions.

ANS: B

Malnutrition impairs immune function.

DIF: Cognitive Level: Remember/Knowledge REF: p. 84 Evidence Based Practice OBJ: Review the anatomy and physiology related to utilization of nutrients.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. A patient, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To

reduce the risk of aspiration, the nurse: a. helps the radiology technician to position the patient to avoid dislodging the tube. b. slows the rate of the feedings until placement has been verified. c. cuts the infusion rate by half. d. stops feedings 10 to 15 minutes before placing flat to obtain the radiograph.

ANS: D

Temporarily stopping feedings when flat minimizes the risk of aspiration if the patient will be supine.

DIF: Cognitive Level: Analyze/Analysis REF: p. 86 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Which statements about total parenteral nutrition are correct? (Select all that apply.) a. assessing fluid volume status and preventing infection are important nursing

considerations. b. fingerstick glucose levels are assessed every 6 hours and prn. c. total parenteral nutrition is administered through a feeding tube and pump. d. total parenteral nutrition with Na dUdReSdI Nl iGp Ti dBs. CpOr oMv i d e s adequate levels of protein,

carbohydrates, and fats. e. soy-based lipids should not be given during the first week of a critical illness.

ANS: A, B, D, E

All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral nutrition.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 80-81 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which interventions are critical during intravenous lipid administration? (Select all that

apply.) a. Assess glucose levels every 6 hours. b. Change the tubing every 24 hours. c. Hold lipids when administering antibiotics through the same line. d. Monitor triglyceride levels periodically. e. Maintain elevation of the head of the bed.

ANS: B, D

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Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride levels must be monitored until stable when administering lipids. Glucose is monitored during treatment with parenteral nutrition, which contains a high level of glucose. Medications are not administered through the IV lines containing lipids or parenteral nutrition. Elevating the head of the bed is important for enteral (tube) feedings to prevent aspiration.

DIF: Cognitive Level: Apply/Application REF: p. 85 |p. 87 Laboratory Alert Box OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Calorie-dense feedings: (Select all that apply.) a. are most useful in heart failure and liver disease. b. are most useful in malabsorption syndromes. c. contain 2 kcal/mL and 70 g protein/L. d. include increased fiber. e. are especially good for patients with lung disease.

ANS: A, C

Calorie-dense feedings are used when volume should be minimized and protein requirements are high, such as in heart failure or liver disease. They contain 2 kcal/mL and 70 g protein/L. Specific formulas, such as Oxepa, are available for lung disease.

DIF: Cognitive Level: Remember/Knowledge REF: p. 83 | Table 6-3 OBJ: Describe interventions to achieve nutritional goals.

TOP: Nursing Process Step: ImplemNeUnR taStiIoNnGTB.COM MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. Risks of total parenteral nutrition include: (Select all that apply.) a. diarrhea. b. elevated blood sugar. c. infection at the catheter site. d. volume overload. e. aspiration.

ANS: B, C, D

Diarrhea and aspiration are more common with enteral tube feedings; the other risks are common with total parenteral nutrition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 85 OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. Which of the following statements is true about insulin and parenteral nutrition? (Select all

that apply.) a. The amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. b. Insulin may be added to a parenteral nutrition solution. c. Subcutaneous insulin is used on a sliding scale during parenteral nutrition.

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d. Supplemental insulin is rarely required for patients receiving parenteral nutrition. e. Lingering hyperglycemia after parenteral nutrition has stopped requires continuing

insulin.

ANS: A, B, C

Hyperglycemia is common when receiving parenteral nutrition; insulin may be administered on a sliding scale for glucose control and/or added to the parenteral solution. The amount of insulin added to the parenteral solution is calculated based on the previous 24-hour laboratory values. Hypoglycemia can result from continuing the insulin after the parenteral nutrition is discontinued.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. A patient with severe burns had a dietitian consultation for nutritional support. The patient

weighs 145 pounds. What recommendations by the dietitian does the nurse anticipate initiating? (Select all that apply.) a. At least 2307 kcal/day b. Juven formula c. 2 cal HN formula d. At least 1648 kcal/day e. Perative formula ANS: A, B

The severely stressed patient requires around 35 kcal/kg/day. This patient weighs 145 pounds, which is 65.9 kg. So this patient nNeeUdRsSaIN t lGeTaB st.C2O3M 07 kcal/day. Juven is an appropriate formula; 2 cal HN is used for patients with heart and/or liver disease and Perative is used for patients with impaired GI function.

DIF: Cognitive Level: Analyze/Analysis REF: p. 83 | Table 6-2 | Table 6-3 OBJ: Discuss the recommended nutritional support for a burn patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity ORDERING 1. The correct order of actions for a patient starting enteral nutrition with a feeding tube is:

, . a. initiate tube feeding b. insert feeding tube c. flush tube to verify patency d. obtain chest radiograph e. assess residuals ANS:

B, D, C, A, E

,

,

,

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Initially the feeding tube will be inserted and final placement verified via chest radiograph.

The next step is to flush the feeding tube and start the tube feedings. Residuals are checked every 4 hours.

DIF: Cognitive Level: Apply/Application OBJ: Discuss practice guidelines related to nutritional support.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 80-82

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Chapter 07: Dysrhythmia Interpretation and Management Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus

node is the pacemaker of the heart because it is a. the fastest pacemaker cell in the heart. b. the only pacemaker cell in the heart. c. the only cell that does not affect the cardiac cycle. d. located in the left side of the heart.

ANS: A

The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells high in the right atria called the sinoatrial node (sinus node or SA node). The SA node has the fastest rate of discharge and thus is the dominant pacemaker of the heart. The AV node has pacemaker properties and can discharge an impulse if the SA node fails. The ventricles have pacemaker capabilities if the sinus node or the AV node ceases to generate impulses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 90 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity 2. One of the functions of the atrioventricular (AV) node is to N U R SINGTB.COM a. pace the heart if the ventricles fai l. b. slow the impulse arriving from the SA node. c. send the impulse to the SA node. d. allow for ventricular filling during systole.

ANS: B

The impulse from the SA node quickly reaches the atrioventricular (AV) node located in the area called the AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular filling during relaxation or ventricular diastole. The AV node has pacemaker properties and can discharge an impulse if the SA node (not the ventricle) fails.

The electrical impulse is then rapidly conducted through the bundle of His to the ventricles (not the SA node) via the left and right bundle branches.

DIF: Cognitive Level: Remember/Knowledge REF: p. 90 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity 3. The normal rate for the SA node when the patient is at rest is a. 40 to 60 beats per minute. b. 60 to 100 beats per minute. c. 20 to 40 beats per minute. d. more than100 beats per minute.

ANS: B

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The sinus node reaches threshold at a rate of 60 to 100 times per minute. Because this is the fastest pacemaker in the heart, the SA node is the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to 60 beats per minute and the His-Purkinje system can fire at a rate of 20 to 40 beats per minute. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.

DIF: Cognitive Level: Remember/Knowledge REF: p. 90 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse caring for patients with cardiac monitoring understands that when an electrical

signal is aimed directly at the positive electrode, the inflection will be: a. negative. b. upside down. c. upright. d. equally positive and negative.

ANS: C

When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the impulse is going away from the positive electrode, a negative deflection is seen; and if the signal is perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is equiphasic, with equally positive and negative deflection.

DIF: Cognitive Level: Understand/Comprehension REF: p. 92 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 5. The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the

monitoring electrodes, the nurse must first a. apply a moist gel to the chest. b. make certain that the electrode gel is dry. c. avoid soaps to avoid skin irritation. d. clip chest hair if needed.

ANS: D

Adequate skin preparation of electrode sites requires clipping the hair, cleansing the skin, and drying vigorously (moisture gels are not applied). Cleansing includes washing with soap and water, or alcohol, to remove skin debris and oils. Before application, the electrodes are checked to ensure that the gel is moist. It is difficult for electrodes to adhere to the chest in the presence of chest hair. Clipping, not shaving, is recommended since shaving may create small nicks that can become a portal for infection.

DIF: Cognitive Level: Apply/Application REF: p. 96 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse using cardiac monitoring understands that each horizontal box on the

electrocardiogram (ECG) paper indicates a. 200 milliseconds or 0.20 seconds duration.

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b. 40 milliseconds or 0.04 seconds duration. c. 3 seconds duration. d. millivolts of amplitude.

ANS: B

ECG paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures voltage or amplitude. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds.

DIF: Cognitive Level: Understand/Comprehension REF: p. 97 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is examining the patient’s cardiac rhythm strip in lead II and notices that all of the P

waves are upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P wave with the abnormal shape is probably a. from the SA node because all P waves come from the SA node. b. from some area in the atria other than the SA node. c. indicative of ventricular depolarization. d. normal even though it is inverted in lead II. ANS: B

Normally a P wave indicates that the SA node initiated the impulse that depolarized the atrium. However, a change in the shape of the P wave may indicate that the impulse arose from a site in the atria other than the SA node. The P wave represents atrial depolarization. It is usually upright in leads I and I I Na Un dR ShI aNsGaT rBo. Cu On dMe d , symmetrical shape. The amplitude of the P wave is measured at the center of the waveform and normally does not exceed three boxes, or 3 millimeters, in height.

DIF: Cognitive Level: Remember/Knowledge REF: p. 98 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse caring for patients on cardiac monitors assesses the patient with a prolonged QT

interval for a. electrolyte disturbances such as hypokalemia. b. symptomatic bradycardias. c. the development of lethal dysrhythmias. d. difficulty maintaining the blood pressure.

ANS: C

The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This interval measures the total time taken for ventricular depolarization and repolarization. Abnormal prolongation of the QT interval increases vulnerability to lethal dysrhythmias, such as ventricular tachycardia and fibrillation. The nurse monitors the patient for the development of these rhythms and is prepared to intervene should they occur. A prolonged QT is not associated with bradycardias, hypokalemia, or blood pressure irregularities.

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DIF: Cognitive Level: Apply/Application REF: p. 100 OBJ: Explain the relationships between electrical and mechanical events in the heart.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse

would first a. identify the markers on the ECG paper that indicate a 6-second strip. b. count the number of small boxes between two consecutive P waves. c. count the number of small boxes between two consecutive QRS complexes. d. divides the number of complexes in a 6-second strip by 10.

ANS: A

The optimal method of determining a heart rate from an ECG strip when the patient has an irregular heart rate is to count the number of P waves or QRS waves within a 6-second strip to obtain both atrial and ventricular heart rates per minute. In order to do this accurately, the nurse first much identify the markers on the ECG paper that indicate a 6-second strip. The other methods are not as accurate with an irregular heart rate.

DIF: Cognitive Level: Apply/Application REF: p. 101 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each

P wave and 20 small boxes between each R wave. What is the ventricular rate? a. 50 beats/min b. 75 beats/min c. 85 beats/min d. 100 beats/min ANS: B

The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to determine the ventricular rate. 1500/20 = 75 beats/min.

This method is accurate only if the rhythm is regular.

DIF: Cognitive Level: Apply/Application REF: p. 101 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 11. The patient is admitted with a fever and rapid heart rate. The patient’s temperature is 103 F

(39.4 C). The nurse places the patient on a cardiac monitor and finds the patient’s atrial and ventricular rates are above 105 beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should focus on providing: a. medications to lower heart rate. b. treatment to lower temperature. c. treatment to lower cardiac output. d. treatment to reduce heart rate.

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ANS: B

Sinus tachycardia results when the SA node fires faster than 100 beats per minute. All other components of the ECG are normal. Sinus tachycardia is a normal response to stimulation of the sympathetic nervous system. Sinus tachycardia is also a normal finding in children younger than 6 years. The fast heart rhythm may cause a decrease in cardiac output because of the shorter filling time for the ventricles. Lowering cardiac output further may complicate the situation. The dysrhythmia itself is not treated, but the cause is identified and treated appropriately. For example, if the patient has a fever or is in pain, the fever (and infection) or pain is treated appropriately.

DIF: Cognitive Level: Apply/Application REF: p. 105 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse notices sinus bradycardia on the patient’s cardiac monitor. The nurse should a. give atropine to increase heart rate. b. begin transcutaneous pacing of the patient. c. start a dopamine infusion to stimulate heart function. d. assess for hemodynamic instability.

ANS: D

Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic, interventions include administration of atropine. If atropine is not effective in increasing heart rate, then transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided for treatment of bradycardia associated with hypothermia.

DIF: Cognitive Level: Apply/Application REF: p. 106 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 13. Which of the following is true about a patient diagnosed with sinus arrhythmia? a. The heart rate varies, dependent on vagal tone and respiratory pattern. b. Immediate treatment is essential to prevent death. c. Sinus arrhythmia is not well tolerated by most patients. d. PR and QRS interval measurements are prolonged.

ANS: A

Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. The ECG tracing demonstrates an alternating pattern of faster and slower heart rate that changes with the respiratory cycle. Interval measurements are normal.

This rhythm is tolerated well, and no treatment is required. The PR and QRS intervals are normal.

DIF: Cognitive Level: Remember/Knowledge REF: p. 106 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity

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14. The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient

is asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient, the nurse should first a. prepare the patient for temporary pacemaker insertion. b. prepare the patient for permanent pacemaker insertion. c. assess the patient’s medication profile. d. apply transcutaneous pacemaker paddles.

ANS: C

AV nodal blocking medications (such as beta blockers, calcium channel blockers, and digoxin) and increased vagal tone may cause sinus exit block. Causes are explored, and prescribed medications may need to be adjusted or discontinued. If patients are symptomatic, significant numbers of pauses may require treatment, including temporary (including transcutaneous) and permanent implantation of a pacemaker.

DIF: Cognitive Level: Apply/Application REF: pp. 106-107 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. The patient’s heart rate is 165 beats per minute. The cardiac monitor shows a rapid rate with

narrow QRS complexes. The P waves cannot be seen, but the rhythm is regular. The patient’s blood pressure has dropped from 124/62 mm Hg to 78/30 mm Hg. The patient’s skin is cold and diaphoretic, and the patient is complaining of nausea. The nurse prepares the patient for a. administration of beta blockers. b. administration of atropine. c. transcutaneous pacemaker insertion. d. emergent cardioversion.

ANS: D

If an abnormal P wave cannot be visualized on the ECG but the QRS complex is narrow, the term supraventricular tachycardia (SVT) is often used. This is a generic term that describes any tachycardia that is not ventricular in origin; it is also used when the source above the ventricles cannot be identified, usually because the rate is too fast. Treatment is directed at assessing the patient’s tolerance of the tachycardia. If the rate is higher than 150 beats per minute and the patient is symptomatic, emergent cardioversion is considered. Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Beta blockers are a possibility if the patient is not symptomatic. Atropine is used in the treatment of bradycardia. If atropine is not effective in increasing heart rate, then transcutaneous pacing is implemented.

DIF: Cognitive Level: Analyze/Analysis REF: p. 109 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 16. The nurse is reading the cardiac monitor and notes that the patient’s heart rhythm is extremely

irregular and that there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is hemodynamically stable. The nurse realizes that the patient’s rhythm is a. atrial fibrillation.

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b. atrial flutter. c. atrial flutter with rapid ventricular response. d. junctional escape rhythm.

ANS: A

Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. No discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. Atrial flutter with rapid ventricular response occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. QRS complex is normal.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 111-112 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. The patient’s heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The

heart rate is 54 beats per minute. The nurse recognizes the rhythm is due to the a. loss of sinus node activity. b. increased rate of the AV node. c. increased rate of the SA node. d. decreased rate of the AV node.

ANS: A

Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire.

The normal heart rate of the AV node is 40 to 60 beats per minute, so the AV node rate has neither increased nor decreased. P waves may be inverted. An increased SA node rate would override the AV node.

DIF: Cognitive Level: Remember/Knowledge REF: p. 114 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. The patient’s heart rate is 70 beats per minute, but the P waves come after the QRS complex.

The nurse correctly determines that the patient’s heart rhythm is a. a normal junctional rhythm. b. an accelerated junctional rhythm. c. a junctional tachycardia. d. atrial fibrillation.

ANS: B

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The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.

DIF: Cognitive Level: Analyze/Analysis REF: p. 114 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The patient is having premature ventricular contractions (PVCs). The nurse’s greatest concern

should be: a. the proximity of the R wave of the PVC to the T wave of a normal beat. b. the fact that PVCs are occurring, because they are so rare. c. whether the number of PVCs is decreasing. d. whether the PVCs are wider than 0.12 seconds.

ANS: A

The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of PVC falls on the T wave of a normal beat, it is referred to aNsUthReSIRN-GoTnB-T. C pOhMe n o m e n on . PVCs may occur in healthy individuals and usually do not require treatment. The nurse must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse should evaluate for potential causes, such as electrolyte imbalances, myocardial ischemia or injury, and hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to the development of sustained ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often wider than 0.16 seconds.

DIF: Cognitive Level: Analyze/Analysis REF: p. 116 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 20. The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed,

the patient is found to be unresponsive with no pulse. The nurse should a. treat with intravenous amiodarone or lidocaine. b. begin cardiopulmonary resuscitation and advanced life support. c. provide electrical cardioversion. d. ignore the rhythm because it is benign.

ANS: B

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Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It also may be used in nonemergency situations, such as when a patient has asymptomatic VT. DIF: Cognitive Level: Apply/Application REF: p. 119 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse is talking with the patient when the monitor alarms and shows a wavy baseline

without a PQRST complex. The nurse should a. defibrillate the patient immediately. b. initiate basic life support. c. initiate advanced life support. d. assess the patient and the electrical leads.

ANS: D

Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment is, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.

DIF: Cognitive Level: Apply/Application REF: pp. 119-120 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 22. The nurse notices that the patient has a first-degree AV block. Everything else about the

rhythm is normal. The nurse should a. prepare to place the patient on a transcutaneous pacemaker. b. give the patient atropine to shorten the PR interval. c. monitor the rhythm and patient’s condition. d. give the patient an antiarrhythmic medication.

ANS: C

First-degree AV block is a common dysrhythmia in the elderly and in patients with cardiac disease. As the normal conduction pathway ages or becomes diseased, impulse conduction becomes slower than normal. It is well tolerated. No treatment is required. Continue to monitor the patient and the rhythm.

DIF: Cognitive Level: Apply/Application REF: pp. 212-122 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. The nurse understands that in a third-degree AV block

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every P wave is conducted to the ventricles. some P waves are conducted to the ventricles. none of the P waves are conducted to the ventricles. the PR interval is prolonged.

ANS: C

Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. Normally every P wave is conducted to the ventricles. If some of the P waves are conducted but others are not, further assessment is needed to determine the type of block present. A prolonged PR interval is a first-degree AV block, and is well tolerated and requires no treatment.

DIF: Cognitive Level: Remember/Knowledge REF: p. 123 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity 24. The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The

patient is on digitalis medication at home. The nurse should expect that a. the patient has had an anterior wall myocardial infarction. b. the physician will order the digitalis to be continued in the hospital. c. a digitalis level would be ordered upon admission. d. the patient will require a transcutaneous pacemaker.

ANS: C

Digitalis toxicity is a major cause of this rhythm, and further digitalis doses should not be given until a digitalis level is obtained. Other causes of Mobitz I include AV nodal blocking drugs, acute inferior wall m y oc a r dNi Ua lRiSnIfNa Gr cTt iBo. nC Oo M r right ventricular infarction, ischemic heart disease, and excess vagal response. This type of block is usually well tolerated, and no treatment is indicated unless the dropped beats occur frequently.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 25. The patient is scheduled to have a permanent pacemaker implanted. The patient asks the

nurse, “How long will the battery in this thing last?” The nurse should answer, a. “Life expectancy is about 1 year. Then it will need to be replaced.” b. “Pacemaker batteries can last up to 25 years with constant use.” c. “Battery life varies depending on usage, but it can last up to 10 years.” d. “Pacemakers are used to treat temporary problems, so the batteries don’t last long.”

ANS: C

Implanted permanent pacemakers are used to treat chronic conditions. These devices have a battery life of up to 10 years, which varies based on the manufacturer’s recommendations and the usage of the device.

DIF: Cognitive Level: Understand/Comprehension OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment

REF: p. 124

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MSC: NCLEX Client Needs Category: Physiological Integrity 26. The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have

demonstrated normal AV node function. This patient may be a candidate for which type of pacing? a. Atrial pacing b. Ventricular pacing c. Dual-chamber pacing d. Transcutaneous pacing ANS: A

Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 126

27. The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the

demand mode at a rate of 60 beats per minute. The nurse realizes that a. the pacemaker will pace only if the patient’s intrinsic heart rate is less than 60 beats per minute. b. the demand mode often competes with the patient’s own rhythm. c. the demand mode places the patient at risk for the R-on-T phenomenon. d. the fixed-rate mode is safer and is the mode of choice.

ANS: A

Pacemakers can be operated in a demand mode or a fixed-rate (asynchronous) mode. The demand mode paces the heart when no intrinsic or native beat is sensed. For example, if the rate control is set at 60 beats per minute, the pacemaker will only pace if the patient’s heart rate drops to less than 60. The fixed-rate mode paces the heart at a set rate, independent of any activity the patient’s heart generates. The fixed-rate mode may compete with the patient’s own rhythm and deliver an impulse on the T wave (R-on-T phenomenon), with the potential for producing ventricular tachycardia or fibrillation. The demand mode is safer and is the mode of choice.

DIF: Cognitive Level: Understand/Comprehension OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 126

28. The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The

cardiac monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse recognizes this as: a. normal pacemaker function.

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b. failure to capture. c. failure to pace. d. failure to sense.

ANS: C

Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate.

DIF: Cognitive Level: Remember/Knowledge OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 127

29. The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or

QRS complexes following the spikes. The nurse recognizes this as: a. normal pacemaker function. b. failure to capture. c. failure to pace. d. failure to sense.

ANS: B

When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). This is not normal pacemaker function. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate.

DIF: Cognitive Level: Remember/Knowledge OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 30. Interpret the following rhythm:

REF: p. 127

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Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus arrhythmia

ANS: A

Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.

DIF: Cognitive Level: Analyze/Analysis REF: p. 105 | Fig 7-24 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 31. Interpret the following rhythm:

a. b. c. d.

Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus arrhythmia

ANS: C

Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly slows during exhalation because of changes in vagal tone.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 105 | Fig 7-25 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 32. Interpret the following rhythm:

a. b. c. d.

Normal sinus rhythm Sinus bradycardia Sinus tachycardia Sinus arrhythmia

ANS: B

Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows slightly during exhalation becauseNoUfRcShI N anGgTeBs . CinOvMagal tone.

DIF: Cognitive Level: Analyze/Analysis REF: p. 106 | Fig 7-26 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 33. Interpret the following rhythm:

a. b. c. d.

Sinus rhythm with PACs Normal sinus rhythm Sinus tachycardia Sinus bradycardia

ANS: A

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The underlying rhythm is identified first. Following this step, the dysrhythmia that is occurring to disrupt the underlying rhythm is then determined. A premature atrial contraction (PAC) is a single ectopic beat arising from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat.

Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Bradycardia is defined as a heart rate less than 60 beats per minute.

DIF: Cognitive Level: Analyze/Analysis REF: p. 107 | Fig 7-29 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 34. Interpret the following rhythm:

NURSINGTB.COM

a. b. c. d.

Atrial flutter with variable conduction Ventricular fibrillation Atrial fibrillation Atrial flutter with RVR (rapid ventricular response)

ANS: A

Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 110-111 | Fig 7-33 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 35. Interpret the following rhythm:

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Atrial fibrillation Atrial flutter Atrial flutter with RVR Junctional escape rhythm

ANS: A

Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth appearance. The ventricular response may be regular or irregular based on how many flutter waves are conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. If a P wave is present before the QRS complex, the PR interval is sNhUo Rr t Se InNeGd Tt Bo . Cl eOs sMt h a n 0.12 milliseconds. QRS complex is normal.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 111-112 | Fig 7-34 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 36. Interpret the following rhythm:

a. b. c. d.

Junctional rhythm An accelerated junctional rhythm A junctional tachycardia Atrial fibrillation

ANS: A

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The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for junctional tachycardia is greater than 100 beats per minute. If a P wave precedes QRS, it is inverted or upside down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR interval is shortened to less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 113-114 | Fig 7-37 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 37. Interpret the following rhythm:

a. b. c. d.

Sinus rhythm with multifocal premature ventricular contractions Sinus rhythm with unifocal premature ventricular contractions Sinus rhythm with bigeminal premature ventricular contractions N U R S IN G T B . C O M Sinus rhythm with paired prem a t u r e v en t r i cu l a r contractions (couplets)

ANS: A

A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (or couplets), and three or more in a row are called nonsustained ventricular tachycardia.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41B OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 38. Interpret the following rhythm:

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Sinus rhythm with multifocal premature ventricular contractions Sinus rhythm with unifocal premature ventricular contractions Sinus rhythm with trigeminal premature ventricular contractions Sinus rhythm with paired premature ventricular contractions (couplets)

ANS: B

A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs also can occur sequentially. Two PVCs in a row are called a pair, and three or more in a row are called nonsustained ventricular tachycardia.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41A OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 39. Interpret the following rhythm:

a. b. c. d.

Sinus rhythm with multifocal premature ventricular contractions UR Sinus rhythm with unifocal pr Nem atSuI rNeGvTeBn. tCr O icM ular contractions Sinus rhythm with bigeminal premature ventricular contractions Sinus rhythm with paired premature ventricular contractions (couplets)

ANS: C

A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (couplet), and three or more in a row are called nonsustained ventricular tachycardia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 109 | pp. 116-117 | Fig 7-41A | Box 7-4 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Client Needs Category: Physiological Integrity 40. Interpret the following rhythm:

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Sinus rhythm with multifocal premature ventricular contractions Sinus rhythm with unifocal premature ventricular contractions Sinus rhythm with bigeminal premature ventricular contractions Sinus rhythm with paired premature ventricular contractions (couplets)

ANS: D

A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs. PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair (couplet), and three or more in a row are called nonsustained ventricular tachycardia.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 116-117 | Fig 7-41C OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 41. Interpret the following rhythm:

a. b. c. d.

R-on-T phenomenon leading to ventricular fibrillation Sinus rhythm with multifocal premature ventricular contractions Nonsustained ventricular tachycardia Sinus rhythm with bigeminal premature ventricular contractions

ANS: A

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The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular tachycardia may occur. When the R wave of a PVC falls on the T wave of a normal beat, it is referred to as the R-on-T phenomenon. This strip does not show sinus rhythm, multi-focal PVCs (PVCs that are from different places in the heart and therefore look different), non-sustained ventricular tachycardia, or bigeminal premature ventricular contractions (where every other beat is a PVC).

DIF: Cognitive Level: Analyze/Analysis TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 116 | Fig 7-42 B

42. The patient is alert and talking when the nurse notices the following rhythm. The patient’s

blood pressure is 90/44 mm Hg. The nurse should

a. b. c. d.

defibrillate immediately. begin basic life support. begin advanced life support. treat with intravenous amiodarone or lidocaine.

ANS: D

Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. Depolarization of the ventricles is abnormal and produces a widened QRS complex. The patient may or may not have a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is stable, the patient can be treated with intravenous amiodarone or lidocaine.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 117-118 | Fig 43B OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 43. The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and

not breathing. The nurse should

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a. b. c. d.

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treat with intravenous amiodarone or lidocaine. provide emergent basic and advanced life support. provide electrical cardioversion. ignore the rhythm because it is benign.

ANS: B

Ventricular fibrillation (VF) is a chaotic rhythm characterized by a quivering of the ventricles, which results in total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the treatment, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness. If no pulse is present, provide emergent basic and advanced life-support interventions, including defibrillation. IV medications can be used as part of advanced life support. Cardioversion is not warranted since the patient is pulseless. This rhythm is not benign and cannot be ignored.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 119-120 | Fig 7-45A OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Implementation | Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg. iCcOalMIntegrity 44. Interpret the following rhythm:

a. b. c. d.

Idioventricular rhythm Accelerated idioventricular rhythm Ventricular tachycardia Ventricular fibrillation

ANS: A

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Idioventricular rhythm is an escape rhythm that is generated by the Purkinje fibers. This rhythm emerges only when the SA and AV nodes fail to initiate an impulse. The Purkinje fibers are capable of an intrinsic rate of 20 to 40 beats per minute. Because this last pacemaker is located in the ventricles, the QRS complex appears wide and bizarre with a slow rate. No P waves are present. If the rate is between 40 and 100 beats per minute, this rhythm is called accelerated idioventricular rhythm (AIVR). Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute. VF produces a wavy baseline without a PQRST complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always important to immediately assess the patient for pulse and consciousness.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 120-121 | Fig 7-46A OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 45. Interpret the following rhythm:

a. b. c. d.

NURSINGTB.COM

Normal sinus rhythm Sinus rhythm with second-degree AV block Complete heart block Sinus rhythm with first-degree AV block

ANS: D

In first-degree block, P and QRS waves are consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20 seconds. QRS complex and QT/QT c measurements are normal. Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds.

In a complete heart block, the atria and ventricles beat independently of each other. A first-degree AV block means the PR interval is greater than 0.20 seconds.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 121-122 | Fig 7-49 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 46. Interpret the following rhythm:

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a. b. c. d.

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First-degree AV block Second-degree AV block Mobitz I (Wenckebach phenomenon) Second-degree AV block Mobitz II Third-degree AV block (complete heart block)

ANS: B

Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS; however, the PR interval is >0.20 seconds.

Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123 | Fig 7-50A OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 47. Interpret the following rhythm:

a. b. c. d.

First-degree AV block Second-degree AV block Mobitz I (Wenckebach phenomenon) Second-degree AV block Mobitz II Third-degree AV block (complete heart block)

ANS: C

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Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 122-123 | Fig 7-51A OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 48. Interpret the following rhythm:

a. First-degree AV block b. Second-degree AV block Mobitz I (Wenckebach phenomenon) c. Second-degree AV block Mobitz II d. Third-degree AV block (complete heart block) ANS: D

Third-degree block is often called complete heart block because no atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and appear throughout the QRS waveform. Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. DIF: Cognitive Level: Analyze/Analysis REF: pp. 123-124 | Fig 7-52B OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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49. Interpret the following rhythm:

a. b. c. d.

Atrial pacing Ventricular pacing Dual-chamber pacing Transcutaneous pacing

ANS: A

Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. However, with this patient, ventricular and AV function are normal. Transcutaneous pacing is delivered through the skin via external electrode pads connected to an external pacemaker.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: AssessN mUenRtSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity 50. Interpret the following rhythm:

a. b. c. d.

Atrial pacing Ventricular pacing Dual-chamber pacing Transcutaneous pacing

ANS: B

REF: pp. 126-127 | Fig 7-58

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Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. This patient’s pacemaker is stimulating the ventricles. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. There is no evidence of a dual pacemaker since the atrial spike is not seen on the ECG strip. Transcutaneous pacing is accomplished via skin electrodes.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 126-127 | Fig 7-59

51. Interpret the following rhythm:

a. b. c. d.

Atrial pacing Ventricular pacing Dual-chamber pacing Transcutaneous pacing

ANS: C

Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers). Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick. Ventricular pacing stimulates ventricular depolarization and is commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal cardiac cycle. This is the case in the scenario provided as seen by pacemaker spikes in both the atrial and ventricular position.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 52. Interpret the following rhythm:

REF: pp. 126-127 | Fig 7-60

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a. b. c. d.

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Normal pacemaker function Failure to capture Failure to pace Failure to sense

ANS: C

Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Note that after the 3-second mark, the pacemaker failed to fire. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker) within the appropriate time frame.

When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate. This is not normal pacemaker function.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts ofNc aUr Rd iSaIcN pGaTcBi n. Cg .O M TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 53. Interpret the following rhythm:

a. b. c. d.

Normal pacemaker function Failure to capture Failure to pace Failure to sense

ANS: D

REF: p. 127 | Fig 7-61

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When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an inappropriate electrical impulse, it is called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patient’s own rhythm, earlier than the programmed rate. This is not normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization is noted, it is described as a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The problem is noted by absence of pacer spikes on the rhythm strip. When the pacemaker does not sense the patient’s own cardiac rhythm and initiates an electrical impulse, it is called failure to sense.

DIF: Cognitive Level: Analyze/Analysis OBJ: Explain the basic concepts of cardiac pacing.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 127 | Fig 63

MULTIPLE RESPONSE 1. The normal width of the QRS complex is which of the following? (Select all that apply.) a. 0.06 to 0.10 seconds. b. 0.12 to 0.20 seconds. c. 1.5 to 2.5 small boxes. d. 3.0 to 5.0 small boxes. e. 0.04 seconds or greater.

ANS: A, C

The waveform that initiates the Q NR US RcSoI m N Gp lTeBx. C( w OM h e t h e r it is a Q wave or an R wave) marks the beginning of the interval. The normal width of the QRS complex is 0.06 to 0.10 seconds.

This width equals 1.5 to 2.5 small boxes. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide; not the QRS interval. A pathological Q wave has a width of 0.04 seconds and a depth that is greater than one fourth of the R wave amplitude; therefore, the QRS complex would be wider than that.

DIF: Cognitive Level: Remember/Knowledge REF: p. 99 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which of the following are common causes of sinus tachycardia? (Select all that apply.) a. Hyperthyroidism b. Hypovolemia c. Hypothyroidism d. Heart Failure e. Sleep ANS: A, B, D

Common causes of sinus tachycardia include hyperthyroidism, hypovolemia, heart failure, anemia, exercise, use of stimulants, fever, and sympathetic response to fear or pain and anxiety. Hypothyroidism and sleep tend to slow the heart rate.

DIF:

Cognitive Level: Remember/Knowledge

REF: p. 105

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OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. Sinus bradycardia is a symptom of which of the following? (Select all that apply.) a. Calcium channel blocker medication b. Beta blocker medication c. Athletic conditioning d. Hypothermia e. Hyperthyroidism ANS: A, B, C, D

Vasovagal response; medications such as digoxin or AV nodal blocking agents, including calcium channel blockers and beta blockers; myocardial infarction; normal physiological variant in the athlete; disease of the sinus node; increased intracranial pressure; hypoxemia; and hypothermia may cause sinus bradycardia. Hyperthyroidism is a cause of sinus tachycardia.

DIF: Cognitive Level: Remember/Knowledge REF: p. 106 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at

greater risk for mortality/morbidity include which of the following? (Select all that apply.) a. Stroke b. Ashman beats c. Pulmonary emboli d. Prolonged PR interval e. Decreased cardiac output ANS: A, C, E

One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The ineffectual contraction of the atria results in loss of “atrial kick.” If too many impulses conduct to the ventricles, atrial fibrillation with rapid ventricular response may result and compromise cardiac output. Ashman beats are not clinically significant. No recognizable or discernible P waves are present; therefore, PR interval is absent.

DIF: Cognitive Level: Remember/Knowledge REF: p. 111 |p. 113 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. The possible P waveforms that are associated with junctional rhythms include which of the

following? (Select all that apply.) a. No P wave b. Inverted P wave c. Shortened PR interval

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d. P wave after the QRS complex e. Normal P wave and PR interval ANS: A, B, C, D

Because of the location of the AV node—in the center of the heart—impulses generated may be conducted forward, backward, or both. With the potential of forward, backward, or bidirectional impulse conduction, three different P waveforms may be associated with junctional rhythms: When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle first. The atria receives the wave of depolarization at the same time as the ventricles; thus, because of the larger muscle mass of the ventricles, there is no P wave. When the AV node impulse is conducted backward, the impulse enters the atria first. When depolarization occurs backward, an inverted P wave is created. Once the atria have been depolarized, the impulse moves down the bundle of His and depolarizes both ventricles normally. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and backward, P waves may be present after the QRS complex.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 113-114 OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node, and the ventricles.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The patient is in third-degree heart block (complete heart block) and is symptomatic. The

treatment for this patient is which of the following? (Select all that apply.) a. Transcutaneous pacemaker b. Atropine IV c. Temporary transvenous pacemaker d. Permanent pacemaker e. Amiodarone IV ANS: A, C, D

Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker. Atropine reduces vagal tone, but that is not a cause of complete heart block and will produce more P waves, but the P waves will still not be associated with the QRS complexes. It is important to note that the only treatment is pacing. Amiodarone IV is used to suppress ventricular dysrhythmia and is not used to treat third-degree heart block.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 123-124 OBJ: Describe appropriate interventions for common dysrhythmias.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 08: Hemodynamic Monitoring Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter.

The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. Cardiac index (CI) of 1.2 L/min/m3 b. Cardiac output (CO) of 4 L/min c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm–5 d. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm–5 ANS: A

A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles), requiring intervention.

The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm–5; and the systemic vascular resistance of 1400 dynes/sec/cm–5.

DIF: Cognitive Level: Analyze/Analysis REF: p. 137 | Table 8-1 | Box 8-8 OBJ: Identify normal hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary

artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? a. Diuretics b. Intravenous fluids c. Negative inotropic agents d. Vasopressors ANS: B

Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. Administration of diuretics would worsen the patient’s volume status. Negative inotropes would not improve the patient’s volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state.

DIF: Cognitive Level: Analyze/Analysis REF: p. 149 | Box 8-1 OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

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3. The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of

complications, what is the priority nursing intervention? a. Apply a pressure dressing to the insertion site. b. Ensure that all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.

ANS: B

Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; radiography is not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.

DIF: Cognitive Level: Apply/Application REF: p. 144 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary

artery occlusion pressure (PAOP) to be significantly higher than previously recorded values.

The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? a. Increase supplemental oxygenNaUnRdSnIN otGifTyBr.CesOpMiratory therapy. b. Notify the provider immediately of the assessment findings. c. Obtain a stat chest x-ray film to verify proper catheter placement. d. Zero reference and level the catheter at the phlebostatic axis.

ANS: D

A hemodynamic value not supported by clinical assessment should be treated as questionable.

To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures.

Clinical manifestations do not support increasing supplemental oxygen. Clinical manifestations do not warrant provider intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.

DIF: Cognitive Level: Analyze/Analysis OBJ: Analyze conditions that alter hemodynamic values.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 140-141

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5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse

assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm–5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. Blood transfusion b. Furosemide c. Dobutamine infusion d. Dopamine hydrochloride infusion ANS: A

Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.

DIF: Cognitive Level: Analyze/Analysis REF: p. 137 | Table 8-1 | Box 8-8 OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of

45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority? a. Apply 50% oxygen via Venturi mask. b. Insert an indwelling urinary catheter.

NURSINGTB.COM c. Begin a dobutamine infusion. d. Obtain stat cardiac enzymes and troponin.

ANS: C

The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time.

DIF: Cognitive Level: Analyze/Analysis REF: p. 150 | Box 8-8 OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a

left radial arterial line. Which assessment finding by the nurse requires immediate action? a. A dampened arterial line waveform b. Numbness and tingling in the left hand c. Slight bloody drainage at subclavian insertion site d. Slight redness at subclavian insertion site ANS: B

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Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.

DIF: Cognitive Level: Apply/Application REF: pp. 143-144 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The provider writes an order to discontinue a patient’s left radial arterial line. When

discontinuing the patient’s invasive line, what is the priority nursing action? a. Apply an air occlusion dressing to insertion site. b. Apply pressure to the insertion site for 5 minutes. c. Elevate the affected limb on pillows for 24 hours. d. Keep the patient’s wrist in a neutral position.

ANS: B

Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not the standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place but unnecessary after catheter discontinuation.

DIF:

RSpIrN Cognitive Level: Understand/N CU om ehGeTnBsi.oCnOM

REF: p. 144

OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 9. Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to

verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best interpretation of these results by the nurse? a. The catheter is not positioned correctly and should be removed. b. The catheter position increases the risk of ventricular dysrhythmias. c. The distal tip of the catheter is in the appropriate position. d. The physician should be called to advance the catheter into the pulmonary artery.

ANS: C

X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery.

DIF: Cognitive Level: Remember/Knowledge REF: p. 146 OBJ: Describe the indications, measurement, complications, and nursing implications associated with

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monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain

a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline.

ANS: C

Balloon inflation should never be forced because the PAC may have migrated farther into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurse’s scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.

DIF: Cognitive Level: Apply/Application REF: pp. 149-150 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive mo nito ringNoUf RhSeImNoGdTyBn.aCmOiM c indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a patient following insertion of a left subclavian central venous

catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site ANS: A

Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.

DIF: Cognitive Level: Apply/Application REF: Box 8-2 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Assessment

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MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who

is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient’s head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values.

ANS: C

Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and aspiration of tube feeding, and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.

DIF: Cognitive Level: Apply/Application REF: p. 141 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC).

Which statement by the family member best indicates understanding of the purpose of the PAC? a. “The catheter will provide multiple sites to give intravenous fluid.” b. “The catheter will allow the provider to better manage fluid therapy.” c. “The catheter tip comes to rest inside my brother’s pulmonary artery.” d. “The catheter will be in position until the heart has a chance to heal.”

ANS: B

A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy.

DIF: Cognitive Level: Understand/Comprehension REF: p. 149 | Box 8-1 OBJ: Describe the indications, measurement, complications, and nursing implications associated with

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monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a

patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation. b. Place the patient in the supine position and document the average PAOP obtained after three measurements. c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained. d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.

ANS: D

Pressures are highest when measured at end exhalation in the spontaneously breathing patient.

In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation.

Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.

DIF: Cognitive Level: Analyze/Analysis REF: p. 149 | Box 8-1 N U R S I N G T B .C O M OBJ: Describe the indications, m e a s u r e m e n t , c om p li cation s, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 15. The charge nurse is supervising care for a group of patients monitored with a variety of

invasive hemodynamic devices. Which patient should the charge nurse evaluate first? a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula ANS: C

A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg and 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mm Hg and a normal oxygen saturation does not require immediate treatment.

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DIF: Cognitive Level: Analyze/Analysis OBJ: Analyze conditions that alter hemodynamic values.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Table 8-1

16. The nurse is caring for a patient following insertion of a left subclavian central venous

catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSI)? a. Review daily the necessity of the central venous catheter. b. Cleanse the insertion site daily with isopropyl alcohol. c. Change the pressurized tubing system and flush bag daily. d. Maintain a pressure of 300 mm Hg on the flush bag.

ANS: A

Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Cleansing the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line but does not reduce the risk of infection.

DIF: Cognitive Level: Apply/Application REF: p. 142 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: InterveN ntUioRnSINGTB.COM MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 17. During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by

inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? a. Deflate the balloon while slowly withdrawing the catheter. b. Instruct the patient to cough and deep-breathe forcefully. c. Inflate the catheter balloon with an additional 1 mL of air. d. Ensure lidocaine hydrochloride (IV) is immediately available.

ANS: D

During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.

DIF: Cognitive Level: Apply/Application REF: p. 146 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

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TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 18. Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse

obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? a. Zero referencing the transducer at the level of the phlebostatic axis following insertion b. Calibrating the system with a central venous blood sample and arterial blood gas value c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks ANS: B

To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.

DIF: Cognitive Level: Apply/Application REF: p. 152 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: InterveN ntUioRnSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter.

Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? a. Arterial lactate level of 1.0 mEq/L b. Cardiac output of 2.5 L/min c. Mixed venous (SvO2) of 40% d. Cardiac index of 1.5 L/min/m2 ANS: A

An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits, indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.

DIF: Cognitive Level: Analyze/Analysis REF: p. 136 OBJ: Identify normal hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity—Physiological Adaptation

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20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings

include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask.

Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following physician’s orders? a. Titrate supplemental oxygen to achieve a SpO2 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.

ANS: D

A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen and obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.

DIF: Cognitive Level: Analyze/Analysis REF: Table 8-1 OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.

TOP: Nursing Process Step: Diagnosis MSC: NCLEX Client Needs Category: Physiological Integrity 21. The charge nurse has a pulse contour cardiac output monitoring system available for use in the

surgical intensive care unit. For which patient is use of this device most appropriate? a. A patient with a history of aor ti c in s uf fi c ie n cy ad mitted with a postoperative N U R S IN G T B .C O M myocardial infarction b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction ANS: D

Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 155-157 OBJ: Explain the clinical relevance and methods of measuring cardiac output.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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22. The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient

being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse?

Figure from Geiter H, Jr.: Swan-Ganz Catheters. http://www.nurse411.com. Accessed April 2012. a. Turn the patient to the left side; obtain a stat portable chest x-ray. b. Place the patient supine; repeat zero referencing of the system. c. Document the wedge pressure; continue to monitor the patient. d. Perform an immediate dynamic response test; obtain a chest x-ray.

ANS: C

After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal pulmonary artery waveform. The nurse should document the occlusive value and continue to monitor the patient. Turning the patient to the left side, zero referencing the system, and performing a dynamic response test are not necessary as the waveform displayed is normal.

DIF: Cognitive Level: Analyze/Analysis REF: p. 148 | Fig 8-18A OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the

patient’s noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by the nurse? a. Activate the rapid response system. b. Place the patient in Trendelenburg position. c. Assess the cuff for proper arm size. d. Administer 0.9% normal saline bolus.

ANS: C

Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary.

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DIF: Cognitive Level: Apply/Application REF: p. 136 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 24. The nurse is caring for a patient with an admitting diagnosis of congestive heart failure. While

attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? a. Limit the patient’s supine position to no more than 10 seconds. b. Administer antianxiety medications while recording the pressure. c. Encourage the patient to take slow, deep breaths while supine. d. Elevate the head of the bed 45 degrees while recording pressures.

ANS: D

Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient who becomes anxious and tachypneic when flat. Administering antianxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow, deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure.

DIF: Cognitive Level: Apply/Application REF: pp. 140-141 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, l e Nf t Ua Rt r Si aI lN, G puTlBm.CoO naMry artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 25. The nurse returns from the cardiac catheterization laboratory with a patient following insertion

of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Before obtaining a cardiac output, which action is most important for the nurse to complete? a. Document a pulmonary artery catheter occlusion pressure. b. Zero reference the transducer system at the phlebostatic axis. c. Inflate the pulmonary artery catheter balloon with 1 mL air. d. Inject 10 mL of 0.9% normal saline into the proximal port.

ANS: B

To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed before obtaining readings. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required before obtaining a cardiac output. The nurse injects 5-10 mL of normal saline into the proximal port in order to measure the cardiac output; this is not a step done before obtaining the measurement.

DIF:

Cognitive Level: Apply/Application

REF: pp. 140-141

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OBJ: Analyze the conditions that alter hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Adaptation 26. The charge nurse is supervising the care of four critical care patients being monitored using

invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? a. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min b. A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg c. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg d. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg ANS: A

A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.

DIF: Cognitive Level: Remember/Knowledge REF: Table 8-1 OBJ: Identify normal hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 27. The nurse is caring for a mechanically ventilated patient being monitored with a left radial

arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? a. The mechanical ventilator is malfunctioning. b. The patient may require fluid resuscitation. c. The arterial line may need to be replaced. d. The left limb may have reduceNdUpReSrIfNuG siToBn..COM ANS: B

The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure.

A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion.

DIF: Cognitive Level: Understand/Comprehension REF: p. 157 OBJ: Analyze the conditions that alter hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Adaptation 28. Upon entering the room of a patient with a right radial arterial line, the nurse assesses the

waveform to be slightly dampened and notices blood to be backed up into the pressure tubing.

What is the best action by the nurse? a. Check the inflation volume of the flush system pressure bag. b. Disconnect the flush system from the arterial line catheter. c. Zero reference the transducer system at the phlebostatic axis. d. Reduce the number of stopcocks in the flush system tubing.

ANS: A

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To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is inappropriate and could increase the risk of infection to the patient.

Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss.

DIF: Cognitive Level: Apply/Application REF: p. 144 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Adaptation 29. The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter

inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.

ANS: D

When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in the patient’s condition. Hemodynamic values and waveforms are recorded at scheduled intervals, and it is important that the tubing not be too long; however, alarm alerts are of highest priority. The lNi nUeRsSaI Nr eGzTeBr .oC rOeMf e re n ce d per hospital policy, more frequently than daily.

DIF: Cognitive Level: Apply/Application REF: Box 8-4 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 30. The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being

monitored with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient? a. Ensure the transducer system is zero referenced at the level of the phlebostatic axis. b. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement. c. Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag. d. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.

ANS: B

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Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety.

DIF: Cognitive Level: Apply/Application REF: Box 8-9 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment MULTIPLE RESPONSE 1. When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best

nursing actions? (Select all that apply.) a. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. b. Inflate the balloon with air, recording the volume necessary to obtain a reading. c. Maintain the balloon in the inflated position for 8 hours following insertion. d. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis. e. Inflate and deflate the balloon on an hourly schedule ANS: A, B, D

To obtain an accurate pulmonary Na rUt eRr SyI NocGcTl Bu s. Ci oOnMp r e s su re (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction. There is no reason to inflate and deflate the catheter’s balloon unless measurements are being obtained.

DIF: Cognitive Level: Apply/Application REF: p. 149 | Box 8-1 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most

appropriate nursing actions? (Select all that apply.) a. Compare measured pressures with other physiological parameters. b. Flush the central venous catheter with 20 mL of sterile saline. c. Inflate the balloon with 3 mL of air and record the pressure tracing. d. Obtain the right atrial pressure measurement during end exhalation. e. Zero reference the transducer system at the level of the phlebostatic axis.

ANS: A, D, E

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To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient’s physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.

DIF: Cognitive Level: Apply/Application REF: p. 138 | Fig 8-7 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of

the catheter, what are the priority nursing actions? (Select all that apply.) a. Allay the patient’s anxiety by providing information about the procedure. b. Ensure that a sterile field is maintained during the insertion procedure. c. Inflate the balloon during the procedure when indicated by the provider. d. Monitor the patient’s cardiac rhythm throughout the procedure. e. Obtain informed consent by informing the patient of procedural risks.

ANS: A, B, C, D

During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient’s anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the provider to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nNuUrR seS,IN buGtTiBt . iCsOoMbt a i ne d by the provider and should occur before the procedure begins.

DIF: Cognitive Level: Apply/Application REF: p. 147 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 4. Which nursing actions are most important for a patient with a right radial arterial line? (Select

all that apply.) a. Checking the circulation to the right hand every 2 hours b. Maintaining a pressurized flush solution to the arterial line setup c. Monitoring the waveform on the monitor for dampening d. Restraining all four extremities with soft limb restraints e. Ensuring all junctions remain tightly connected ANS: A, B, C, E

Options A, B, C, and E are required to ensure proper functioning of the arterial line.

There is no need to restrain all extremities. Depending on the patient’s level of sedation, the right hand may need gentle restraint.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 143-144 OBJ: Describe the indications, measurement, complications, and nursing implications associated with

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monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 5. Which of the following situations may result in a low cardiac output and low cardiac index?

(Select all that apply.) a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock e. Fever ANS: B, C, D

Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output.

Cardiac output is usually increased with exercise and fever.

DIF: Cognitive Level: Remember/Knowledge OBJ: Analyze conditions that alter hemodynamic values.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Box 8-8

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Chapter 09: Ventilatory Assistance Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. A patient has coronary artery bypass graft surgery and is transported to the surgical intensive

care unit at noon and is placed on mechanical ventilation. Interpret the initial arterial blood gas levels pH: 7.31 PaCO2: 48 mm Hg Bicarbonate: 22 mEq/L PaO2: 115 mm Hg O2 saturation: 99% a. Normal arterial blood gas levels with a high oxygen level b. Partly compensated respiratory acidosis; normal oxygen c. Uncompensated metabolic acidosis with high oxygen levels d. Uncompensated respiratory acidosis; hyperoxygenated ANS: D

The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis) and a normal bicarbonate level. No metabolic compensation has occurred.

DIF: Cognitive Level: Analyze/Analysis REF: Box 9-3 | Table 9-3 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases,NaUndRSnIoNnGinTvBa.sCivOeMtechniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. The provider orders the following mechanical ventilation settings for a patient who weighs 75

kg. The patient’s spontaneous respiratory rate is 22 breaths/min. Which arterial blood gas abnormality may occur if the patient continues to be tachypneic at these ventilator settings?

Settings: Tidal volume: 600 mL (8 mL per kg) FiO2: 0.5 Respiratory rate: 14 breaths/min Mode assist/control Positive end-expiratory pressure: 10 cm H2O a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: D

Assist/control ventilation may result in respiratory alkalosis, especially when the patient is breathing at a higher rate that the ventilator rate. Each time the patient initiates a spontaneous breath—in this case 22 times per minute—the ventilator will deliver 600 mL of volume.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 186

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OBJ: Relate complications associated with mechanical ventilation.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 3. A patient’s ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen

is increased from 0.6 to 0.7, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these adjustments, the nurse notes that the patient’s blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What is the most likely cause of this decrease in blood pressure? a. Decrease in cardiac output b. Hypovolemia c. Increase in venous return d. Oxygen toxicity ANS: A

Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return. Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the patient to identify optimal positive end-expiratory pressure—the highest amount that can be applied without compromising cardiac output.

Although hypovolemia can result in a decrease in blood pressure, there is no indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to the alveoli.

DIF: Cognitive Level: Analyze/Analysis REF: p. 184 | p. 196 OBJ: Relate complications associated with mechanical ventilation.

N U RSINGTB.COM TOP: Nursing Process Step: Evalua tio n MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse is caring for a patient with an endotracheal tube. The nurse understands that

endotracheal suctioning is needed to facilitate removal of secretions and that the procedure a. decreases intracranial pressure. b. depresses the cough reflex. c. is done as indicated by patient assessment. d. is more effective if preceded by saline instillation.

ANS: C

Suctioning is performed as indicated by patient assessment. Suctioning is associated with increases in intracranial pressure; therefore, it is important to hyperoxygenate the patient before suctioning to reduce this complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is associated with negative physiological outcomes and is not recommended as part of the suctioning procedure; it does not loosen secretions, which is a common misperception.

DIF: Cognitive Level: Understand/Comprehension OBJ: Discuss methods for maintaining an open airway.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 180

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5. A patient is admitted to the progressive care unit with a diagnosis of community-acquired

pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes.

A set of arterial blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg; bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect: a. hypoxemia and compensated metabolic alkalosis. b. hypoxemia and compensated respiratory acidosis. c. normal oxygenation and partly compensated metabolic alkalosis. d. normal oxygenation and uncompensated respiratory acidosis.

ANS: B

The PaO2 of 65 mm Hg is lower than normal range (80 to 100 mm Hg), indicating hypoxemia.

The high PaCO2 indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is normal, the underlying acid-base alteration is compensated.

Given the patient’s history of chronic pulmonary disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic with fully compensated respiratory acidosis.

DIF: Cognitive Level: Analyze/Analysis REF: Table 9-3 | Box 9-3 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. A patient’s status worsens and needs mechanical ventilation. The pulmonologist wants the

patient to receive 10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously between the mechanical breaths at his own tidal volume. This mode of ventilation is called a. assist/control ventilation. b. controlled ventilation. c. intermittent mandatory ventilation. d. positive end-expiratory pressure.

ANS: C

The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation, spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent mandatory and assist/control ventilation.

DIF: Cognitive Level: Apply/Application OBJ: Describe types and modes of mechanical ventilation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 186

7. A patient’s endotracheal tube is not secured tightly. The respiratory care practitioner assists

the nurse in taping the tube. After the tube is retaped, the nurse auscultates the patient’s lungs and notes that the breath sounds over the left lung fields are absent. The nurse suspects that a. the endotracheal tube is in the right mainstem bronchus.

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b. the patient has a left pneumothorax. c. the patient has aspirated secretions during the procedure. d. the stethoscope earpiece is clogged with wax.

ANS: A

The endotracheal tube can become dislodged during repositioning and is likely to be in the right mainstem bronchus. It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube. Aspiration may occur during the procedure but would be manifested in changes in the chest x-ray or by hypoxemia, for example. The stethoscope is not a factor.

DIF: Cognitive Level: Remember/Knowledge REF: p. 191 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 8. A mode of pressure-targeted ventilation that provides positive pressure to decrease the

workload of spontaneous breathing through the endotracheal tube is a. continuous positive airway pressure. b. positive end-expiratory pressure. c. pressure support ventilation. d. T-piece adapter.

ANS: C

Pressure support (PS) is a mode of ventilation in which the patient’s spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure.

Positive end-expiratory pressure pNroUvRiSdIeNsGpToBs.iCtiOvM e pressure at end expiration during mechanical breaths, and continuous positive airway pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen with spontaneous, unassisted breaths.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe types and modes of mechanical ventilation.

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 187 TOP: Nursing Process Step: N/A

9. The primary mode of action of neuromuscular blocking agents is a. analgesia. b. anticonvulsant. c. paralysis. d. sedation.

ANS: C

Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or anticonvulsant effects.

DIF: Cognitive Level: Remember/Knowledge REF: p. 198 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. One of the early signs of hypoxemia on the nervous system is

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Sole: Introduction to Critical Care Nursing,8E

cyanosis. restlessness. agitation. tachypnea.

ANS: B

Decreased oxygenation to the nervous system may result in restlessness and agitation—early signs of hypoxemia. Cyanosis is a late sign. Tachypnea may occur, but CNS changes tend to occur earlier. Agitation is not usually seen with hypoxemia.

DIF: Cognitive Level: Remember/Knowledge REF: Box 9-1 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. The amount of effort needed to maintain a given level of ventilation is termed a. compliance. b. resistance. c. tidal volume. d. work of breathing.

ANS: D

Work of breathing is the amount of effort needed to maintain a given level of ventilation.

Compliance is a measure of the distensibility, or stretchability, of the lung and chest wall.

Resistance refers to the opposition to the flow of gases in the airways. Tidal volume is the volume of air in a typical breath.

DIF: Cognitive Level: R e m e m b e r / KN nUoRwSlIeNdGg eT B . C O M REF: p. 162 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. Which of the following devices is best suited to deliver 65% oxygen to a patient who is

spontaneously breathing? a. Face mask with non-rebreathing reservoir b. Low-flow nasal cannula c. Simple face mask d. Venturi mask ANS: A

Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or 60% to 80% (non-rebreather), depending on the flowmeter setting, the fit of the mask, and the patient’s respiratory pattern. The high-flow nasal cannula, not the traditional low-flow models, can provide higher flows. The simple face mask can deliver flows up to 60%. The Venturi mask allows better regulation of oxygen concentration and generally does not deliver more than 60% oxygen.

DIF: Cognitive Level: Remember/Knowledge OBJ: Compare commonly used oxygen delivery devices.

TOP: Nursing Process Step: Planning

REF: p. 172

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MSC: NCLEX Client Needs Category: Physiological Integrity 13. A patient is being mechanically ventilated in the synchronized intermittent mandatory

ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min.

He receives a dose of morphine sulfate, and his spontaneous respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: C

The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis.

DIF: Cognitive Level: Apply/Application REF: p. 193 | Box 9-2 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 14. A patient is being mechanically ventilated in the synchronized intermittent mandatory

ventilation mode at a rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min.

He receives a dose of morphine sulfate, and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patient’s ventilator settings? a. Add positive end-expiratory pressure (PEEP). b. Add pressure support. c. Change to assist/control ventilation at a rate of 4 breaths/min.

UR S IN G TB . C O M d. Increase the synchronized i nt eNrm i t t e nt m a n d a t ory ventilation respiratory rate.

ANS: D

The morphine caused respiratory depression. As a result, the frequency and depth of respiration is compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to be increased. PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is an option; however, the rate needs to be set higher than 4 breaths/min.

DIF: Cognitive Level: Analyze/Analysis REF: p. 186 OBJ: Relate complications associated with mechanical ventilation.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 15. Current guidelines recommend the oral route for endotracheal intubation. The rationale for

this recommendation is that nasotracheal intubation is associated with a greater risk for a. basilar skull fracture. b. cervical hyperextension. c. impaired ability to “mouth” words. d. sinusitis and infection.

ANS: D

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Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilator-associated infection. Nasal intubation is contraindicated in patients with basilar skull fracture. The procedure is sometimes performed in patients with cervical spine injury; the procedure can be done without hyperextending the neck. Patients with nasotracheal tubes are generally more comfortable and have a greater ability to “mouth words.”

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss methods for maintaining an open airway.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 191

16. Oxygen saturation (SaO2) represents a. alveolar oxygen tension. b. oxygen that is chemically combined with hemoglobin. c. oxygen that is physically dissolved in plasma. d. total oxygen consumption.

ANS: B

Oxygen saturation value reflects the saturation of the hemoglobin. It does not represent alveolar oxygen tension, oxygen that is dissolved in plasma, or total oxygen consumption.

DIF: Cognitive Level: Remember/Knowledge REF: p. 165 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. Pulse oximetry measures a. arterial blood gases. b. hemoglobin values. c. oxygen consumption. d. oxygen saturation.

ANS: D

Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases, but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels or oxygen consumption.

DIF: Cognitive Level: Understand/Comprehension REF: p. 169 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. A PaCO2 of 48 mm Hg is associated with a. hyperventilation. b. hypoventilation. c. increased absorption of O2. d. increased excretion of HCO3.

ANS: B

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PaCO2 rises in patients with hypoventilation. Hyperventilation results in a decrease in PaCO2.

PaCO2 does not affect oxygen absorption. Increased excretion of bicarbonate would result in metabolic acidosis.

DIF: Cognitive Level: Remember/Knowledge REF: Box 9-2 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse notes that the patient’s arterial blood gas levels indicate hypoxemia. The patient is

not intubated and has a respiratory rate of 22 breaths/min. The nurse’s first intervention to relieve hypoxemia is to: a. call the provider for an emergency intubation procedure. b. obtain an order for bilevel positive airway pressure (BiPAP). c. notify the provider of values and obtain a prescription for oxygen. d. suction secretions from the oropharynx.

ANS: C

Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in cases of hypoxemia. Emergency intubation is not warranted at this time.

BiPAP may be considered if administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient requires suctioning.

DIF: Cognitive Level: Analyze/Analysis REF: p. 171 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 20. A patient presents to the emergency department demonstrating agitation and complaining of

numbness and tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The nurse interprets these blood gas values as: a. compensated metabolic alkalosis. b. normal values. c. uncompensated respiratory acidosis. d. uncompensated respiratory alkalosis.

ANS: D

The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.

DIF: Cognitive Level: Analyze/Analysis REF: Box 9-2 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 21. Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the

following condition: a. Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume. b. For each spontaneous breath taken by the patient, the tidal volume is determined

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by the patient’s ability to generate negative pressure. c. The patient must have a respiratory drive, or no breaths will be delivered. d. There is pressure remaining in the lungs at the end of expiration that is measured in

cm H2O. ANS: D

PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters of water.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe types and modes of mechanical ventilation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 183-184

22. The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care,

the nurse understands that a. communication with intubated patients is often difficult. b. controlled ventilation is the preferred mode for most patients. c. patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation. d. wrist restraints are applied to all patients to avoid self-extubation.

ANS: A

Communication difficulties are common because of the artificial airway. Restraints must be determined individually. Patients with chronic obstructive pulmonary disease often have difficulty weaning. Synchronized intermittent mandatory ventilation and assist/control ventilation are the commonly used modes.

DIF: Cognitive Level: Remember/Knowledge REF: p. 198 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 23. A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the

patient for which potential cause of this difficult weaning? a. Cardiac output of 6 L/min. b. Hemoglobin of 8 g/dL. c. Negative sputum culture and sensitivity. d. White blood cell count of 8000.

ANS: B

The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence of infection, which should promote rather than hinder weaning.

DIF: Cognitive Level: Analyze/Analysis REF: Box 9-10 OBJ: Explain methods for weaning patients from mechanical ventilation.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

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24. A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery with the

following arterial blood gas (ABG) levels. What action by the nurse is best? pH: 7.4 PaCO2: 40 mm Hg Bicarbonate: 24 mEq/L PaO2: 95 mm Hg O2 saturation: 97% Respirations: 20 breaths/min a. Call the provider to request rapid intubation. b. Document the findings and continue to monitor. c. Request that another set of ABGs be drawn and run. d. Correlate the patient’s O2 saturation with the ABGs. ANS: B

These are normal values. All parameters are within normal limits. No action other than documentation and continued observation is warranted.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 167-168 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 25. A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four

hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. The following information pertains to the 1900 assessment.

Assessments and Vital Signs Restless Increased to 110 beats/min Respirations 36 breaths/min

Blood pressure 156/98 mm Hg Sinus tachycardia 10 PVCs/min Elevated pulmonary artery pressure Loud crackles throughout New ABGs: pH: 7.28 PaCO2: 46 mm Hg Bicarbonate: 22 mEq/L PaO2: 58 mm Hg O2 saturation: 88% What action by the nurse is best? a. Prepare for rapid intubation. b. Increase the patient’s oxygen. c. Prepare to administer a diuretic.

Nursing Action Performs complete assessment Suctions patient for pink, frothy secretions Obtains prescriptions from provider for ABGs, electrolyte levels, and portable chest x-ray

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d. Change the ventilator settings.

ANS: C

These levels show respiratory acidosis. The bicarbonate is normal; therefore, no compensation has occurred. This patient is also hypoxemic. The sputum indicates pulmonary edema. The nurse should prepare to administer a diuretic. The patient is already intubated. Increasing the oxygen by itself will not correct the situation. The ventilator settings may need to be changed; however, this is not usually performed by the nursing staff. The priority for the nurse is to address the problem.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 167-168 | Box 9-2 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 26. A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery. Four

hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. The following information pertains to the 1900 assessment.

Assessments and Vital Signs Restless Increased to 110 beats/min Respirations 36 breaths/min

Nursing Action Performs complete assessment Suctions patient for pink, frothy secretions Obtains prescriptions from provider for ABGs, electrolyte levels, and portable h.eCsO tM x-ray NURSINGTcB

Blood pressure 156/98 mm Hg Sinus tachycardia 10 PVCs/min Elevated pulmonary artery pressure Loud crackles throughout New ABGs: pH: 7.28 PaCO2: 46 mm Hg Bicarbonate: 22 mEq/L PaO2: 58 mm Hg O2 saturation: 88% What interdisciplinary staff member does the nurse notify to assist in the care of this patient while preparing to give this patient diuretics? a. Respiratory therapist to adjust ventilator b. Social worker to notify family c. Phlebotomy to obtain another set of blood gasses d. Nursing assistant to help reposition the patient ANS: A

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The next step for this patient is most likely ventilator setting changes as the patient was originally attempting to wean and now the patient’s condition has deteriorated. The nurse calls the respiratory therapist for this. A social worker may be needed, but the question does not have information about family issues. The patient will need more lab drawn, but this is not the priority. Repositioning the patient is important for many reasons, but again is not the priority action.

DIF: Cognitive Level: Analyze/Analysis REF: p. 200 OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of arterial blood gases, and noninvasive techniques.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 27. The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm

sounding. The nurse cannot quickly identify the cause of the alarm and notes the patient’s oxygen saturation is decreasing and heart rate and respiratory rate are increasing. The nurse’s priority action is to a. ask the respiratory therapist to get a new ventilator. b. call the rapid response team to assess the patient. c. continue to find the cause of the alarm and fix it. d. manually ventilate the patient while calling for a respiratory therapist.

ANS: D

The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory therapist. Continuing to assess for the cause NURSINGTB.COM without manually ventilating the patient can result in patient compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the situation.

DIF: Cognitive Level: Analyze/Analysis REF: p. 197 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 28. The nurse is caring for a patient whose ventilator settings include 15 cm H 2O of positive

end-expiratory pressure (PEEP). What complication does the nurse assess the patient for? a. Fluid overload secondary to decreased venous return b. High cardiac index secondary to more efficient ventricular function c. Hypoxemia secondary to prolonged positive pressure at expiration d. Low cardiac output secondary to increased intrathoracic pressure ANS: D

Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index secondary to increased intrathoracic pressure, which impedes venous return.

Fluid overload is not an expected finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat hypoxemia; it does not cause it.

DIF: Cognitive Level: Analyze/Analysis

REF: p. 184 | p. 194

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OBJ: Relate complications associated with mechanical ventilation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 29. When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect

of hypoxemia on the cardiovascular system is a. heart block. b. restlessness. c. tachycardia. d. tachypnea.

ANS: C

Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation. Dysrhythmias may occur; however, they are not an early sign and tend to be premature ventricular contractions. Restlessness is an early neurological sign, whereas tachypnea is an early respiratory sign.

DIF: Cognitive Level: Remember/Knowledge REF: Box 9-1 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 30. The nurse is caring for a mechanically ventilated patient. The providers are considering

performing a tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to tracheostomy, the nurse understands which of the following? a. Patient outcomes are better if the tracheostomy is done within a week of intubation. b. Percutaneous tracheostomy caN nUbReSdIN onGeTB sa.CfeOlM y at the bedside by the respiratory therapist. c. Procedures performed in the operating room are associated with fewer complications. d. The greatest risk after a percutaneous tracheostomy is accidental decannulation.

ANS: D

Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not associated with any higher risks than those done in the operating room.

Trained physicians safely perform percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental decannulation because the trachea is not surgically attached.

DIF: Cognitive Level: Remember/Knowledge REF: p. 178 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 31. The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient.

The rationale for this assessment is to a. assess for tension pneumothorax. b. assess the level of positive end-expiratory pressure. c. compare the tidal volume delivered with the tidal volume prescribed. d. determine the patient’s work of breathing.

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ANS: C

The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed.

Volume may be lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of breathing.

DIF: Cognitive Level: Remember/Knowledge REF: p. 184 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory

pressure alarm. Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that apply.) a. Coughing or attempting to talk b. Disconnection from the ventilator c. Kinks in the ventilator tubing d. Need for suctioning e. Spontaneous breathing ANS: A, C, D

Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm, not a high-pressure alarm. Spontaneous breathing does not trigger alarms.

DIF: Cognitive Level: Analyze/Analysis REF: Table 9-4 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Select all of the factors that may predispose the patient to respiratory acidosis. (Select all that

apply.) a. Anxiety and fear b. Central nervous system depression c. Diabetic ketoacidosis d. Nasogastric suctioning e. Overdose of sedatives ANS: B, E

Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis.

DIF: Cognitive Level: Remember/Knowledge REF: Box 9-2 OBJ: Review the anatomy and physiology of the respiratory system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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3. The nurse is assisting with endotracheal intubation and understands that correct placement of

the endotracheal tube in the trachea would be identified by which of the following? (Select all that apply.) a. Auscultation of air over the epigastrium b. Equal bilateral breath sounds upon auscultation c. Position above the carina verified by chest x-ray d. Positive detection of carbon dioxide (CO2) through CO2 detector devices e. Fogging of the endotracheal tube ANS: B, C, D

The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather than the trachea. Fogging of the ET tube does not indicate correct placement.

DIF: Cognitive Level: Remember/Knowledge REF: p. 177 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment ORDERING 1. The nurse is caring for a mechanically ventilated patient and is charting outside the patient’s

room when the ventilator alarm sounds. What is the priority order for the nurse to complete these actions: , , , ? a. check quickly for possible causes of the alarm that can be fixed b. after troubleshooting, connect back to mechanical ventilator and reassess patient c. go to patient’s bedside d. manually ventilate the patient while getting a respiratory therapist ANS:

C, A, D, B The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting the problem. Once the problem has been corrected, the patient must be reassessed.

DIF: Cognitive Level: Apply/Application REF: pp. 190-191 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 2. The nurse is assisting with endotracheal intubation of the patient and recognizes that the

procedure will be done in what order: , ,

,

, ?

a. assess balloon on endotracheal tube for symmetry and leaks

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b. assess lung fields for bilateral expansion c. inflate balloon of endotracheal tube d. insert endotracheal tube with laryngoscope and blade e. suction oropharynx ANS:

A, E, D, C, B Intubation is done systematically by the physician, therapist, or anesthetist. Equipment is gathered and assessed (e.g., balloon/cuff on endotracheal tube). The patient is hyperoxygenated and secretions are suctioned from the oropharynx to visualize the vocal cords. The tube is inserted, and the balloon is inflated once the tube is in place. The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide testing, and chest x-ray.

DIF: Cognitive Level: Analyze/Analysis REF: p. 175 | p. 177 OBJ: Formulate a plan of care for the mechanically ventilated patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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Chapter 10: Rapid Response Teams and Code Management Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse chooses which method and concentration of oxygen administration until intubation

is established in a patient who has sustained a cardiopulmonary arrest? a. Bag-valve-mask at FiO2 of 100% b. Bag-valve-mask at FiO2 of 50% c. Mouth-to-mask ventilation with supplemental oxygen d. Non-rebreather mask at FiO2 of 100% ANS: A

Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.

DIF: Cognitive Level: Apply/Application REF: p. 212 | Table 10-3 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside

a hospital setting? a. Automatic external defibrillator b. Carbon dioxide detector c. Pocket mask d. Transcutaneous pacemaker ANS: A

Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.

DIF: Cognitive Level: Understand/Comprehension OBJ: Identify equipment used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 218

3. When doing manual ventilations during a code, the nurse would administer ventilations

following which guideline? a. Approximately 8 to 10 breaths per minute b. During the fifth chest compression c. Every 3 seconds or 20 times per minute d. While compressions are stopped ANS: A

Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

DIF: Cognitive Level: Apply/Application REF: p. 212 | Table 10-3 OBJ: Differentiate basic and advanced life-support measures used during a code.

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TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. The patient has been admitted to a critical care unit with a diagnosis of acute myocardial

infarction. Suddenly the monitor alarms and the screen shows a flat line. What action should the nurse take first? a. Administer epinephrine by intravenous push. b. Begin chest compressions. c. Check patient for unresponsiveness. d. Defibrillate at 360 J. ANS: C

The first intervention is to assess unresponsiveness.

DIF: Cognitive Level: Apply/Application REF: p. 214 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. During a code, the nurse would place paddles for anterior defibrillation in what locations? a. Second intercostal space, left sternal border and fourth intercostal space, left

midclavicular line b. Second intercostal space, right sternal border and fourth intercostal space, left

midaxillary line c. Second intercostal space, right sternal border and fifth intercostal space, left

midclavicular line d. Fourth intercostal space, right sternal border and fifth intercostal space, left

midclavicular line ANS: C

Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.

DIF: Cognitive Level: Apply/Application REF: p. 216 | Figure 10-8 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. During cardioversion, the nurse would synchronize the electrical charge to coincide with

which wave of the ECG complex? a. P b. R c. S d. T ANS: B

During cardioversion, the electrical shock is synchronized to deliver shock on the R wave.

This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.

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DIF: Cognitive Level: Understand/Comprehension OBJ: Identify equipment used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 218

7. The nurse knows that in advanced cardiac life support, the secondary survey includes steps

A-B-C-D, in which “D” refers to: a. defibrillate. b. differential diagnosis. c. diltiazem intravenous push. d. do not resuscitate.

ANS: B

The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support (ACLS) secondary survey involves the performance of more in-depth assessments and interventions. Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a specific therapy can be initiated.

DIF: Cognitive Level: Apply/Application REF: p. 213 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 8. The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse

prepares which medication to administer to the patient? a. Adenosine b. Amiodarone c. Diltiazem d. Procainamide ANS: A

Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is administered rapidly.

DIF: Cognitive Level: Apply/Application REF: p. 215 | Table 10-4 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2

minutes, what is the next action to take? a. Administer amiodarone. b. Administer lidocaine. c. Assess rhythm and pulse. d. Prepare for transcutaneous pacing.

ANS: C

Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.

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Cognitive Level: Apply/Application

REF: p. 214

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OBJ: Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 10. The patient’s monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature

ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug? a. Atropine 0.5 to 1 mg intravenous push b. Dopamine drip—continuous infusion c. Lidocaine 1 mg/kg intravenous push d. Transcutaneous pacemaker ANS: A

This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg.

Atropine is not indicated in second-degree atrioventricular (AV) block type II or third-degree AV block.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 214-214 | Table 10-4 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 11. The monitor technician notifies the nurse “stat” that the patient has a rapid, chaotic rhythm

that looks like ventricular tachycardia. What is the nurse’s first action? a. Call a code overhead. b. Check the patient immediately. c. Go to the nurses’ station and lN ooUkRSaItNthGeTB rh.CyO thM m strip. d. Take the crash cart to the room.

ANS: B

The first intervention in this situation is to assess unresponsiveness by checking the patient.

DIF: Cognitive Level: Analyze/Analysis REF: p. 211 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. Which rhythm would be an emergency indication for the application of a transcutaneous

pacemaker? a. Asystole b. Bradycardia (heart rate 40 beats/min), normotensive and alert c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope d. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive ANS: C

Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine. This patient is symptomatic.

DIF: Cognitive Level: Apply/Application REF: p. 215 | Table 10-4 OBJ: Discuss treatment of special problems that can occur during a code.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. A patient is admitted to the coronary care unit with an inferior wall myocardial infarction and

develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug? a. Amiodarone b. Atropine c. Lidocaine d. Magnesium ANS: B

Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with symptomatic bradycardia.

DIF: Cognitive Level: Apply/Application REF: p. 215 | Table 10-4 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 14. A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug? a. Adenosine b. Atropine c. Lidocaine d. Magnesium ANS: C

Lidocaine is an antidysrhythmic dNr uUgR tShI Na tGsTuBp.pCrOe sMs e s ventricular ectopic activity.

DIF: Cognitive Level: Analyze/Analysis REF: p. 223 | Table 10-4 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 15. It is determined that the patient needs a transcutaneous pacemaker until a transvenous

pacemaker can be inserted. What is the most appropriate nursing intervention? a. Apply conductive gel to the skin. b. Provide adequate sedation and analgesia. c. Recheck leads to make sure that the rhythm is asystole. d. Set the milliamperes to 2 mA below the capture level.

ANS: B

The alert patient who requires transcutaneous pacing may experience some discomfort.

Because the skeletal muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be indicated.

DIF: Cognitive Level: Analyze/Analysis REF: p. 220 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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16. The nurse needs to evaluate arterial blood gases before the administration of which drug? a. Calcium chloride b. Magnesium sulfate c. Potassium d. Sodium bicarbonate ANS: D

Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial blood gas analysis or laboratory measurement.

DIF: Cognitive Level: Apply/Application REF: p. 224 | Table 10-4 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 17. During a code situation, the nurse would prepare to use which preferred intravenous fluid? a. 5% dextrose in 0.45% normal saline b. 5% dextrose in water c. Dopamine infusion d. Normal saline ANS: D

Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular volume better than infusions containing dextrose.

DIF: Cognitive Level: Understand/Comprehension REF: p. 209 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: NursingNPUrRoSceINssGSTtBep.C: O Im Mplementation MSC: NCLEX Client Needs Category: Physiological Integrity 18. A nursing home patient is admitted to the critical care unit with a severe case of pneumonia.

No living will or designation of health care surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse’s action? a. Activate the code team, but initiate a “slow” code. b. Call the nursing home to determine the patient’s or family’s wishes. c. Code the patient for 5 minutes and then cease efforts. d. Initiate intubation and/or cardiopulmonary resuscitation efforts.

ANS: D

In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must be initiated if indicated.

DIF: Cognitive Level: Analyze/Analysis REF: p. 205 OBJ: Identify psychosocial, legal, and ethical issues related to code management.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 19. A patient is brought to the critical care unit after a motor vehicle crash. On admission, the

patient reports dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. The patient suddenly experiences cardiac arrest.

What assessment by the nurse takes priority?

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Heart tones Lung sounds Peripheral pulses Neurological status

ANS: B

The nurse should listen to lung sounds first. The signs and symptoms the patient experienced are consistent with a tension pneumothorax, which is a reversible cause of cardiac arrest. A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest pain, tachypnea, tachycardia, and jugular venous distension.

DIF: Cognitive Level: Analyze/Analysis REF: Box 10-2 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 20. The patient has pulseless electrical activity (PEA). What action by the nurse takes priority? a. Begin high-quality CPR. b. Assist with chest tube placement. c. Prepare equipment for a pericardiocentesis. d. Attach the patient to a transcutaneous pacemaker.

ANS: A

A patient in PEA does not have a pulse or blood pressure. The nurse initiates high-quality CPR. Chest tube insertion, pericardiocentesis, and transcutaneous pacing are not required.

DIF: Cognitive Level: Apply/Application REF: p. 214 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 21. What is the major reason for using a treatment to lower body temperature after cardiac arrest

to promote better neurological recovery? a. Hypothermia decreases the metabolic rate by 7% for each decrease of 1 C. b. Lower body temperatures are beneficial in patients with low blood pressure. c. Temperatures of 40 C may reduce neurological impairment. d. The lower body temperature leads to decreased oxygen delivery.

ANS: A

Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1 C in temperature; decreased metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32 C to 34 C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 227-228 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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22. The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS

complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following? a. Obtain a 12-lead electrocardiogram (ECG). b. Call for a pacemaker interrogation. c. Palpate the pulse. d. Run a 2-minute monitor strip for analysis.

ANS: C

The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a pacemaker “spike” that indicates that the pacemaker is initiating electrical activity.

The spike is followed by a broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.

DIF: Cognitive Level: Analyze/Analysis REF: p. 220 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus

rhythm. Upon further assessment, it is noted that the patient is hypotensive. The appropriate treatment for her hypotension may include (Select all that apply) a. adenosine. b. dopamine infusion. c. magnesium. d. normal saline infusion. e. sodium bicarbonate.

ANS: B, D

The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected. Adenosine, magnesium, and sodium bicarbonate are not indicated in this situation.

DIF: Cognitive Level: Apply/Application REF: p. 213 | Table 10-4 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min

and frequent premature ventricular contractions. The nurse notes that the patient is lethargic and reports dizziness for the past 12 hours. Which of the following are acceptable initial treatments for this patient? (Select all that apply.) a. Atropine b. Epinephrine c. Lidocaine d. Transcutaneous pacemaker e. Magnesium sulfate infusion ANS: A, D

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Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine infusion can be used if atropine is not effective but it is not a first-line choice. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min. Magnesium is not indicated for bradycardia.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 214-215 | Box 10-3 OBJ: Identify medications used in code management, including use, action, side effects, and nursing implications.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 3. Ventricular fibrillation should initially be treated by which of the following? (Select all that

apply) a. Administration of amiodarone, followed by defibrillation at 360 J b. Atropine 1 mg, followed by defibrillation at 200 J c. Defibrillation at 200 J with biphasic defibrillation d. Defibrillation at 360 J with monophasic defibrillation e. Dopamine continuous infusion.

ANS: C, D

If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks. Dobutamine is used for hypotension not related to hypovolemia.

Amiodarone can be used for ventricular fibrillation not responsive to CPR, defibrillation, and vasopressors. Atropine is not useNdUiRn StIhNi Gs TsiBt u. CaOt iM on.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 213-214 OBJ: Discuss treatment of special problems that can occur during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. Which code drugs can be given safely through an endotracheal tube? (Select all that apply) a. Adenosine b. Atropine c. Epinephrine d. Vasopressin e. Amiodarone ANS: B, C, D

Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.

DIF: Cognitive Level: Understand/Comprehension REF: Table 10-4 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 5. Which of the following statements about defibrillation are correct? (Select all that apply) a. Early defibrillation (if warranted) is recommended before other actions. b. It is not necessary to ensure that personnel are clear of the patient if hands-off

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defibrillation is used. c. It is not necessary to synchronize the defibrillation shocks. d. Paddles/patches can be placed anteriorly and posteriorly on the chest. e. All models of defibrillators are the same for standardization.

ANS: A, C, D

Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement. Defibrillators come in many models, and nurses must ensure they are familiar with the model in use on their unit.

DIF: Cognitive Level: Apply/Application REF: pp. 215-216 OBJ: Differentiate basic and advanced life-support measures used during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. Postresuscitation goals include which of the following? (Select all that apply) a. Control dysrhythmias b. Maintain airway c. Maintain blood pressure d. Wean off oxygen e. Early ambulation ANS: A, B, C

Postresuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and c oNn Ut r Ro Sl IoNf GdTyBs .rChOytMhm ia s. Weaning off oxygen and early ambulation are good actions when possible but are not goals of postresuscitation care.

DIF: Cognitive Level: Apply/Application OBJ: Describe care of patients after resuscitation.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 225 |p. 227

7. Which of the following are documented as part of the cardiopulmonary arrest record? (Select

all that apply) a. Medication administration times b. Defibrillation times, joules, outcomes c. Rhythm strips of cardiac rhythm(s) noted d. Signatures of recorder and other personnel e. Model of defibrillator used.

ANS: A, B, C, D

Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the patient’s response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation and defibrillation (and the energy used) must be documented, along with the patient’s response. The time and sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be accurately recorded. Rhythm strips are recorded to document events and response to treatment.

Signatures of those involved in the code effort, including the recorder, are essential.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 225 | Figure 10-15 OBJ: Identify information to be documented during a code.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 8. Benefits of having the family present during resuscitation include which of the following?

(Select all that apply) a. Facilitates the grief process b. Lets the family see that everything is being done c. Sustains patient-family relationships d. Allows the staff easy access to ask for organ transplant e. Provides a sense of closure ANS: A, B, C, E

Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.

DIF: Cognitive Level: Analyze/Analysis REF: p. 227 OBJ: Identify psychosocial, legal, and ethical issues related to code management.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 9. The nurse should call the rapid response team for which patients? (Select all that apply) a. 53-year-old with pneumonia and severe respiratory distress b. 17-year-old with apnea following a severe head injury TB c. 24-year-old experiencing a sevNeUreRSaIsNthGm at. iCcOaMttack with stridor d. 73-year-old patient with bradycardia of 40 beats per minute e. 52-year-old patient with no palpable pulse ANS: A, C, D

Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient’s clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.

DIF: Cognitive Level: Analyze/Analysis REF: p. 205 OBJ: Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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Chapter 11: Organ Donation Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient who has a Glasgow Coma Scale (GCS) score of 3.

Discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation? a. “I need to notify the local Organ Procurement Organization of my patient’s impending death.” b. “I will contact the provider to obtain informed consent for organ donation.” c. “The charge nurse will notify the local Organ Procurement Organization once the patient has been pronounced brain dead.” d. “I need the physician to evaluate my patient’s suitability for organ donation.”

ANS: A

Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the provider, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur before death, not after the patient has been pronounced dead.

DIF: Cognitive Level: Understand/Comprehension REF: p. 233 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: ImplemNeUnR taStiIoNnGTB.COM MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 2. The nurse is managing a donor patient six hours before the scheduled harvesting of the

patient’s organs. Which assessment finding requires immediate action by the nurse? a. Morning serum blood glucose of 128 mg/dL b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L c. Pulmonary artery temperature of 97.8° F d. Central venous pressure of 8 mm Hg ANS: B

Donor management focuses on maintaining hemodynamic stability and normal laboratory parameters. Standardized order sets are usually used, and they focus on preserving organ function and viability. Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L. The finding indicates metabolic acidosis. All other values are within normal limits.

DIF: Cognitive Level: Analyze/Analysis REF: p. 239 OBJ: Describe clinical triggers associated with brain death.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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3. The charge nurse is reviewing the status of patients in the critical care unit. Regarding which

patient should the nurse notify the organ procurement organization to evaluate for possible organ donation? a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram b. A 68-year-old patient admitted with unstable atrial fibrillation who has suffered a stroke c. A 40-year-old brain-injured patient with a history of ovarian cancer and a Glasgow Coma Scale score of 7 d. A 53-year-old diabetic with a history of unstable angina status postresuscitation ANS: A

A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.

DIF: Cognitive Level: Apply/Application REF: Table 11-4 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal

disease, whose blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best qualifies for evaluation? a. A 65-year-old brother with a history of hypertension; blood type A positive b. A 35-year-old female with a history of food allergies; blood type O negative c. A 14-year-old son, otherwise h e a lt h y w it h n o hist ory; blood type B negative N U R S I NG T B . C O M d. A 70-year-old mother, with a history of sinus infections; blood type A positive ANS: B

To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease, and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food allergies and a blood type of O negative (universal donor) best qualifies for evaluation. The brother and mother, although blood-type compatible, are outside acceptable age ranges for living donation. The minor son does not qualify based on blood type.

DIF: Cognitive Level: Apply/Application REF: p. 239 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Adaptation 5. The nurse is caring for a patient who is being evaluated clinically for brain death. Which

assessment finding supports brain death? a. Absence of a corneal reflex b. Unequal, reactive pupils c. Withdrawal from painful stimuli d. Core temperature of 100.8° F ANS: A

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Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain core temperature indicate brainstem activity.

DIF: Cognitive Level: Understand/Comprehension REF: Table 11-3 OBJ: Describe clinical triggers associated with brain death.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity—Physiological Adaptation 6. The nurse often assists with brain-death testing. Which patient might have confounding

factors for this testing? a. Patient post motorcycle crash with C2-C3 fracture b. Patient with massive hemorrhagic stroke c. Patient with long-standing neuromuscular disease d. Patient with flail chest and paradoxical chest wall motion.

ANS: A

High spinal cord injury is a confounding factor as it can yield absent responses to brainstem testing with preserved brain/brainstem function. The other scenarios would not have confounding factors.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe clinical triggers associated with brain death.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Table 11-5

7. The nurse is caring for a mechanically ventilated patient following bilateral lung

transplantation. When planning t hNe Uc Ra rSeI NoGf TthBi.sC pOaMtient, what is the priority nursing intervention? a. Thirty-degree elevation of head of bed b. Endotracheal suctioning as needed c. Frequent side to side repositioning d. Sequential compression stockings ANS: B

Denervation of the lung that occurs during lung transplantation causes changes in mucous production and ciliary movement. As a result, to promote the drainage of secretions and prevent mucous plugging, endotracheal and oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed elevation, side to side repositioning, and application of sequential compression stockings are appropriate nursing interventions, but they are not the priority intervention.

DIF: Cognitive Level: Apply/Application REF: p. 244 Lung Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 8. A family member of a gravely ill child approaches the child’s nurse and states, “We want to

donate our child’s organs.” What is the best action by the nurse? a. Arrange a multidisciplinary meeting with physicians. b. Consult the hospital’s ethics committee for a ruling. c. Notify the organ procurement organization (OPO).

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d. Obtain family consent to withdraw life support.

ANS: C

It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary meeting with physicians and consulting the hospital’s ethics committee are inappropriate actions in this scenario. Informed consent to withdraw life support is provided by the provider.

DIF: Cognitive Level: Apply/Application REF: p. 233 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 9. The nurse is caring for a patient in the critical care unit who, after being declared brain dead,

is being managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control ventilation. The oxygen saturation (SpO 2) is 99% and core temperature 93.8° F. Which provider prescription should the nurse implement first? a. Apply forced-air warming device to keep temperature 96.8 F. b. Obtain basic metabolic panel every 4 hours until surgery. c. Begin phenylephrine (Neo-Synephrine) for systolic BP <90 mm Hg. d. Draw arterial blood gas every 4 hours until surgery.

ANS: C

Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a p h e n y Nl eUp Rh rSiInNeG(TNBe. Co O- SMynephrine) infusion to get systolic BP >90 mm Hg. Maintaining normothermia is the next priority. Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this scenario.

DIF: Cognitive Level: Apply/Application REF: Table 11-6 OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 10. The charge nurse of a transplant unit is reviewing the clinical course of several transplant

patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post-op with a 3/10 pain level b. Lung transplant recipient, 1 day post-op with a productive cough c. Heart transplant recipient, 1 day post-op with a cardiac output of 4 L/min d. Liver transplant recipient, 2 days post-op with a serum creatinine of 3.7 mg/dL ANS: D

One complication of liver transplant is renal failure. The patient with the elevated serum creatinine requires immediate action. Postoperative pain level of 3/10 in a renal transplant patient, a lung transplant patient with a productive cough, and a heart transplant recipient with a cardiac output of 4 L/min are normal or expected findings, requiring no immediate action.

DIF: Cognitive Level: Apply/Application REF: p. 247 Liver Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant

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procedures.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Blood

pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula; temperature is 97.8° F; and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely. b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician. c. Apply thermal warming blanket; administer all fluids through warming device. d. Assess the patient for pain; administer pain medications as ordered.

ANS: A

Fluid replacement therapy is a priority in a postoperative renal transplant patient; a CVP of 2 mm Hg and elevated heart rate indicate hypovolemia. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 245 Kidney Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse is caring for a postoperative renal transplant recipient from a cadaver donor in the U Ra lS IuNr G critical care unit. After seeing m i nNi m i nTeBo. Cu Ot pMu t in the catheter for most of the day, the patient expresses concern to the nurse. What is the best response by the nurse? a. “Your kidney has unfortunately failed and will be removed.” b. “It can take a few days for your kidney to start working.” c. “You are experiencing an acute rejection episode.” d. “You will have to have daily hemodialysis until a new donor is found.”

ANS: B

There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold times, altered perfusion states during surgery). A kidney from a cadaver may not function immediately, and hemodialysis may be needed until it functions adequately. This is not necessarily a sign that the kidneys have failed and need removal or that the patient is experiencing acute rejection. There is also no indication that a retransplant needs to occur.

DIF: Cognitive Level: Understand/Comprehension REF: p. 245 Kidney Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity—Physiological Adaptation 13. A patient being cared for in the ICU before organ donation shows increased PVCs on the

cardiac monitor What medication does the nurse prepare to administer first? a. Nitroprusside b. Esmolol

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c. Dobutamine d. Normal saline ANS: B

Esmolol is a beta blocker used to control tachycardia and decrease myocardial oxygen consumption from catecholamine release, and it protects heart muscle from ischemia. An increase in PVCs indicates increased cardiac irritability, perhaps from cellular ischemia. The other drugs would not be indicated.

DIF: Cognitive Level: Analyze/Analysis REF: Table 11-6 OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is caring for a patient following a bilateral lung transplant. When planning

postoperative care of the patient, priority is placed on pulmonary hygiene. Which statement provides the best explanation for this priority? a. Immunosuppressant medications reduce the body’s ability to fight infections. b. During the early postoperative period, atelectasis decreases oxygenation. c. Pulmonary hygiene reduces the risk of early primary graft dysfunction. d. Loss of cough reflex results in decreased ability to remove secretions effectively.

ANS: D

Nerves of the autonomic nervous system are severed during lung transplant surgery. This results in denervation of the lung and loss of the cough reflex. Loss of this reflex places the patient at greater risk for infection because of the potential inability to clear secretions effectively. Although immunosuppressant medications reduce the body’s ability to fight infections, this is a general e xpla nNa tUi oRnS IfNoGr Ta Bll . CinOcM r eased risk of infection in transplant recipients. Atelectasis decreases oxygenation. The primary reason for pulmonary hygiene is to expectorate secretions. Primary graft dysfunction is caused by ischemia, surgical trauma, or denervation and is similar to acute respiratory distress syndrome.

DIF: Cognitive Level: Understand/Comprehension REF: p. 244 Lung Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 15. While following up on a postoperative renal transplant recipient, the nurse discovers that the

patient tested positive for cytomegalovirus (CMV). What is the priority action by the nurse? a. Notify the OPO transplant coordinator. b. Verify results with the lab technician. c. Repeat all preprocedure viral studies. d. Continue to monitor for signs of rejection.

ANS: A

It is mandatory to report any donor-derived infections to the organ procurement organization (OPO). The priority action is to notify the transplant coordinator. Verifying results with the lab technician, if indicated, would be the responsibility of the transplant coordinator.

Repeating viral studies and continuing to monitor for signs of rejection are appropriate actions but not the immediate priority.

DIF:

Cognitive Level: Apply/Application

REF: p. 239

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OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 16. A nurse is caring for a patient declared brain dead following a car crash in preparation for the

harvesting of organs. The patient’s urine output was 1050 mL in the last hour. What medication does the nurse prepare to administer? a. Vasopressin b. Methylprednisolone c. Desmopressin acetate d. Esmolol ANS: C

The patient’s history and urine output point to diabetes insipidus. The nurse should prepare to administer desmopressin acetate to control the urine output. Vasopressin, methylprednisolone, and esmolol would not be warranted.

DIF: Cognitive Level: Analyze/Analysis REF: Table 11-6 OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 17. The nurse obtains initial vital signs on a patient 2 weeks post–liver transplant who presents for

follow-up monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate action? a. Blood pressure of 100/60 mm Hg b. Serum creatinine of 1.5 mg/dL c. Hemoglobin of 9.2 gm/dL d. Tenderness over graft site ANS: D

Tenderness over the graft site may be indicative of acute rejection in a liver transplant recipient 2 weeks posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and do not require immediate action.

DIF: Cognitive Level: Apply/Application REF: p. 248 Liver Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. The transplant clinic social worker is completing a social history on a patient with end-stage

renal disease who is being evaluated for transplant. Which statement by the patient warrants further action? a. “I only smoke marijuana on an occasional basis.” b. “I have two sisters who live within two hours of me.” c. “I have attended all of my scheduled dialysis sessions.” d. “My mother’s side of the family has a history of cancer.”

ANS: A

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IV drug use is a contraindication to transplantation. A patient who reports using any recreational drugs should be evaluated further for other types of drug use. Family support is critical during posttransplant care. Adherence to dialysis indicates probable success in adhering to future treatment plans. A patient history of active or recent malignancy is a contraindication to transplantation.

DIF: Cognitive Level: Apply/Application REF: p. 238 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 19. The transplant clinic nurse is educating a patient about the renal criteria that must be met in

order to be placed on the transplant waiting list. Which statement by the patient best indicates an understanding of the criteria? a. “I qualify if I have end-stage renal disease.” b. “I will not qualify until I have to go on regular hemodialysis treatments.” c. “My blood type does not have to be a match with the donor blood type.” d. “The national waiting list is based on the ability to pay for medications.”

ANS: A

Candidates are placed on the UNOS national waiting list once they have end-stage renal disease. Patients may be on dialysis or have a glomerular filtration rate of less than 5 to 20 mL/minute. ABO compatibility is necessary for successful renal transplantation. A point system is used to rank candidates to determine who will receive a kidney when a donor becomes available.

DIF: Cognitive Level: Evaluate/Evaluation OBJ: Discuss processes associated N wU ithRSoIrN gaGnTdBo.CnO atM ion.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 244 Lung Transplant Box

20. The nurse is educating a renal transplant patient about his immunosuppressant medication

therapy. Which statement by the patient best indicates an appropriate understanding? a. “I will be gradually weaned off my medications during my lifetime.” b. “After 6 months, I will be down to taking one medication for life.” c. “Complications of these medications include diabetes, infection, hypertension, and bone loss.” d. “I will only need to take my mediations every other day for life.”

ANS: C

Posttransplant recipients will be on immunosuppressant medications for life. They have many side effects, including nephrotoxicity, hypertension, hyperlipidemia, bone loss, new-onset diabetes mellitus, and infection.

DIF: Cognitive Level: Evaluate/Evaluation REF: p. 245 Kidney Transplant Box OBJ: Discuss immunosuppression of the solid organ transplant recipient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 21. A nurse is preparing to admit a post-heart transplant patient for a second myocardial biopsy in

3 weeks. What conclusion does the nurse draw from this admission information?

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The patient is having rejection.

The patient is being monitored for rejection.

The new heart is functioning poorly.

The patient is being evaluated for a repeat transplant.

ANS: B

After heart transplant, patients undergo myocardial biopsy every week for 4-6 weeks. After that period of time, biopsies are scheduled based on patient condition. The patient is not necessarily rejecting the heart, there is no indication the heart is not functioning well, and the patient is not being evaluated for a new transplant.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 246 Heart Transplant Box

22. The nurse is providing postoperative education to a heart transplant patient’s family. When

asked about detecting rejection, which answer by the nurse is most appropriate? a. “Endomyocardial biopsies will be performed weekly for the first 6 weeks after surgery.” b. “Increased shortness of breath most likely indicates immediate, acute rejection of the heart.” c. “Biopsies of the heart are done every 6 months after the day of the transplant surgery.” d. “As time passes, the more biopsies that are performed, the more reliable the results become.”

ANS: A

The traditional method of rejection surveillance in a heart transplant recipient is through endometrial biopsies performed weekly during the first 6 weeks posttransplant. Shortness of breath can be a symptom of rejection, but only in combination with other symptoms.

Rejection is confirmed through biopsy. The need for biopsies decreases over time unless the patient suffers signs and symptoms suggestive of rejection.

DIF: Cognitive Level: Remember/Knowledge REF: p. 246 Heart Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 23. The transplant clinic nurse is conducting a pretransplant education session for patients being

evaluated for liver transplantation. Which statement by the nurse provides the best explanation of the numeric system used to classify the severity of a patient’s liver disease? a. “A score is calculated based upon kidney function, clotting time, and bilirubin levels.” b. “A score is calculated that ranges between 6 and 40, with the lower score being more serious.” c. “There are currently no exceptions to the MELD score calculation for severity of disease.” d. “The calculated score represents the patient’s risk of death within 1 year of diagnosis.”

ANS: A

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The Model for End-Stage Liver Disease (MELD) score uses the patient’s serum creatinine, international normalized ratio (INR) for prothrombin time, and serum bilirubin to predict survival. The MELD score measures the severity of liver disease.

Higher calculated MELD scores indicate a more critically ill patient. MELD exception points may be generated by the presence of hepatocellular carcinoma (HCC), worsening hypoxemia, ascites, or other consequences of liver disease.

DIF: Cognitive Level: Understand/Comprehension OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 247 Liver Transplant Box

24. Which statement best represents appropriate donor-to-recipient criteria for liver

transplantation? a. Blood type and HLA tissue type b. HLA tissue type and body type c. Blood type and body size d. Blood type and donor history ANS: C

Blood type and body size are the two criteria necessary for matching a donor liver to a recipient. HLA tissue typing is not used because it has not been known to affect outcomes.

Donors are carefully screened for infectious diseases and carcinomas during the process, but blood type and body type are the essential matching criteria.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: AssessN mUenRtSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 247 Liver Transplant Box

25. The nurse assesses morning lab results for a postoperative day 1 liver transplant recipient. Lab

results noted by the nurse include aspartate transaminase (AST) 365 U/L; alanine aminotransferase (ALT) 400 U/L; and serum glucose of 85 mg/dL. What is the best action by the nurse? a. Notify the provider of liver enzyme results. b. Treat hypoglycemia with 50 mL 5% dextrose. c. Repeat the liver enzyme results in 4 hours. d. Prepare to administer IV insulin infusion.

ANS: A

Rejection is suspected with a rise in aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin and warrants a liver biopsy. These values are very high, which warrants notifying the provider. Glucose of 85 mg/dL is considered within normal limits by most laboratories and would not require treatment with glucose or insulin to normalize. Repeating the enzyme results in 4 hours would be appropriate, but it is not the immediate priority.

DIF: Cognitive Level: Apply/Application REF: pp. 247-248 Liver Transplant Box OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

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26. The transplant clinic nurse is educating a group of transplant recipients on health promotion

and maintenance. What is the priority statement by the nurse? a. “Adhere to all future scheduled appointments with the clinic.” b. “Obtain annual vaccinations for pneumonia from your physician.” c. “Report all routine lab results to your primary care physician.” d. “Notify the transplant clinic of all future hospital admissions.”

ANS: B

To protect against viruses that would be detrimental to a transplant recipient, it is most important for transplant patients to consult with their clinic providers to obtain the appropriate vaccinations. Adherence to future scheduled appointments, reporting lab results, and notifying the clinic of all future hospitalizations are part of long-term care, but appropriate vaccinations are essential to the health of the patient.

DIF: Cognitive Level: Apply/Application REF: this info is in each organ transplant box OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 27. A renal transplant recipient presents to the outpatient transplant clinic with blood glucose

values for the past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf) 2 mg twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best interpretation of this finding by the nurse? a. The patient is at increased risk for infection. b. The patient has developed posttransplant diabetes. c. Temporary elevations in bloodNU suRgSaIrNsGaTreB.nCoOrM mal. d. Discontinuation of steroids will normalize values.

ANS: B

A patient taking steroids and calcineurin inhibitors is at risk for the development of posttransplant diabetes as a complication of long-term medication therapy. Although the lab values in isolation do not indicate infection, blood sugars must be normalized to promote healing. Hemoglobin A1C levels indicate the level of blood sugar control over the past 2 to 3 months. Findings should not be considered temporary. Although steroids can elevate blood sugar values, discontinuation of steroid therapy may not be feasible in all transplant recipients.

DIF: Cognitive Level: Understand/Comprehension REF: p. 245 Kidney Transplant Box OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 28. The postanesthesia care unit receives handoff communication from the CRNA indicating that

the renal transplant recipient received induction therapy in the operating room with antithymocyte globulin (ATG). What is the best understanding of the administration of this drug by the nurse? a. The drug is administered for recipients of CMV-positive donor organs. b. Administration of the drug decreases initial postoperative rejection rates. c. Antiproliferative agents are recommended for routine induction therapy.

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d. Antithymocyte globulin (ATG) is given as a single dose in the OR. ANS: B

Administration of antiproliferative agents such as antithymocyte globulin (ATG) has been shown to decrease rejection rates in the initial postoperative period. Antiviral agents are administered if CMV donor status is positive. Antiproliferative agents are recommended as first choice for induction therapy in recipients at high immunological risk. ATG is given in the operating room as well as for several days postoperative.

DIF: Cognitive Level: Understand/Comprehension REF: p. 246 Heart Transplant Box OBJ: Discuss immunosuppression of the solid organ transplant recipient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 29. The nurse is preparing to administer a renal transplant recipient’s first dose of mycophenolate

mofetil (CellCept). What is the best understanding of this medication by the nurse? a. It is a calcineurin inhibitor used for induction therapy. b. It is an antimetabolite used for maintenance therapy. c. It is an antiproliferative agent used for maintenance therapy. d. It is an mTOR inhibitor used for maintenance therapy.

ANS: C

Mycophenolate mofetil (CellCept) is an antiproliferative agent that inhibits T lymphocytes.

CellCept is used for maintenance immunosuppression therapy.

DIF: Cognitive Level: Remember/Knowledge REF: p. 246 Heart Transplant Box OBJ: Discuss immunosuppression of the solid organ transplant recipient.

TOP: Nursing Process Step: PlanninNgURSINGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity 30. A patient presents to the outpatient transplant clinic stating, “I would like to donate one of my

kidneys.” What is the best response by the nurse? a. “To be a living donor, you must be related to the recipient.” b. “You must be over the age of 30 to be a living donor.” c. “Living donor donation is coordinated by UNOS.” d. “Let us orient you to the process required to become a donor.”

ANS: D

An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a stranger. The nurse can help the patient navigate the donation process. Living donors may be related or unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years. All transplant centers coordinate the living donation process.

DIF: Cognitive Level: Apply/Application REF: p. 234 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 31. Which clinical scenario best represents hyperacute rejection? a. A cardiac transplant patient with a 3-month history of shortness of breath b. A lung transplant patient with small pustules that follow a dermatome

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c. A liver transplant patient with several small lumps under the skin d. An implanted renal transplant that, upon reperfusion, becomes cyanotic ANS: D

A hyperacute rejection occurs within hours or days of the transplanted organ. An implanted renal transplant that becomes cyanotic upon reperfusion represents a hyperacute rejection. A cardiac transplant patient with a 3-month history of shortness of breath represents an acute rejection. Small pustules that follow a dermatome most likely represent herpes zoster. Several small lumps under the skin may indicate squamous cell carcinoma.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 244-246 OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 32. Which statement best describes the lung allocation score (LAS) used to prioritize lung

transplant recipients? a. The LAS estimates the probability of survival and benefits from transplantation. b. Lungs from children and adolescents are offered to adults first. c. The LAS is limited to candidates under the age of 65 years. d. The score was developed to estimate 5-year survival rates.

ANS: A

The LAS generates a score that estimates the probability of survival posttransplant and the benefits of transplant for potential lung recipients. Lungs from children and adults are offered to pediatric and adolescent candidates first. The LAS is used for all patients who are listed on the organ donor registry. The LAS was developed to estimate the change of first-year survival after transplantation.

DIF: Cognitive Level: Remember/Knowledge OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 244 Lung Transplant Box

33. The nurse is caring for a renal transplant recipient in the postanesthesia care unit (PACU).

One hour after the transplant recipient was admitted to the PACU, the RN notes the patient’s blood pressure has dropped to 82/60 mm Hg and the pulse is 138 beats/min. Which physician order should the nurse implement first? a. Administer an extra dose of the ordered pain medication. b. Administer a 500-mL bolus of 0.9% normal saline intravenously stat. c. Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline. d. Provide maintenance IV fluids of D5 0.45% normal saling to infuse at 100 mL/hr.

ANS: C

Surgical complications following renal transplantation include arterial or venous bleeding due to failure of the surgical anastomoses. A fluid bolus can replace preload temporarily until the provider determines the cause of this change in status. Extra pain medications may or may not be needed. Irrigating the catheter is not related to this scenario. Hypotonic fluids are generally not used in the immediate postoperative period.

DIF: Cognitive Level: Apply/Application REF: p. 245 Kidney Transplant Box

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OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 34. The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The

patient asks the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse? a. “Your admission lab results will determine whether your kidney is being rejected.” b. “A procedure called a renal biopsy will be the best way to confirm rejection.” c. “Monitoring over the next few days will determine whether your kidney is failing.” d. “An ultrasound of your kidney will determine whether your kidney has failed.”

ANS: B

Renal biopsy confirms the presence of rejection. Admission lab results will provide information related to the current functional level of the kidney but will not confirm rejection.

Monitoring the patient will not confirm the presence of rejection. An ultrasound of the kidney will determine whether there is blood flow to the kidney but will not provide information at the cellular level.

DIF: Cognitive Level: Understand/Comprehension REF: p. 245 Kidney Transplant Box OBJ: Discuss complications associated with the long-term management of solid organ transplant recipients.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. The family of a critically ill patient has asked to discuss organ donation with the patient’s

nurse. When preparing to answer the family’s questions, the nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.) a. Donor disfigurement influences on funeral care b. Fear of inferior medical care provided to donor c. Age and location of all possible organ recipients d. Concern that donated organs will not be used e. Fear that the potential donor may not be deceased f. Concern over financial costs associated with donation ANS: A, B, E, F

Common fears and concerns that can influence a family’s decision to donate include fear of disfigurement of the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the donor may not really be deceased, and concern that the family of the donor will assume the financial burden associated with the donation. The number of individuals awaiting transplant, along with the current UNOS registry system, ensures that all procured organs will be transplanted. The age and location of recipients are not disclosed by the OPO. DIF: Cognitive Level: Understand/Comprehension REF: p. 236 OBJ: Discuss processes associated with organ donation.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

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Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready

brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a. Assess the blood pressure by Doppler. b. Estimate the systolic pressure as 60 mm Hg. c. Obtain an electronic blood pressure monitor. d. Record the blood pressure as “not assessable.”

ANS: A

Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction.

If blood pressure is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is inappropriate without further attempts using different modalities.

DIF: Cognitive Level: Apply/Application REF: p. 260 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a N U R S I N G T B . C OM

patient with severe sepsis. One h o u r la t e r, w hi ch laboratory result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L ANS: B

Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation in shock, and as an outcome predictor. All other listed values are within normal limits and do not require additional follow-up.

DIF: Cognitive Level: Remember/Knowledge REF: p. 263 Laboratory Alert box OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse has been administering 0.9% normal saline intravenous fluids in a patient with

severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. Blood pressure and oral temperature c. Oral temperature and capillary refill d. Right atrial pressure and urine output

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ANS: D

Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of fluid therapy. Capillary refill provides a quick assessment of the patient’s overall cardiovascular status, but this assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of oral temperature does not assess the effectiveness of fluid therapy in patients in shock.

DIF: Cognitive Level: Evaluate/Evaluation OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 283-284

4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two

hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a. The assessed values are within normal limits. b. The patient is at risk for developing cardiogenic shock. c. The patient is at risk for developing fluid volume overload. d. The patient is at risk for developing hypovolemic shock.

ANS: D

Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia. Both urine output and chest drainage values are high, contributing to the N U R S IN G T B. C O M hypovolemia. Assessed values a r e n o t w i t h i n n o r m a l limits.

A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not volume overload, as evidenced by excessive hourly chest drainage and urine output.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 271-272 | Table 12-5 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. A patient is admitted after collapsing at the end of a summer marathon. The patient is

lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer’s bolus d. Packed red blood cells ANS: C

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The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and lactated Ringer’s solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is no evidence to support a transfusion in the given scenario.

DIF: Cognitive Level: Analyze/Analysis OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 265

6. The nurse is caring for a patient in the early stages of septic shock. The patient is slightly

confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery occlusive pressure and high cardiac output b. High systemic vascular resistance and low cardiac output c. Low pulmonary artery occlusive pressure and low cardiac output d. Low systemic vascular resistance and high cardiac output ANS: D

As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In the early stages of septic shock, cardiac output is high.

DIF: Cognitive Level: Remember/Knowledge REF: Table 12-5 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse

include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from two sites c. IV antibiotic administration d. Isotonic fluid challenge ANS: D

Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour; however, volume resuscitation is the priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis OBJ: Describe management strategies for each type of shock.

REF: pp. 283-284

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TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 8. Which patient being cared for in the emergency department is most at risk for developing

hypovolemic shock? a. A patient admitted with abdominal pain and an elevated white blood cell count b. A patient with a temperature of 102° F and a general dermal rash c. A patient with a 2-day history of nausea, vomiting, and diarrhea d. A patient with slight rectal bleeding from inflamed hemorrhoids ANS: C

Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient scenarios.

DIF: Cognitive Level: Remember/Knowledge REF: p. 271 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings

obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m 2. What is the priority pharmacological intervention? a. Dobutamine b. Furosemide c. Phenylephrine d. Sodium nitroprusside ANS: A

A high PAOP and a low cardiac index are findings consistent with cardiogenic shock. Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As contractility increases, cardiac output and index increase and improve tissue perfusion.

Administration of furosemide will assist only in managing fluid volume overload.

Phenylephrine administration enhances vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 275 | Table 12-4 | Table 12-5 OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 10. Ten minutes following administration of an antibiotic, the nurse assesses a patient to have

edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention? a. Diphenhydramine 50 mg intravenously b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously

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d. Ranitidine 50 mg intravenously ANS: B

The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3 to 5 mL of 1:10,000 solution) is administered intravenously.

Diphenhydramine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone, are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension.

Ranitidine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

DIF: Cognitive Level: Analyze/Analysis OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 79-280

11. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The

nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance ANS: A

In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pNulUmRoS nI NarGyT aBr. tCeOr yMoc c l usi o n pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.

DIF: Cognitive Level: Analyze/Analysis REF: p. 275 | Table 12-4 | Table 12-5 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. During the initial stages of shock, what are the physiological effects of decreased cardiac

output? a. Arterial vasodilation b. High urine output c. Increased parasympathetic stimulation d. Increased sympathetic stimulation ANS: D

A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 260 OBJ: Correlate the four classifications of shock to their pathophysiology.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. While monitoring a patient for signs of shock, the nurse understands which system assessment

to be of priority? a. Central nervous system b. Gastrointestinal system c. Renal system d. Respiratory system ANS: A

The central nervous system experiences decreased perfusion first. The patient will have central nervous system changes early during the course of shock, such as changes in the level of consciousness. Although the gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central nervous system provide the earliest indication of decreased perfusion.

DIF: Cognitive Level: Remember/Knowledge REF: p. 260 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is caring for a patient in cardiogenic shock being treated with an intraaortic balloon

pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain tNhUe RI SAI NB GP T? B . C O M a. “The action of the machine will improve blood supply to the damaged heart.” b. “The machine will beat for the damaged heart with every beat until it heals.” c. “The machine will help cleanse the blood of impurities that might damage the heart.” d. “The machine will remain in place until the patient is ready for a heart transplant.”

ANS: A

The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve both forward and backward blood flow. It does not “beat” for the damaged heart. An IABP does not filter blood impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are not effective. It is indicated for short-term use, not as a bridge to transplant.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 276

15. The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for

cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg

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c. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg d. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm−5 ANS: A

Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are high and would not indicate an appropriate response to therapy.

DIF: Cognitive Level: Understand/Comprehension REF: p. 276 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 16. The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving

accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient’s skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The patient is developing neurogenic shock. b. The patient is experiencing an allergic reaction. c. The patient most likely has an elevated temperature. d. The vital signs are normal for this patient.

ANS: A

The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an e l e Nv aUt Re dS I tNe GmTpBe. rCaOt uMr e , can develop from uncontrolled heat loss associated with vasodilation in neurogenic shock. Vital signs are not normal given the clinical situation.

DIF: Cognitive Level: Analyze/Analysis REF: p. 278 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70

mm Hg, heart rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of 94.8° F. Which intervention is most important for the nurse to include in the patient’s plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via face mask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine) ANS: C

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Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patient’s oxygen saturation is 95% on room air with an adequate respiratory rate. The application of 100% oxygen via face mask is not indicated. The patient’s heart rate is adequate to support a normal blood pressure.

DIF: Cognitive Level: Apply/Application OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 278

18. The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a

patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.

ANS: B

Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not responded appropriately to therapy aimed at increasing circulating volume.

Additional intervention is needed because response to therapy is not appropriate, values are abnormal, and timely interventionNiU s RcrSiItNicGaTl Bfo. Cr OaMpatient with low circulating blood volume.

DIF: Cognitive Level: Analyze/Analysis REF: p. 265 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The emergency department nurse admits a patient following a motor vehicle collision. Vital

signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient’s plan of care? a. Insertion of an 18-gauge peripheral intravenous line b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions ANS: A

Given the patient’s diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 266 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 20. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient

admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hours. b. Notify the physician of the elevated temperature. c. Titrate rate of blood administration to patient response. d. Notify the physician of the patient’s heart rate.

ANS: C

Given the acute nature of the patient’s blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient’s blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.

DIF: Cognitive Level: Analyze/Analysis REF: p. 266 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood

pressure of 105/60 mm Hg, heart rNaUteR1SI1N0GbTeBa.tCsO /mMin, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes ANS: A

Timely identification of the causative organism through blood cultures and the initiation of appropriate antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are not the priority in this scenario.

DIF: Cognitive Level: Apply/Application REF: p. 283 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 22. The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a

diagnosis of severe sepsis. As part of this patient’s care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning

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b. Monitoring intake and output c. Enteral feedings d. Pain management ANS: C

Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning, and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours following admission.

DIF: Cognitive Level: Analyze/Analysis REF: p. 264 |p. 286 Evidence Based Practice Box OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 23. The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid

resuscitation in a patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temperature b. Balanced intake and output c. Adequate pain management d. Urine output of 0.5 mL/kg/hr ANS: D

Adequate urine output of at least 0.5 mL/kg/hr indicates adequate perfusion to the kidneys following administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain maNnUagReSm INeGnTt Ba . rCe OnMo t assessment findings indicating an adequate response to fluid therapy. During fluid resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is restored.

DIF: Cognitive Level: Understand/Comprehension REF: p. 271 Nursing Care Plan OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Adaptation 24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the

nurse notes a blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure (CVP/RAP) of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Administer acetaminophen 650-mg suppository prn every 6 hours for pain. b. Titrate dopamine intravenously for blood pressure less than 90 mm Hg systolic. c. Complete neurological assessment every 4 hours for the next 24 hours. d. Administer furosemide 20 mg IV every 4 hours for a CVP greater than or equal to 20 mm Hg. ANS: B

Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume deficit, which this patient displays. The nurse should question the use of the dopamine infusion. All other listed orders are appropriate and have potential for use in the treatment of a hypovolemic shock.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 268 | Table 12-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 25. The nurse is administering intravenous norepinephrine at 5 mcg/kg/min via a 20-gauge

peripheral intravenous (IV) catheter. Which assessment finding requires immediate action by the nurse? a. Blood pressure 100/60 mm Hg b. Swelling at the IV site c. Heart rate of 110 beats/min d. Central venous pressure (CVP) of 8 mm Hg ANS: B

Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine through an infiltrated IV site can lead to tissue necrosis and requires immediate intervention by the nurse.

A blood pressure of 100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate intervention.

DIF: Cognitive Level: Understand/Comprehension REF: Table 12-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic

values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m 2, heart rate of 70 beats/min, and a systemic vasculaNr U reRsSisItNaG ncTeB.(CSOVMR) of 2200 dynes/sec/cm−5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to 20 mm Hg b. Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain c. Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 d. Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg ANS: B

The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation of other listed physician order options.

DIF: Cognitive Level: Analyze/Analysis REF: Table 12-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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27. The nurse is caring for a mechanically ventilated patient following insertion of a left

subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line–associated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management ANS: A

Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate interventions to reduce the risk of ventilator-acquired pneumonia.

DIF: Cognitive Level: Apply/Application REF: p. 262 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse

assesses the patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18 ANS: D

As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a late stage of shock. All other listed arterial blood gas values are within normal limits.

DIF: Cognitive Level: Apply/Application REF: p. 284 | Table 12-2 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 29. The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2

hours, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient every 2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.

ANS: C

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Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body temperature is a priority. While administration of pain management, repositioning the patient every 2 hours, and application of heel protectors should be part of the patient care, given the rapid transfusion of blood products, these interventions are not the priority in this scenario.

DIF: Cognitive Level: Apply/Application REF: p. 268 | Table 12-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of

dobutamine. The physician’s order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m 2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a. Obtain a stat serum potassium level. b. Order a stat 12-lead electrocardiogram. c. Reduce the rate of dobutamine. d. Assess the patient’s hourly urine output.

ANS: C

Dobutamine is used to stimulate contractility and heart rate while causing vasodilation in low cardiac output states, improving overall cardiac performance. The patient’s cardiac index is well above normal limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is no evidence to support the need for a serum potassium or 12-lead electrocardiogram. A s s e s sNmUeRnSt I No fGhToBu. Cr lOy Mu r i ne output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 268 | Table 12-4 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 31. After receiving a handoff report from the night shift, the nurse completes the morning

assessment of a patient with severe sepsis. Vital signs are: blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO 2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse initiates which provider prescription first? a. Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is less than 5 mm Hg. b. Increase supplemental oxygen therapy to maintain SpO2 greater than 94%. c. Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30 mL/hr. d. Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat temperature greater than 101° F. ANS: A

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Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient’s CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen.

Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated.

DIF: Cognitive Level: Analyze/Analysis REF: p. 265 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 32. The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of

lactated Ringer’s solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required. b. Hemoglobin and hematocrit results indicate hemodilution. c. Fluid resuscitation has resulted in fluid volume overload. d. Fluid resuscitation has resulted in third-spacing of fluid.

ANS: B

Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no evidence to support the need for a blood transfusion and no evidence of fluid overload. Although administration of large volumes of crystalloid can result in hemodilution of plasma proteinNs UleRaSdIiNnG gTtB o.C thOirMd-spacing of fluid, this fact does not support the hemoglobin and hematocrit results.

DIF: Cognitive Level: Understand/Comprehension REF: p. 265 OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing interventions, and rationales.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the

nurse assesses a drop in the patient’s blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and a temperature of 102° F. The nurse notes the new onset of hematuria in the patient’s Foley catheter. What are the priority nursing actions?

(Select all that apply.) a. Administer acetaminophen. b. Document the patient’s response. c. Increase the rate of transfusion. d. Notify the blood bank. e. Notify the provider. f. Stop the transfusion.

ANS: D, E, F

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In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction, interventions used, and patient response to treatment are documented although this occurs after immediate action has been taken.

Acetaminophen is not warranted in the immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the infusion further increases the likelihood of worsening the transfusion reaction.

DIF: Cognitive Level: Analyze/Analysis OBJ: Describe management strategies for each type of shock.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Client Needs Category: Physiological Integrity

REF: p. 266

2. The nurse is caring for a patient admitted with shock. The nurse understands which

assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. Blood pressure b. Heart rate c. Level of consciousness d. Pupil response e. Respirations f. Urine output ANS: A, C, F

The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary response and reSsIpNiG raTtB io.C nsOM do not assess perfusion.

NUR DIF: Cognitive Level: Analyze/Analysis REF: p. 264 OBJ: Relate assessment findings to the classification and stage of shock.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 13: Cardiovascular Alterations Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The patient is admitted with a suspected acute myocardial infarction (AMI). In assessing the

12-lead electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave myocardial infarction (MI)? a. ST-segment elevation on ECG and elevated CPK-MB or troponin levels b. Depressed ST-segment on ECG and elevated total CPK c. Depressed ST-segment on ECG and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels ANS: A

ST segment elevation and elevated cardiac enzymes are seen in Q wave MI. DIF: Cognitive Level: Analyze/Analysis REF: p. 313 | Nursing Care Plan OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse

expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. Nausea and vomiting ANS: C

In left-sided heart failure, signs and symptoms are related to pulmonary congestion.

Dependent edema and distended neck veins are related to right-sided heart failure.

DIF: Cognitive Level: Analyze/Analysis REF: p. 326 | Box 13-13 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an

angiotensin-converting enzyme (ACE) inhibitor should be started within 24 hours to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia ANS: C

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Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and inflammatory cytokines; it causes myocyte hypertrophy and loss of contractile function in the areas of the heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.

DIF: Cognitive Level: Analyze/Analysis REF: p. 328 | Table 13-13 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. A patient presents to the emergency department (ED) with chest pain that he has had for the

past 2 hours. The patient is nauseated and diaphoretic, with dusky skin color. The electrocardiogram shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery ANS: A

The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.

DIF: Cognitive Level: Analyze/Analysis REF: p. 312 N U R S I N G T B .

C O M OBJ: Compare and contrast p h arm a c ol o g i c a l , o p e r a t i v e , and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the

physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery ANS: C

In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and requires more frequent nitrate therapy. Complete occlusion is associated with a myocardial infarction. A fatty streak is present in all vessels affected by coronary artery disease. Vasospasm leads to Prinzmetal’s angina.

DIF: Cognitive Level: Analyze/Analysis REF: p. 295 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. A patient is admitted with angina. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics

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b. Morphine sulfate and oxygen c. Nitroglycerin, oxygen, and beta blockers d. Statins, bile acid, and nicotinic acid ANS: C

Conservative intervention for the patient experiencing angina includes nitrates, beta blockers, and oxygen.

DIF: Cognitive Level: Analyze/Analysis REF: p. 306 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 7. A patient is having a cardiac evaluation to assess for possible valvular disease. Which study

best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead electrocardiogram b. Cardiac catheterization c. Echocardiogram d. Electrophysiology study ANS: C

Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize the cardiac structures and the motion and function of cardiac valves and chambers. The ECG provides information related to the heart’s electrical activity. A cardiac catheterization directly visualizes coronary arteries. Electrophysiology studies are done to evaluate dysrhythmias.

DIF: Cognitive Level: U nd e r s t a nd / NCUo m R Sp IrNe hGeTnBs i. oCnO M REF: p. 336 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be

prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins ANS: D

The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering drugs such as bile acid resins and nicotinic acid. Nitroglycerin is used for chest pain.

DIF: Cognitive Level: Understand/Comprehension REF: p. 301 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse

is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture?

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Sole: Introduction to Critical Care Nursing,8E

Gallop rhythm New murmur S1 heart sound S3 heart sound

ANS: B

The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage and impending complications.

DIF: Cognitive Level: Analyze/Analysis REF: p. 294 OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to

explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance).

ANS: C

Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches. Coronary artery spasms and transient oxygen imbalance are not related to a myocardial infarction. Ischemia, if not reversed, will eventually lead N toUtRisSsIuNeGnTeBc.C roOsM is.

DIF: Cognitive Level: Analyze/Analysis REF: p. 311 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity 11. A 72-year-old woman is brought to the ED by her family. The family states that she’s “just

not herself.” Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST segments in leads II, III, and aVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non–Q wave MI c. Silent myocardial infarction d. Unstable angina ANS: C

Some individuals may have ischemic episodes without knowing it, thereby having a “silent” infarction. These can occur with no presenting signs or symptoms; however, the patient’s troponin levels and ECG are consistent with an MI. Asymptomatic or nontraditional symptoms are more common in elderly persons, in women, and in diabetic patients. The patient does not fit the criteria for hypokalemia, a non–Q wave MI, or unstable angina.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 311 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. A patient presents to the ED complaining of severe substernal chest pressure radiating to the

left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient’s 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a. The patient is not a candidate for thrombolysis. b. The patient’s history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non–Q wave MI. d. Thrombolysis should be started immediately.

ANS: A

To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours.

Therefore, this patient is not a candidate for this therapy.

DIF: Cognitive Level: Analyze/Analysis REF: p. 314 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. The patient presents to the ED with severe chest discomfort. A cardiac catheterization and

angiography shows an 80% occlusion of the left main coronary artery. Which procedure will be most likely performed on this patient? a. Coronary artery bypass graft sNuU rgReSrIyNGTB.COM b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty (PTCA) d. Transmyocardial revascularization ANS: A

Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%). The stent or PTCA are not appropriate because the patient is a candidate for CABG. The transmyocardial revascularization is reserved for patients who do not have other treatment options.

DIF: Cognitive Level: Remember/Knowledge REF: p. 317 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist

believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. Implantable cardioverter-defibrillator placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement ANS: C

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Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia caused by a reentry circuit, and an abnormal conduction pathway. A cardioverter-defibrillator is used on patients with potentially lethal rhythms such as ventricular fibrillation. A pacemaker is not used for this condition.

DIF: Cognitive Level: Analyze/Analysis REF: p. 320 | p. 322 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 15. The patient presents to the ED with sudden, severe sharp chest discomfort, radiating to the

back and down both arms, as well as numbness in the left arm. While taking the patient’s vital signs, the nurse notices a 30-point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results. b. contact the physician and prepare the patient for thrombolytic therapy. c. contact the physician immediately and begin prepping the patient for surgery. d. give the patient aspirin and heparin.

ANS: C

These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and arm paresthesia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 339 OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.

TOP: Nursing Process Step: ImplemNeUnR taStiIoNnGTB.COM MSC: NCLEX Client Needs Category: Physiological Integrity 16. A patient is admitted to the emergency department with clinical indications of an acute

myocardial infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep oxygen saturation levels to at least 88% d. Maintain heart rate above 100 beats/min ANS: A

Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium, preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or acute interventional therapy such as angioplasty. Because interventional cardiology is unavailable, thrombolytic therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not indicated with this scenario.

DIF: Cognitive Level: Apply/Application REF: p. 314 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

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17. A patient has been prescribed nitroglycerin (NTG) in the ED for chest pain. In taking the

health history, the nurse will be sure to verify whether the patient has taken medications before admission for: a. erectile dysfunction. b. prostate enlargement. c. asthma. d. peripheral vascular disease.

ANS: A

A history of the patient’s use of sildenafil citrate or similar medications taken for erectile dysfunction is necessary to know when considering NTG administration. These medications potentiate the hypotensive effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient has any food or drug allergies. The other conditions would not be a contraindication for nitroglycerin.

DIF: Cognitive Level: Analyze/Analysis REF: p. 295 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex

before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test ANS: B

In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which is inserted into the posterior pharynx and advanced into the esophagus.

After the procedure, the patient is unable to eat until the gag reflex returns. The other tests do not alter the gag reflex.

DIF: Cognitive Level: Apply/Application REF: p. 299 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family

wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient’s quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option ANS: B

LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the LVAD is therapy for patients with terminal heart failure. It would provide better management than medical therapy alone. The IABP is for short-term management of acute heart failure.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 331 | Box 13-14 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 20. The provider prescribes a pharmacological stress test for a patient with activity intolerance.

The nurse would anticipate that the drug of choice would be a. dopamine. b. dobutamine. c. adenosine. d. atropine.

ANS: C

If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine is preferred over dobutamine because of its short duration of action and because reversal agents are not needed. Dopamine and atropine are not used.

DIF: Cognitive Level: Analyze/Analysis REF: p. 299 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 21. A patient has been diagnosed with Marfan syndrome. What information does the nurse plan to

teach the patient about this condition? a. It is an autosomal dominant inherited disorder of connective tissue. b. It is caused by a random genetic mutation and is not familial. c. There are no drugs that help co NnUtR roSlIN thGeTcBa.C rdOiaMc symptoms of the disease. d. Contact sports are permitted if precautions against concussion are taken.

ANS: A

Marfan syndrome is an autosomal dominant inherited disorder of connective tissue with a definite familial pattern. Beta blockers and ACE inhibitors are commonly used to treat the condition. Contact sports and weight lifting are generally prohibited.

DIF: Cognitive Level: Understand/Comprehension REF: p. 338 Genetics Box OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity 22. The patient’s spouse is feeling overwhelmed about cooking different dinners for the patient

and the rest of the family to satisfy a cholesterol-reducing diet. Which response by the nurse is best? a. “It will be worth it to have a healthy spouse, won’t it?” b. “The low-cholesterol diet is one from which everyone can benefit.” c. “As long as you change at least a few things in the diet, it will be okay.” d. “You can go on the diet with him, and then let the children eat whatever they want.”

ANS: B

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Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for everyone, not only those with a known cardiovascular disease. It will be easier if the family members all eat the same type of meal, so the nurse should suggest this option. Asking whether it’s worth the trouble is not giving the spouse any information with which to make decisions. A diet low in cholesterol requires changing more than just a few things.

DIF: Cognitive Level: Understand/Comprehension REF: p. 301 OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 23. Percutaneous coronary intervention is contraindicated for patients with lesions in which

coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery ANS: D

Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.

Lesions in the other locations are candidates for this procedure.

DIF: Cognitive Level: Understand/Comprehension REF: p. 317 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs CategoN ryU: RPShIyNsiGoTloBg.iCcO alMIntegrity 24. Which comment by the patient indicates a good understanding of a diagnosis of coronary

heart disease? a. “I had a heart attack because I work too hard, and it puts too much strain on my heart.” b. “The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on.” c. “If I change my diet and exercise more, I should get over this and be healthy.” d. “What kind of pills can you give me to get me over this and back to my lifestyle?”

ANS: B

Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion. Stress and strain can increase the heart’s oxygen demands but do not typically cause coronary artery disease. Coronary artery disease is a chronic illness. The patient asking for pills and a return to a previous lifestyle does not understand how risk factors lead to coronary artery disease.

DIF: Cognitive Level: Evaluate/Evaluation REF: p. 295 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity

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25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the

nurse’s responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second-degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions ANS: B

Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.

DIF: Cognitive Level: Analyze/Analysis REF: p. 320 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 26. An essential aspect of teaching that may prevent recurrence of heart failure is a. notifying the provider if a 2-lb weight gain occurs in 24 hours. b. compliance with diuretic therapy. c. taking nitroglycerin if chest pain occurs. d. assessment of an apical pulse.

ANS: B

Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart failure. Notifying the provider of a weight gain and assessing a pulse are important self-care activities but will not prevent a recurrence of heart failure. Nitroglycerin is used for coronary artery disease.

DIF: Cognitive Level: Apply/Application REF: p. 327 | Table 13-12 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Health Promotion and Maintenance 27. A patient is having an emergent coronary intervention, and the nurse is starting an infusion of

abciximab. The patient asks what the purpose of this drug is. What response by the nurse is best? a. “This will help prevent chest pain until the intervention is complete.” b. “This medication dries oral and respiratory secretions during the procedure.” c. “This is a mild sedative and amnesic agent, so you’ll be very relaxed.” d. “This drug helps prevent blood clotting and is often used for this procedure.”

ANS: D

Abciximab is a glycoprotein IIb/IIIc inhibitor and antiplatelet agent. It is used to prevent clotting in acute coronary syndromes and coronary intervention patients. The other statements are inaccurate.

DIF: Cognitive Level: Understand/Comprehension REF: p. 308 OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity

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28. A patient is having a stent and asks why it is necessary after having an angioplasty. Which

response by the nurse is best? a. “The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel.” b. “The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again.” c. “This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open.” d. “The stent will remove any clots that are in the vessel and protect the heart muscle from damage.”

ANS: B

Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.

DIF: Cognitive Level: Understand/Comprehension REF: p. 316 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX: Client Needs Category: Physiological Integrity 29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the

patient warrants further assessment and intervention by the critical care nurse? a. “I have an incredible headache!” b. “There is blood on my toothbrush!” c. “Look at the bruises on my arms!” d. “My arm is bleeding where m y IV i s !”

N U RS I N GTB.COM ANS: A

The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not a cause for concern. The worst complication is intracranial bleeding. Any neurological signs and symptoms must be taken seriously, and all fibrinolytic and/or heparin therapies must be discontinued until this is ruled out.

DIF: Cognitive Level: Analyze/Analysis REF: p. 313 | Nursing Care Plan OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. A patient with a 10-year history of heart failure presents to the emergency department

reporting severe shortness of breath. Assessment reveals crackles throughout the lung fields and labored breathing. The patient takes beta blockers, ACE inhibitors, and diuretics as directed. What treatment strategies does the nurse plan to implement for immediate short-term management? (Select all that apply.) a. Dobutamine b. Intraaortic balloon pump c. Nesiritide d. Ventricular assist device

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e. Biventricular pacemaker ANS: A, B, C

This patient is showing signs and symptoms of an acute exacerbation of heart failure.

Dobutamine and nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic balloon pump or insertion of a biventricular pacemaker also may be warranted as long-term therapy, but neither is appropriate for this acute exacerbation.

DIF: Cognitive Level: Apply/Application REF: p. 327 | Table 13-12 OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment of cardiac disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 2. Identify the priority interventions for managing symptoms of an acute myocardial infarction

(AMI) in the ED. (Select all that apply.) a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. Oxygen therapy e. Transfusion of packed red blood cells ANS: A, B, D

The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects. Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for repairing the damaged tissue around the site of the infarct. Transfusion is not r e q uNi Ur eRdS eI Nx Gc eTpBt . Ci nO tMh e setting of severe anemia, which may limit oxygen delivery to the heart. Dopamine infusion is usually used to treat hypotension but causes tachycardia which would be deleterious for the patient having an AMI because it increases the heart’s workload and demand for oxygen.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 314-315 OBJ: Develop a research-related care plan for the acutely ill cardiovascular patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences. b. Men have more atypical symptoms than women. c. Midsternal chest pain is a common presenting symptom. d. Some patients are asymptomatic. e. Patients may complain of jaw or back pain.

ANS: A, C, D, E

Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some individuals may have ischemic episodes without knowing it, thereby having a “silent” infarction. Women are more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back or jaw pain.

DIF: Cognitive Level: Analyze/Analysis REF: p. 311 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

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TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all

that apply.) a. Angina b. Nonischemic c. Non–Q wave d. Q wave e. Frequent PVCs ANS: C, D

AMI can be classified as Q wave or non–Q wave.

DIF: Cognitive Level: Remember/Knowledge REF: p. 313 Nursing Care Plan OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for

which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture e. Chest pain ANS: A, B, C, D

Dysrhythmias, heart failure, pericarditis and ventricular rupture are potential complications of AMI. Chest pain is a possible symptom of AMI. DIF: Cognitive Level: Remember/Knowledge REF: p. 312 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The patient tells the nurse, “I didn’t think I was having a heart attack because the pain was in

my neck and back.” The nurse explains: (Select all that apply.) a. “Pain can occur anywhere in the chest, neck, arms, or back. Don’t hesitate to call the emergency medical services if you think it’s a heart attack.” b. “For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone.” c. “The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack.” d. “You need to make sure it’s a heart attack before you call the emergency response personnel.” e. “Often symptoms can be treated with nitroglycerin, so be sure to take several before calling 911.”

ANS: A, B, C

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Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to the back, the shoulder, the jaw, and/or the neck. In the statement about treating symptoms with nitroglycerin, the word “several” is vague.

DIF: Cognitive Level: Analyze/Analysis REF: p. 311 | p. 312 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity 7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. Jugular venous distension b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses e. Hepatomegaly ANS: A, B, E

Jugular venous distension, liver tenderness, hepatomegaly, and peripheral edema are signs of right ventricular failure. Crackles are indicative of left ventricular failure. Weak peripheral pulse are not a manifestation of right ventricular failure. Crackles are indicative of left sided failure.

DIF: Cognitive Level: Remember/Knowledge REF: Box 13-13 OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the head of the bed by 45 degrees for 6 hours. b. Assess pedal pulses on the involved limb every 15 minutes for 1 to 2 hours. c. Monitor the vascular hemostatic device for signs of bleeding. d. Instruct the patient to bend his or her knee every 15 minutes while the sheath is in

place. e. Maintain NPO status for 12 hours.

ANS: B, C

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.

NPO status does not need to be maintained after the patient is fully alert.

DIF: Cognitive Level: Apply/Application REF: p. 300 OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize complications of cardiac and vascular patients.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 14: Nervous System Alterations Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient’s plan of care? a. Frequent neurological assessments b. Side to side position changes c. Range-of-motion to extremities d. Frequent oropharyngeal suctioning ANS: A Nurses complete neurological assessments based on prescribed frequency and the severity of the patient’s condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient’s plan of care.

Side to side position changes, range-of-motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient’s plan of care, but in the setting of increased intracranial pressure they should not be regularly performed unless indicated.

DIF: Cognitive Level: Apply/Application REF: p. 350 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: NuNrUsiRnSgINPGroTcBe. sCsOSMtep: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)? a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg ANS: C CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

DIF: Cognitive Level: Apply/Application REF: p. 354 OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse? a. Both pressures are high. b. Both pressures are low.

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c. ICP is high; CPP is normal. d. ICP is high; CPP is low.

ANS: C The ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range.

All other listed responses are incorrect.

DIF: Cognitive Level: Understand/Comprehension REF: p. 354 OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse? a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient’s head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.

ANS: D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient’s plan of care; however, spacing out interventions is the priority.

DIF: Cognitive Level: Apply/Application REF: p. 361 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action? a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.

ANS: C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment.

Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

DIF: Cognitive Level: Apply/Application REF: p. 368 OBJ: Describe the nursing and medical management of patients with skull fractures.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

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6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3.

What is the priority nursing action? a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the provider immediately.

ANS: D These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient, and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the provider is a priority given the severity in change of neurological status.

DIF: Cognitive Level: Analyze/Analysis REF: p. 369 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action? a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg ANS: D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

DIF: Cognitive Level: Analyze/Analysis REF: p. 362 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow? a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

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ANS: C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.

To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO 2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

DIF: Cognitive Level: Remember/Knowledge REF: p. 344 OBJ: Describe the pathophysiology of increased intracranial pressure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3.

Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action? a. Monitor the patient’s airway patency. b. Elevate the head of the patient’s bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.

ANS: A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient’s airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10NbUreRaStIhNsG/m in.Cm TB Oa My result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

DIF: Cognitive Level: Apply/Application REF: p. 351 | p. 360 Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

ANS: C

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This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 351 | Figure 14-7 OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.

ANS: D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertio N n UoR f SbIiNlaGteTrBa.lCeOaM r plugs is not standard of care.

DIF: Cognitive Level: Apply/Application REF: p. 368 OBJ: Describe the nursing and medical management of patients with skull fractures.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)? a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

ANS: D In this scenario, the patient’s temperature is elevated, which increases metabolic demands.

Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

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DIF: Cognitive Level: Apply/Application REF: p. 360 Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action? a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient’s mouth and insert a padded tongue blade. d. Restrain the patient’s extremities until the seizure subsides.

ANS: A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration.

Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient’s jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

DIF: Cognitive Level: Apply/Application REF: p. 380 OBJ: Describe the pathophysiology and management for status epilepticus.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs C N atUegRoS rIN y:GPThBy.CsiOoM logical Integrity 14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury? a. pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b. pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c. pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d. pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg ANS: C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia.

Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg. DIF: Cognitive Level: Understand/Comprehension REF: p. 360 Nursing Care Plan OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

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15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse? a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the provider of the patient’s blood pressure.

ANS: B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow, deep breaths will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the provider.

DIF: Cognitive Level: Apply/Application REF: p. 387 Clinical Alert Box OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action? a. Assess for the presence of a headache. b. Assess the patient’s general orientation. c. Determine the patient’s drug allergies. d. Determine the time of symptom onset.

ANS: D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

DIF: Cognitive Level: Apply/Application REF: p. 374 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. Which patient being cared for in the emergency department should the charge nurse evaluate first? a. A patient with a complete spinal cord injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula

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c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg ANS: A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. DIF: Cognitive Level: Analyze/Analysis REF: p. 382 OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED. ANS: B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient’s a i r w a Ny Ui sR cS oI NmGpTr Bo .mC Oi sM e d . The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

DIF: Cognitive Level: Understand/Comprehension REF: p. 385 | p. 388 OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action? a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.

ANS: B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury.

Monitoring blood pressure is a priority. Hand washing is important for all patients. There is no indication the patient has temperature alterations. Padding bony prominences may or may not be needed.

DIF: Cognitive Level: Remember/Knowledge REF: p. 386 | p. 388 Nursing Care Plan

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OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 20. The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol.

The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient? a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg ANS: C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg  70 kg) + (5.4 mg  70 kg)  23 hours = 10,794 mg.

DIF: Cognitive Level: Apply/Application REF: Table 14-9 OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse receives a patient from the emergency department following a closed head injury.

After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma CO Scale score of 4, and intracraniaNl U prReSsIsNuG reTB (I.C P)Mof 18 mm Hg. Which provider prescription should the nurse institute first? a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous ANS: A The patient’s GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-9 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first? a. Blood cultures (2 specimens) for temperature >101°F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours ANS: C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage.

Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 372 | p. 378 | Table 14-9 OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes UgR/ShIrN, G after beginning the infusion at 5Nm thTeBn.CuOrsMe assesses the patient’s blood pressure to be 160/90 mm Hg. What is the best action by the nurse? a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the provider of the BP. d. Begin weaning the infusion.

ANS: B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient’s blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the provider of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 24. The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse? a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous.

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c. Contact the provider. d. Assess cardiac rhythm.

ANS: C The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

DIF: Cognitive Level: Apply/Application REF: Table 14-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 25. The nurse is caring for a patient admitted to the emergency department in status epilepticus.

Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first? a. Obtain stat serum electrolytes. b. Administer lorazepam. c. Obtain stat portable chest x-ray. d. Administer phenytoin.

ANS: B The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticuNsU. RP ShIeNnGy TtoBi .nC iOsMadministered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

DIF: Cognitive Level: Apply/Application REF: Table 14-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 26. The provider prescribes fosphenytoin, 1.5 g intravenous (IV) loading dose, for a 75-kg patient in status epilepticus. What is the most important action by the nurse? a. Contact the admitting physician. b. Administer the drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient’s weight. Fosphenytoin does not have to be administered with normal saline or via a central line.

DIF: OBJ:

Cognitive Level: Apply/Application REF: Table 14-9 Discuss the nursing assessment and care of a critically ill patient with

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cerebrovascular disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 27. The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse? a. Administer over 2 minutes. b. Administer over 20 to 30 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

ANS: B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

DIF: Cognitive Level: Apply/Application REF: Table 14-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 28. The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus.

To prevent patient complications, what is the best action by the nurse? a. Ensure patency of intravenoN usU(RISVIN )G linT eB..COM b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

ANS: A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

DIF: Cognitive Level: Understand/Comprehension REF: Table 14-9 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority?

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Lasix 20 mg intravenous push as needed 500 mL albumin intravenous infusion Decadron 10 mg intravenous push Dilantin 50 mg intravenous push

ANS: B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate.

Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

DIF: Cognitive Level: Apply/Application REF: p. 378 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 30. After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F ANS: D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal f i n Nd iUnRg SaI nN dG Ts hBo. CuOl dMb e investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 381 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 31. The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse? a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports before use. d. Dispose of all bloody dressings in biohazard bags.

ANS: A

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Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection.

Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing of all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

DIF: Cognitive Level: Understand/Comprehension REF: p. 381 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action? a. Elevate the head of the bed 30 degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.

ANS: C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement sN eiUzR uSreINpGreTcBa.uCtOioMns in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bed rest are all appropriate nursing interventions but are not the priorities in this scenario.

DIF: Cognitive Level: Apply/Application REF: p. 381 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment MULTIPLE RESPONSE 1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a. Use of a heparin flush solution b. Manually flushing the device “prn” c. Recording ICP as a “mean” value d. Use of a pressurized flush system e. Zero referencing the transducer system ANS: C, E

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Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP. DIF: Cognitive Level: Remember/Knowledge REF: p. 357 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.) a. Doll’s eyes absent indicate a disruption in normal brainstem processing. b. Doll’s eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

ANS: A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll’s eye): turn the patient’s head quickly from side to side while holding the eyes open. Note movement of eyes. The doll’s eye reflex is present if the eyes move bilaterally in the S I eNnGt .T B . C O M opposite direction of the head mNoUveRm DIF: Cognitive Level: Understand/Comprehension REF: Table 14-10 OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient’s plan of care? (Select all that apply.) a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

ANS: A, C

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The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-2 | Table 14-10 OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 15: Acute Respiratory Failure Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse is caring for a patient with acute respiratory failure and identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours.

ANS: D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan OBJ: Formulate a plan of care for the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 2. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. b. c. d.

Decreasing PaO2 levels despite increased FiO2 administration Elevated alveolar surfactant levels Increased lung compliance with increased FiO2 administration Respiratory acidosis associated with hyperventilation

ANS: A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 298-299

3. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels ANS: B

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Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.

DIF: Cognitive Level: Analyze/Analysis REF: p. 390 | p. 392 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Intrapulmonary shunting refers to a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

ANS: C Shunting refers to blood that is not oxygenated in the lungs.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 390-391

5. When fluid is present in the a l v eNoUl iR, SINGTB.COM a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

ANS: B Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 391

6. In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness.

ANS: D

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Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia.

Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 392

7. The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

ANS: C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.

DIF: Cognitive Level: Understand/Comprehension REF: p. 398 | Figure 15-2 OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. TN hUeR pS Ir No vGiTdBe .rCpOr M e s c r i b e s a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

ANS: C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent nonpharmacological approach to manage anxiety; however, the nontraditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated to treat this patient, who is restless and appears to be in discomfort.

Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility program for critically ill patients.

DIF: Cognitive Level: Analyze/Analysis REF: p. 400 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

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9. A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device ANS: C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is no indication of an obstructed airway.

DIF: Cognitive Level: Analyze/Analysis REF: p. 414 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 10. Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 404

11. An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators ANS: B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.

DIF:

Cognitive Level: Understand/Comprehension

REF: p. 403

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OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a. “If you get the pneumococcal vaccine, you’ll never get pneumonia again.” b. “It is important for you to get an annual influenza shot to reduce your risk of pneumonia.” c. “Stay away from cold, drafty places because that increases your risk of pneumonia when you get home.” d. “Since you have been treated for pneumonia, you now have immunity from getting it in the future.”

ANS: B The influenza vaccine reduces the risk of pneumonia by more than 50%. The pneumococcal vaccine is important but protects only against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it.

DIF: Cognitive Level: Analyze/Analysis REF: p. 406 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to preN veUnRtSeIN xaGcTeBrb.CaO tiM on by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until the patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a “prn” basis according to symptoms.

ANS: C Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patient’s activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 405 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis

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d. Pursed-lip breathing ANS: B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.

DIF: Cognitive Level: Analyze/Analysis REF: p. 402 OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.

ANS: B The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs C N atUegRoSrIN y:GPThBy. CsiOoM logical Integrity

REF: p. 410

16. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility ANS: D Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.

DIF: Cognitive Level: Apply/Application OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 411 | Box 15-7

17. Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE.

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d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

ANS: A PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the “classic” signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE, and all should receive prophylaxis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 411 | Box 15-7 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. “I’m going to contact the pharmacist to see if you can take this medication by mouth.” b. “This injection is being given to prevent blood clots from forming.” c. “This medication will dissolve any blood clots you might get.” d. “You should not be receiving this medication. I will contact the provider to get it stopped.”

ANS: B Enoxaparin, or low–molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk aN ndURthSeINmGeTdBi.cCaOtiM on is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.

DIF: Cognitive Level: Apply/Application OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 411 | Box 15-8

19. A definitive diagnosis of pulmonary embolism can be made by a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

ANS: C The angiogram is one test that can confirm pulmonary embolism. A spiral CT scan is the other definitive test. Both tests have the limitation of not always being able to visualize small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is inconclusive.

DIF: Cognitive Level: Understand/Comprehension OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Assessment

REF: p. 412

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MSC: NCLEX Client Needs Category: Physiological Integrity 20. A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

ANS: C A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE. DIF: Cognitive Level: Apply/Application OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 412

21. Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics ANS: D Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot.

Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot.

DIF: Cognitive Level: Understand/Comprehension OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 411

22. The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio >300 ANS: B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.

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DIF: Cognitive Level: Apply/Application OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 399

23. The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio ANS: B 78/0.60 = 130, which meets the criteria for ARDS. DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 24. The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

ANS: B A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.

DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan OBJ: Describe methods for assessing the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 25. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family ANS: A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.

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DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 400

26. During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning.

ANS: A Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas, such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protection of the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.

DIF: Cognitive Level: Apply/Application REF: p. 400 OBJ: Discuss medical management of the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 27. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.

ANS: A Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema.

None of the other responses apply.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 397

28. From the following illustrations of the alveolar-capillary membrane, select the image that demonstrates shunting.

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a.

b.

c.

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d.

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e.

ANS: C Figure C shows a shunt. A is a normal alveolar-capillary unit. B is hypoventilation with increased PaCO2 and decreased PaO2. D is a ventilation/perfusion mismatch. E is a diffusion defect.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: N/A MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Figure 15-1

MULTIPLE RESPONSE 1. Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg ANS: A, C Diagnostic criteria for ARDS include bilateral infiltrates, or “white out,” on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition.

DIF: Cognitive Level: Remember/Knowledge OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 396-397

2. Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

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e. Using oral swabs or toothettes are just as effective as brushing the teeth.

ANS: B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.

DIF: Cognitive Level: Apply/Application OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Box 15-6

3. Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention ANS: A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.

DIF: Cognitive Level: U n d e r sNt aUnRdS/ ICNoGmT pB r. Ce hOeMn s i o n REF: p. 400 OBJ: Discuss medical management of the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

ANS: A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.

DIF: Cognitive Level: Apply/Application OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 407

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5. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low–molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage ANS: A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.

DIF: Cognitive Level: Understand/Comprehension OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Box 15-8

6. The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following?

(Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation.

ANS: A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient’s airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily “sedation holidays” help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

DIF: Cognitive Level: Understand/Comprehension OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Box 15-5

7. The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a. high Fowler’s. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg.

ANS: A, B, C

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Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement.

High Fowler’s is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler’s position are all appropriate ways to position the patient to facilitate gas exchange and comfort.

DIF: Cognitive Level: Understand/Comprehension OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 393

8. The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant ANS: A, B, C, E The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF. DIF: Cognitive Level: Apply/Application OBJ: Discuss medical manageNmUeRnSt I oNfGtThBe . CpaOtM ient with ARF. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 413-414

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Chapter 16: Acute Kidney Injury Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The critical care nurse knows that in critically ill patients, renal dysfunction a. is a very rare problem. b. affects nearly two thirds of patients. c. has a low mortality rate once renal replacement therapy has been initiated. d. has little effect on morbidity, mortality, or quality of life.

ANS: B The kidney is the primary regulator of the body’s internal environment. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate metabolic waste. Renal dysfunction is a common problem in critically ill patients, with nearly two thirds of patients experiencing some degree of renal dysfunction. The most severe cases, requiring renal replacement therapy, have a reported mortality rate of 50% to 60%. Acute kidney injury that progresses to chronic renal failure is associated with increased morbidity, mortality, and reduced quality of life.

DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 417

2. The nurse is caring for a patient NwUhRoS IhNaGs Ts uB s. Ct aOi nMe d blunt trauma to the left flank area, and is evaluating the patient’s urinalysis results. The nurse should become concerned when a. creatinine levels in the urine are similar to blood levels of creatinine. b. sodium and chloride are found in the urine. c. urine uric acid levels have the same values as serum levels. d. red blood cells and albumin are found in the urine.

ANS: D Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane. Their presence in urine may indicate glomerular damage.

DIF: Cognitive Level: Understand/Comprehension OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. A normal glomerular filtration rate is a. less than 80 mL/min. b. 80 to 125 mL/min. c. 125 to 180 mL/min. d. more than 189 mL/min.

REF: p. 418

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ANS: B At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephrons’ tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta.

DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 448

4. A normal urine output is considered to be a. 80 to 125 mL/min. b. 180 L/day. c. 80 mL/min. d. 1 to 2 L/day.

ANS: D At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate. As the filtrate passes through the various components of the nephrons’ tubules, 99% is reabsorbed into the peritubular capillaries or vasa recta. Eventually, the remaining filtrate (1% of the original 180 L/day) is excreted as urine, for an average urine output of 1 to 2 L/day.

DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: ANssUeRssSm INeGnTt B.COM MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 418

5. Renin plays a role in blood pressure regulation by a. activating the renin-angiotensin-aldosterone cascade. b. suppressing angiotensin production. c. decreasing sodium reabsorption. d. inhibiting aldosterone release.

ANS: A Specialized cells in the afferent and efferent arterioles and the distal tubule are collectively known as the juxtaglomerular apparatus. These cells are responsible for the production of a hormone called renin, which plays a role in blood pressure regulation. Renin is released whenever blood flow through the afferent and efferent arterioles decreases. A decrease in the sodium ion concentration of the blood flowing past the specialized cells (e.g., in hypovolemia) also stimulates the release of renin. Renin activates the renin-angiotensin-aldosterone cascade, which ultimately results in angiotensin II production.

Angiotensin II causes vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow and increasing sodium and water reabsorption in the distal tubule and collecting ducts.

DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment

REF: p. 418

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MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be a. an increased glomerular filtration rate (GFR). b. a normal serum creatinine level. c. increased ability to excrete drugs. d. hypokalemia.

ANS: B The most important renal physiological change that occurs with aging is a decrease in the GFR. After age 40, renal blood flow gradually diminishes at a rate of 10% per decade. With advancing age, there is also a decrease in renal mass, the number of glomeruli and peritubular density. Serum creatinine levels may remain the same in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased creatinine production. Tubular changes include a diminished ability to excrete drugs, including radiocontrast dyes used in diagnostic testing, which necessitates a decrease in drug dosing to avoid nephrotoxicity. Many medications, including antibiotics, require dose adjustments as kidney function declines. Age-related changes in renin and aldosterone levels also occur, which can lead to fluid and electrolyte abnormalities. Renin levels are decreased by 30% to 50% in the elderly, resulting in less angiotensin II production and lower aldosterone levels.

Together these can cause an increased risk of hyperkalemia. The aging kidney is also slower to correct an increase in acids, causing a prolonged metabolic acidosis and the subsequent shifting of potassium out of cells and worsening hyperkalemia.

DIF: Cognitive Level: Understand/Comprehension REF: p. 423 Lifespan box OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is a. oliguria. b. azotemia. c. acute kidney injury. d. prerenal disease.

ANS: B Azotemia refers to increases in blood urea nitrogen and serum creatinine. Oliguria is defined as urine output less than 0.5 mL/kg/hr. Elevation of BUN and creatinine can be the result of acute kidney injury or chronic kidney diseases. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal.

DIF: Cognitive Level: Remember/Knowledge REF: p. 419 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The most common cause of acute kidney injury in critically ill patients is a. sepsis.

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b. fluid overload. c. medications. d. hemodynamic instability.

ANS: A The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI. DIF: Cognitive Level: Remember/Knowledge REF: p. 419 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours.

The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should a. contact the provider and expect a prescription for a normal saline bolus. b. wait until the provider makes rounds to report the assessment findings. c. continue to evaluate urine output for 2 more hours. d. ignore the urine output, as this is most likely postrenal in origin.

ANS: A Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 16-2). These c o nNd Ui t Ri oSnI Ns G reTdBu.cCeOtM he glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal function resumes. Most forms of prerenal AKI can be reversed by treating the cause.

DIF: Cognitive Level: Apply/Application REF: Box 16-2 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. Acute kidney injury from postrenal etiology is caused by a. obstruction of the flow of urine. b. conditions that interfere with renal perfusion. c. hypovolemia or decreased cardiac output. d. conditions that act directly on functioning kidney tissue.

ANS: A Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on functioning kidney tissue are classified as intrarenal.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 422 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as intrarenal. The most common intrarenal condition is a. prolonged ischemia. b. exposure to nephrotoxic substances. c. acute tubular necrosis (ATN). d. hypotension for several hours.

ANS: C The most common intrarenal condition is ATN. This condition may occur after prolonged ischemia (prerenal), exposure to nephrotoxic substances, or a combination of these. Some patients have ATN after only several minutes of hypotension or hypovolemia, whereas others can tolerate hours of renal ischemia without having any apparent tubular damage.

DIF: Cognitive Level: Remember/Knowledge REF: p. 420 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should a. not be concerned unless uri nNeUoRuSt pI NuGt TdB ec.CreOaM ses. b. evaluate the patient’s serum creatinine for up to 72 hours after the procedure. c. obtain an order for a renal ultrasound. d. evaluate the patient’s postvoid residual volume to detect intrarenal injury.

ANS: B Contrast- induced kidney injury is diagnosed by an increase in serum creatinine of 25%, or 0.5 mg/dL, within 48 to 72 hours following the administration of contrast. Urine output usually remains normal. The renal ultrasound and postvoid residual assessment are not warranted.

DIF: Cognitive Level: Analyze/Analysis REF: p. 421 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response? a. “Unfortunately, kidney injury is not reversible; it is permanent.” b. “Kidney function usually returns within 2 weeks.” c. “You will know for sure if you start urinating a lot all at once.” d. “Recovery is possible, but it may take several months.”

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ANS: D Renal dysfunction is potentially reversible during the initiation phase. This phase spans several hours to 2 days, during which time the normal renal processes begin to deteriorate, but actual intrinsic renal damage has not yet occurred. During the maintenance phase, intrinsic renal damage is established, and the GFR stabilizes at approximately 5 to 10 mL/min. This phase usually lasts 8 to 14 days, but it may last up to 11 months. The longer a patient remains in this stage, the slower the recovery and the greater the chance of permanent renal damage will be. The recovery phase is the period during which the renal tissue recovers and repairs itself. A gradual increase in urine output and an improvement in laboratory values occur. Recovery may take as long as 4 to 6 months.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 421-422 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who a. has been on aminoglycosides for the past 6 days b. has a history of controlled hypertension with a blood pressure of 138/88 mm Hg c. was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks d. has a history of fluid overload as a result of heart failure ANS: C Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug (more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after e x po s u rNeU. R BSeIcNaG uTseB.oCfOtM his delay, the patient must be questioned about any recent medical therapy for which an aminoglycoside may have been prescribed.

The blood pressure of 138/88 mm Hg controlled by medication would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure.

DIF: Cognitive Level: Analyze/Analysis REF: p. 424 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal BUN/creatinine ratio. These levels most likely indicate a. increased nitrogen intake. b. acute kidney injury, such as acute tubular necrosis (ATN). c. hypovolemia. d. fluid resuscitation.

ANS: B A normal BUN/creatinine ratio is present in ATN. In ATN, there is actual injury to the renal tubules and a rapid decline in the GFR; hence, BUN and creatinine levels both rise proportionally as a result of increased reabsorption and decreased clearance. Hypovolemia would result in prerenal condition, which usually increases the BUN/creatinine ratio.

DIF:

Cognitive Level: Understand/Comprehension

REF: pp. 425-426

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OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 16. The patient’s serum creatinine level is 0.7 mg/dL. The expected BUN level should be a. 1 to 2 mg/dL. b. 7 to 14 mg/dL. c. 10 to 20 mg/dL. d. 20 to 30 mg/dL. ANS: B The normal BUN/creatinine ratio is 10:1 to 20:1. Therefore, the expected range for this creatinine level would be 7 to 14 mg/dL. DIF: Cognitive Level: Analyze/Analysis REF: p. 425 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a reliable 24-hour urine collection is not possible, a. it is not possible to determine the GFR. b. the BUN may be used to determine renal function. c. an elevated BUN/creatinine ratio can be used. d. a standardized formula mayNbU e RuSs IeNdGt To Bc. aClOcuMlate GFR. ANS: D Historically, timed 24-hour urine collections have been used to evaluate GFR or creatinine clearance. If a reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the creatinine clearance from a serum creatinine value.

The BUN level is not a reliable indicator of kidney function because the rate of protein metabolism is not constant. An increased BUN/creatinine ratio is typically noted with prerenal conditions, but does not provide an estimate of GFR. DIF: Cognitive Level: Understand/Comprehension REF: p. 427 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually: a. the same as for men. b. greater than that for men. c. multiplied by 0.85. d. multiplied by 1.15.

ANS: C

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For women, the calculated result is multiplied by 0.85 to account for the smaller muscle mass as compared to men.

DIF: Cognitive Level: Remember/Knowledge REF: p. 427 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has: a. acute kidney injury from a prerenal condition. b. acute kidney injury from postrenal obstruction. c. intrarenal disease, probably acute tubular necrosis. d. a urinary tract infection.

ANS: C Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria and a small amount of protein also may be seen. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Bacteria would be present in a urinary tract infection.

DIF: Cognitive Level: Analyze/Analysis REF: p. 427 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

INeGnTt B.COM TOP: Nursing Process Step: ANssUeRssSm MSC: NCLEX Client Needs Category: Physiological Integrity 20. The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that the patient’s condition is a. prerenal. b. postrenal. c. intrarenal. d. not renal related.

ANS: B Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from the obstruction. Coarse, muddy brown granular casts are classic findings in ATN (intrarenal), along with microscopic hematuria and a small amount of protein. In prerenal conditions, the urine typically has no cells but may contain hyaline casts. The flank pain and urinalysis definitely indicate a renal condition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 427 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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21. What is a minimally acceptable urine output for a patient weighing 75 kg? a. Less than 30 mL/hour b. 37 mL/hour c. 80 mL/hour d. 150 mL/hour ANS: B Normal urine output is 0.5 to 1 mL/kg of body weight each hour.

DIF: Cognitive Level: Remember/Knowledge REF: p. 429 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 22. Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 97.5 kg. This morning it is 99 kg.

The nurse understands that this corresponds to a(n) a. fluid retention of 1.5 liters. b. fluid loss of 1.5 liters. c. equal intake and output due to insensible losses. d. fluid loss of 0.5 liters.

ANS: A A 1-kg gain in body weight is equal to a 1000-mL fluid gain. This patient has gained 1.5 kg, or 1.5 liters of fluid.

DIF: Cognitive Level: Analyze/Analysis REF: p. 429 OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on intravenous (IV) fluids and IV mannitol. What action by the nurse is best? a. Assess the patient’s hearing. b. Assess the patient’s lungs. c. Decrease IV fluids once the diuretic has been administered. d. Give extra doses before giving radiological contrast agents.

ANS: B Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of intravascular volume triggered by mannitol. Hearing is assessed with the administration of loop diuretics, such as furosemide, which have been associated with deafness. Aggressive fluid administration is required in rhabdomyolysis.

Diuretics may increase the risk of acute kidney injury from volume depletion when they are given before procedures requiring radiological contrast agents or if the patient is hypovolemic. Adequate hydration before the administration of diuretics is essential.

DIF:

Cognitive Level: Apply/Application

REF: p. 431

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OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 24. A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends a. a diet of 2500 to 3500 kcal per day. b. protein intake of less than 50 grams per day. c. potassium intake of 10 mEq per day. d. fluid intake of less than 500 mL per day.

ANS: A Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per day (2500 to 3500 kcal) and protein intake of no less than 0.8 g/kg body weight. Patients who are extremely catabolic such as those on hemodialysis should receive protein in the amount of 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day; calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patient’s urine output plus an additional 600 to 1000 mL/day.

DIF: Cognitive Level: Apply/Application REF: p. 431 OBJ: Develop a plan of care for the patient with acute kidney injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 25. The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma pot a ssi uNmU Rl eSvI NelGs TaBn. dC Ot oMta l body potassium content safely in a patient with renal dysfunction? a. Sodium polystyrene sulfonate b. Sodium polystyrene sulfonate with sorbitol c. Regular insulin d. Calcium gluconate ANS: A Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate) actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction. In the past, sorbitol has been combined with sodium polystyrene sulfonate powder for administration. The concomitant use of sorbitol with sodium polystyrene sulfonate has been implicated in cases of colonic intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of regular insulin and calcium gluconate, “protect” the patient for only a short time until dialysis or cation exchange resins can be instituted.

DIF: Cognitive Level: Remember/Knowledge REF: p. 432 OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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26. The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The patient complains of general malaise and is tachypneic. An arterial blood gas shows that the patient’s pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to a. administer morphine to slow the respiratory rate. b. prepare for intubation and mechanical ventilation. c. administer intravenous sodium bicarbonate. d. cancel tomorrow’s dialysis session.

ANS: C Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury.

Treatment of metabolic acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less than 7.20 are usually treated with intravenous sodium bicarbonate. The goal of treatment is to raise the pH to a value greater than 7.20.

Rapid correction of the acidosis should be avoided, because tetany may occur as a result of hypocalcemia. Renal replacement therapies also may correct metabolic acidosis because it removes excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore, dialysis would not be canceled. The tachypnea is a compensatory mechanism for the metabolic acidosis, and treatments to decrease the respiratory rate are not indicated. Treatment is aimed at correcting the metabolic acidosis, and this scenario does not provide data to support the need for intubation.

DIF: Cognitive Level: Analyze/Analysis REF: p. 432 OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 27. The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as a. dialysis. b. diffusion. c. clearance. d. ultrafiltration.

ANS: D Ultrafiltration is the removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at decreasing waste products and treating fluid and electrolyte imbalances. Diffusion (or clearance) is the movement of solutes such as urea from the patient’s blood to the dialysate cleansing fluid, across a semipermeable membrane (the hemofilter).

DIF: Cognitive Level: Remember/Knowledge REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 28. The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the patient for insertion of a. a percutaneous catheter at the bedside.

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b. a percutaneous tunneled catheter at the bedside. c. an arteriovenous fistula. d. an arteriovenous graft.

ANS: A Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be used immediately. Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing hemodialysis; however, these catheters are usually inserted in the operating room. An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. Arteriovenous grafts are created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon. Grafts are placed under the skin and are surgically anastomosed between an artery and a vein. The graft site usually heals within 2 to 4 weeks.

DIF: Cognitive Level: Apply/Application REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 29. The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The catheter has been in place for 5 days. The nurse should a. prepare to assist with a routine dialysis catheter change. b. evaluate the patient for signs and symptoms of infection. c. teach the patient that the catheter is designed for long-term use. d. use one of the three lumens for fluid administration.

ANS: B Routine replacement of hemodialysis catheters to prevent infection is not recommended.

The decision to remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical catheter has a single or double lumen and is designed only for short-term renal replacement therapy during acute situations. The catheter is not used for fluid and medication administration.

DIF: Cognitive Level: Apply/Application REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 30. The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply, a. “It can be used immediately, so the catheter can come out anytime.” b. “It will take 2 to 4 weeks to heal before it can be used.” c. “The fistula will be usable in about 4 to 6 weeks.” d. “The fistula was made using graft material, so it depends on the manufacturer.”

ANS: C

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An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.

DIF: Cognitive Level: Understand/Comprehension REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 31. The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should a. draw blood from the left arm. b. take blood pressures from the left arm. c. start a new intravenous line in the left lower arm. d. auscultate the left arm for a bruit and palpate for a thrill.

ANS: D An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz every 8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such activities produce pressure changes within the altered vessels that could result in clotting or rupture.

DIF: Cognitive Level: Remember/Knowledge REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

SIN TOP: Nursing Process Step: ImNpUlRem enGtTatBio.CnOM MSC: NCLEX Client Needs Category: Physiological Integrity 32. The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should a. reassess the patient in an hour. b. raise the arm above the level of the patient’s heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.

ANS: C Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit and thrill indicate a loss of blood flow, most likely due to clotting. The patient will need to return to surgery as soon as possible for declotting. Raising the arm above the level of the heart will not help. Warm packs may or may not help.

DIF: Cognitive Level: Apply/Application REF: pp. 434-435 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 33. The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should

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apply a sterile gauze dressing to maintain sterility. replace the transparent dressing every 10 days to prevent manipulation. assess the catheter site for redness and/or swelling. use the catheter for drawing blood samples to reduce patient discomfort.

ANS: C Tenderness at the insertion site, swelling, erythema, or drainage should be reported to the physician. Transparent, semipermeable polyurethane dressings are recommended as they allow continuous visualization for assessment of signs of infection. Replace transparent dressings on temporary percutaneous catheters at least every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or loose. The catheter is not used for the administration of fluids or medications or for the sampling of blood unless a specific order is obtained to do so.

DIF: Cognitive Level: Apply/Application REF: p. 434 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 34. The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a little later, of becoming confused. The nurse realizes these are symptoms of a. dialyzer membrane incompatibility. b. a shift in potassium levels. c. dialysis disequilibrium syndrome. d. hypothermia.

ANS: C Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid. The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures. Dialyzer membrane incompatibility may cause hypotension.

Hyperthermia, not hypothermia, may result if the temperature control devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac dysrhythmias.

DIF: Cognitive Level: Remember/Knowledge REF: p. 436 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 35. Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that a. a hemofilter is used to facilitate ultrafiltration. b. it provides faster removal of solute and water.

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c. it does not allow diffusion to occur. d. the process removes solutes and water slowly.

ANS: D CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared to the rapid removal of water and solutes that occurs with intermittent hemodialysis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 436 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 36. Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to a. remove plasma water in cases of volume overload. b. remove fluids and solutes through the process of convection. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection, and dialysis.

ANS: A Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma wNaUteRrS. II Nt G diTfBfe.CrsOiM n that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal.

DIF: Cognitive Level: Remember/Knowledge REF: p. 436 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 37. Continuous venovenous hemofiltration is used to a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection, and dialysis.

ANS: A Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is used to remove plasma water in cases of volume overload. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal.

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DIF: Cognitive Level: Remember/Knowledge REF: pp. 436-437 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 38. Continuous venovenous hemodialysis is used to a. remove fluids and solutes through the process of convection. b. remove plasma water in cases of volume overload. c. remove plasma water and solutes by adding dialysate. d. combine ultrafiltration, convection and dialysis ANS: C Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute removal.

DIF: Cognitive Level: Remember/Knowledge REF: p. 438 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 39. The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should a. assess that the blood tubing is warm to the touch. b. assess the hemofilter every 6 hours for clotting. c. cover the dialysis lines to protect them from light. d. use clean technique during vascular access dressing changes.

ANS: A The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration without a change in the patient’s hemodynamic status). The CRRT system is frequently assessed to ensure filter and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch. The ultrafiltrate is assessed for blood (pink-tinged to frank blood), which is indicative of membrane rupture.

Sterile technique is performed during vascular access dressing changes.

DIF: Cognitive Level: Apply/Application REF: p. 438 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 40. Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis a. is more frequently used for acute kidney injury.

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b. uses the patient’s own semipermeable membrane (peritoneal membrane). c. is not useful in cases of drug overdose or electrolyte imbalance. d. is not indicated in cases of water intoxication.

ANS: B Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patient’s own semipermeable membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity. This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its comparatively slow ability to alter biochemical imbalances. Clinical indications for peritoneal dialysis include acute and chronic kidney injury, severe water intoxication, electrolyte disorders, and drug overdose.

DIF: Cognitive Level: Remember/Knowledge REF: p. 438 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Analysis MSC: NCLEX Client Needs Category: Physiological Integrity 41. An advantage of peritoneal dialysis is that a. peritoneal dialysis is time intensive. b. a decreased risk of peritonitis exists. c. biochemical disturbances are corrected rapidly. d. the danger of hemorrhage is minimal.

ANS: D Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and d i a lNyUs aRtSe I Ns oGl Tu Bt i .oCnOs Mc a n be individualized. In addition, automated peritoneal dialysis systems are available. Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity is sometimes difficult; and the risk of peritonitis is high.

DIF: Cognitive Level: Understand/Comprehension REF: p. 438 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Analysis MSC: NCLEX Client Needs Category: Physiological Integrity 42. The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should a. assess peritoneal dialysate return. b. check the patient’s blood sugar. c. evaluate the patient’s neurological status. d. inform the provider of probable visceral perforation.

ANS: A Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.

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DIF: Cognitive Level: Apply/Application REF: p. 439 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 43. The patient is on intake and output (I&O), as well as daily weights. The nurse notes that output is considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse should a. draw a trough level after the next dose of antibiotic. b. obtain an order to place the patient on fluid restriction. c. assess the patient’s lungs. d. insert an indwelling catheter.

ANS: C The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be determined by the provider upon physical examination and analysis of laboratory results. An indwelling urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it would not be done secondary to imbalanced intake and output.

DIF: Cognitive Level: Apply/Application REF: p. 439 OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs C N atUegRoSrIN y:GPThBy. CsiOoM logical Integrity 44. The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. Blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; the patient has not voided in 8 hours, and the bladder is not distended. The nurse anticipates a prescription for “stat” administration of a. a blood transfusion. b. fluid replacement with 0.45% saline. c. infusion of an inotropic agent. d. an antiemetic.

ANS: B This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement. Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a hypotonic solution, such as 0.45% saline. Blood products would be indicated only in the presence of bleeding following assessment of hemoglobin and hematocrit levels. The inotrope is contraindicated in the presence of volume depletion.

An antiemetic may be needed; however, the priority to prevent shock and acute kidney injury is fluid administration.

DIF: Cognitive Level: Analyze/Analysis REF: p. 430 OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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MULTIPLE RESPONSE 1. Identify which substances in the glomerular filtrate would indicate a problem with renal function. (Select all that apply.) a. Protein b. Sodium c. Creatinine d. Red blood cells e. Uric acid ANS: A, D The glomerular capillary membrane is approximately 100 times more permeable than other capillaries. It acts as a high-efficiency sieve and normally allows only substances with a certain molecular weight to cross. Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular membrane.

DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 418

2. The patient is admitted with a c uNt eUkRiSdInNeGyTiBn.jCuOr yMf r om a postrenal cause. Acceptable treatments for that diagnosis include: (Select all that apply.) a. bladder catheterization. b. increasing fluid volume intake. c. ureteral stenting. d. placement of nephrostomy tubes. e. increasing cardiac output.

ANS: A, C, D The location of the obstruction in the urinary tract determines the method by which the obstruction is treated and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes. Fluid volume intake may be recommended to treat prerenal causes of AKI. Increasing cardiac output would be indicated in certain prerenal causes of AKI. DIF: Cognitive Level: Remember/Knowledge OBJ: Review the anatomy and physiology of the renal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 422

3. Noninvasive diagnostic procedures used to determine kidney function include which of the following? (Select all that apply.) a. Kidney, ureter, bladder (KUB) x-ray b. Renal ultrasound

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c. Magnetic resonance imaging (MRI) d. Intravenous pyelography (IVP) e. Renal angiography ANS: A, B, C Noninvasive diagnostic procedures are usually performed before any invasive diagnostic procedures are conducted. Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys, ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging. Invasive diagnostic procedures for assessing the renal system include intravenous pyelography, computed tomography, renal angiography, renal scanning, and renal biopsy.

DIF: Cognitive Level: Remember/Knowledge REF: p. 428 OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of laboratory values and radiological diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.) a. Acidosis b. Hypokalemia c. Volume overload d. Hyperkalemia e. Uremia ANS: A, C, D, E The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume overload, and uremia. Dialysis is usually started early in the course of the renal dysfunction before uremic complications occur. In addition, dialysis may be started for fluid management when total parenteral nutrition is administered.

DIF: Cognitive Level: Remember/Knowledge REF: p. 434 OBJ: Describe the medical management of the patient with acute kidney injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.) a. Hypotension b. Dysrhythmias c. Muscle cramps d. Hemolysis e. Air embolism ANS: A, B

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Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications, preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism, and hyperthermia are rare complications of hemodialysis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 435 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.) a. evaluate morning laboratory results and report abnormal results. b. administer the patient’s antihypertensive medications. c. assess the dialysis access site and report abnormalities. d. weigh the patient to monitor fluid status. e. give all medications except for antihypertensive medications.

ANS: A, C, D The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse. Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble) medications are not given until after treatment.

The dialysis nurse or pha rma c i stN cUaRnS bI Ne GcToBn .sCuOl tM e d to determine which medications to withhold or administer. Supplemental doses are administered as ordered after dialysis.

Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of other medications that lower blood pressure (narcotics, sedatives) are reduced, if possible. The percutaneous catheter, fistula, or graft is assessed frequently; unusual findings such as loss of bruit, redness, or drainage at the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis disequilibrium syndrome.

DIF: Cognitive Level: Remember/Knowledge REF: p. 436 | Box 16-7 OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 17: Hematological and Immune Disorders Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Of the four major blood components, plasma a. is made up of circulating ions. b. comprises about 55% of blood volume. c. is transported to the cells by serum proteins. d. comprises about 45% of blood volume.

ANS: B Blood has four major components: (1) a fluid component called plasma, (2) circulating solutes such as ions, (3) serum proteins, and (4) cells. Plasma comprises about 55% of blood volume and is the transportation medium for important serum proteins such as albumin, globulin, fibrinogen, prothrombin, and plasminogen. The hematopoietic cells comprise the remaining 45% of blood volume.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441 OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called a. erythropoietin. b. a reticulocyte. c. hemoglobin. d. 2,3-DPG ANS: C Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygen-carrying molecule called hemoglobin. RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia.

Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441 OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called a. reticulocytes. b. hemoglobin.

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c. 2,3-DPG. d. erythropoietin.

ANS: D RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the number of available mature cells. The RBC transports hemoglobin, whose function is the transport of oxygen and carbon dioxide.

Hemoglobin binds with oxygen in the lungs and transports it to the tissues. The oxygen affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and depends on the blood pH and body temperature.

DIF: Cognitive Level: Remember/Knowledge REF: p. 441 OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse is caring for a patient who has undergone a splenectomy and notices that the patient’s platelet count has increased. The nurse realizes that the increase is due to a. platelet response to infection. b. stimulation secondary to erythropoietin. c. the patient’s inability to store platelets. d. the platelet’s 120-day life cycle.

ANS: C Two thirds of the platelets c i r c u Nl aUt eR iSnI Nt hGeT Bb l. Co oOdM. The spleen stores the remaining third and may become enlarged if excess or rapid platelet removal occurs. In patients who have had a splenectomy, 100% of the platelets remain in circulation. Platelets are the first responders in the clotting response (not infection), and they form a platelet plug that temporarily repairs an injured vessel. RBCs (not platelets) are generated from precursor stem cells under the influence of a growth factor called erythropoietin. Platelets have a life span of 8 to 12 days, but they may be used more rapidly if there are many vascular injuries or clotting stimuli.

Maturation of RBCs takes 4 to 5 days, and their life span is about 120 days.

DIF: Cognitive Level: Understand/Comprehension REF: p. 444 OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 5. The nurse examines the patient’s complete blood count with differential analysis and notices that the patient’s neutrophils are elevated but that the lymphocytes are lower than normal.

The drop in lymphocyte count in the differential is most likely due to a. the increase in neutrophil count. b. a new viral infection. c. a decreased number of “bands.” d. the lack of immature neutrophils.

ANS: A

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The differential count measures the percentage of each type of white blood cell (WBC) present in the venous blood sample, the total adding up to 100%. If the percentage of one type of WBC goes up (neutrophil count), the percentage of the remaining WBCs must go down as a result of the mathematical function of the differential. An elevation in the neutrophil count usually indicates a bacterial infection. “Bands” are immature neutrophils.

The phrase “a shift to the left” refers to an increased number of “bands,” or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report.

This finding generally indicates an acute bacterial infectious process (not viral) that draws on the WBC reserves in the bone marrow and causes less mature forms to be released.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 446-447 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse is caring for a patient receiving chemotherapeutic agents and notices that the patient’s neutrophil count is low. The nurse realizes that a. the patient has a bacterial infection. b. a shift to the left is occurring. c. chemotherapeutic agents alter the ability to fight infection. d. neutrophils have a long life span and multiply slowly.

ANS: C The survival time of neutrophils is short. When serious infection is present, neutrophils may live only hours as the neutrophils phagocytize infectious organisms. Because of this short life span, drugs that affect rapidly multiplying cells (e.g., chemotherapeutic agents) quickly decrease the neutrophil count a nNdUaRl tSeI rNtGh Te Bp. aCtOi eMn t ’ s ability to fight infection. An elevation in the neutrophil count usually indicates a bacterial infection. “Bands” are immature neutrophils. The phrase “a shift to the left” refers to an increased number of “bands,” or band neutrophils, compared with mature neutrophils on a complete blood count (CBC) report.

DIF: Cognitive Level: Remember/Knowledge REF: p. 445 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. When examining the patient’s laboratory values, the nurse notices an elevation in the eosinophil count. The nurse realizes that eosinophils become elevated a. with acute bacterial infections. b. in response to allergens and parasites. c. when the spleen is removed. d. in situations that do not require phagocytosis.

ANS: B An elevation in the neutrophil count (not eosinophil count) usually indicates a bacterial infection. Eosinophils are important in the defense against allergens and parasites and are thought to be involved in the detoxification of foreign proteins. Eosinophils are found largely in the tissues of the skin, lung, and gastrointestinal tract (not the spleen). Eosinophils respond to chemotactic mechanisms triggering them to participate in phagocytosis.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 445 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. Although monocytes may circulate for only 36 hours, they can survive for months or even years as tissue macrophages. Monocytes found in the liver are called a. alveolar macrophages. b. Kupffer’s cells. c. histiocytes. d. monokines.

ANS: B Monocytes are the largest of the leukocytes and constitute only 3% to 7% of the WBC differential. Once they migrate from the bloodstream into the tissues, monocytes mature into tissue macrophages, which are powerful phagocytes. In the lung, these tissue macrophages are known as alveolar macrophages; in the liver, they are Kupffer’s cells; in connective tissue, they are histiocytes. When activated by antigens, macrophages secrete substances called monokines that act as chemical communicators between the cells involved in the immune response.

DIF: Cognitive Level: Remember/Knowledge REF: p. 445 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. Lymphocytes are made up of B cells and T cells. B cells a. mature in lymphoid tissue. b. mediate humoral immunity. c. migrate to the thymus gland. d. destroy virus-infected cells.

ANS: B Lymphocytes are responsible for specific immune responses and participate in two types of immunity: (1) humoral immunity, which is mediated by B lymphocytes, and (2) cellular immunity, which is mediated by T lymphocytes. B lymphocytes, or B cells, originate in the bone marrow and are also thought to mature there. B cells perform in antibody production.

T cells are produced in the bone marrow, but they migrate to the thymus for maturation; then, most of them travel and reside in lymphoid tissues throughout the body. They live longer than B cells and participate in long-term immunity. The natural killer cell is a third type of lymphocyte, thought to be a differentiated form of the T lymphocyte. It is responsible for surveillance and destruction of virus-infected and malignant cells.

DIF: Cognitive Level: Remember/Knowledge REF: p. 446 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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10. The process by which the body actively produces cells and mediators that result in the destruction of the antigen is called a. passive immunity. b. active immunity. c. autoimmunity. d. recognition of self as nonself.

ANS: B Active immunity is a term used when the body actively produces cells and mediators that result in the destruction of the antigen. Passive immunity is that which is transferred from another person (e.g., maternal antibodies transferred to the newborn through the placenta).

In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues.

DIF: Cognitive Level: Remember/Knowledge REF: p. 447 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. The process in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell is known as a. opsonization. b. phagocytosis. c. the lymphoreticular system. d. the portal circulation.

ANS: A Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell. When infectious organisms escape the local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood, where infectious organisms can be removed before infecting the tissues.

DIF: Cognitive Level: Remember/Knowledge REF: p. 448 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These responses a. are mutually exclusive. b. are nonspecific immune responses. c. are producers of antigens. d. work together to provide immunity.

ANS: D

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Specificity refers to the finding that an immune response stimulates cells to develop immunity for a specific antigen. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. They are not mutually exclusive but act together to provide immunity. They do not produce antigens; they produce antibodies.

DIF: Cognitive Level: Remember/Knowledge REF: p. 448 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. Cellular immunity is mediated by a. B lymphocytes. b. T lymphocytes. c. immunoglobulins. d. suppressor B cells.

ANS: B Cellular immunity is mediated by the T lymphocyte. Humoral immunity is mediated by B lymphocytes and involves the formation of antibodies (immunoglobulins) in response to specific antigens that bind to their receptor sites. Suppressor T cells (not B cells) downgrade and suppress the humoral and cell-mediated responses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 449 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower-than-normal ratio may indicate acquired immunodeficiency syndrome (AIDS). This is because T4 cells a. enhance humoral immune response. b. suppress the humoral response. c. suppress the cell-mediated response. d. are a feature of an autoimmune disease.

ANS: A Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells, suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be distinguished by proteins present on the cell surface called cluster of differentiation (CD). Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells) is found in acquired immunodeficiency syndrome (AIDS), whereas a higher ratio (a decrease in suppressor T cells in relation to helper T cells) is a feature of an autoimmune disease.

DIF: Cognitive Level: Remember/Knowledge REF: p. 449 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment

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MSC: NCLEX Client Needs Category: Physiological Integrity 15. The nurse understands that immunosurveillance is a function of a. helper T lymphocytes. b. suppressor T lymphocytes. c. T4 lymphocytes. d. killer T lymphocytes.

ANS: D Cytotoxic or killer T cells (CD8 marker) participate directly in the destruction of antigens by binding to and altering the intracellular environment, which ultimately destroys the cell.

Killer cells also release cytotoxic substances into the antigen cell that cause cell lysis. Killer T cells additionally provide the body with immunosurveillance capabilities that monitor for abnormal cells or tissue. This mechanism is responsible for the rejection of transplanted tissue and the destruction of single malignant cells. Helper T cells (also known as T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cell-mediated responses.

DIF: Cognitive Level: Remember/Knowledge REF: p. 449 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 16. With minor vessel injury, primary hemostasis is achieved a. after several minutes. b. with fibrin to solidify the plaNtU elRetSIpNluGgT.B.COM c. usually within seconds. d. as a permanent solution.

ANS: C With minor vessel injury, primary hemostasis is temporarily achieved with platelet plugs, usually within seconds. During secondary hemostasis, the platelet plug is solidified with fibrin, an end product of the coagulation pathway, and requires several minutes to reach completion.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. In vivo, the primary activator of the coagulation cascade occurs via the a. intrinsic pathway. b. extrinsic pathway. c. common pathway. d. either intrinsic or extrinsic pathway.

ANS: B

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The classic theory of coagulation is viewed as occurring through two distinct pathways, intrinsic and extrinsic, which share a common “final” pathway, formation of insoluble fibrin. It is now known that the classic cascade theory of coagulation illustrates what occurs in vitro. In vivo, the primary activator of the coagulation cascade occurs via the extrinsic pathway. The intrinsic pathway serves to amplify the coagulation cascade.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. Common to both the intrinsic and the extrinsic pathway is a. factor XII. b. factor VII. c. factor X. d. subendothelial collagen.

ANS: C When blood is exposed to subendothelial collagen or is “injured,” factor XII is activated, which initiates coagulation via the intrinsic pathway. In the extrinsic pathway, tissue injury precipitates release of a substance known as tissue factor, which activates factor VII. Factor VII is key in initiating blood coagulation, and the two pathways intersect at the activation of factor X. Both coagulation pathways illustrate a final common pathway of clot formation, retraction, and fibrinolysis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450 OBJ: Describe pathophysiologNicUaRl ScIhNaGnTgBe .sCtOhM at affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze from the patient’s rectum and intravenous site. The nurse contacts the provider expecting a prescription for a. an infusion of protein S factor. b. blood work to evaluate protein C level. c. a laboratory test to determine factor X level. d. vitamin K injections.

ANS: D The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S (anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired hemostasis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 450 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that increases the risk for clotting. The nurse understands that the provider may request a test for a. factor VII deficiency. b. factor X deficiency. c. protein C deficiency. d. factor IX deficiency.

ANS: C The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the liver. Vitamin K is necessary for synthesis of factors II, VII, IX, and X, necessary for clotting to occur and for anticoagulation factors protein C and protein S. A deficiency of anticoagulation factors could lead to increased clot formation and problems such as stroke and pulmonary emboli. A deficiency of protein C can be seen in factor V Leiden, which increases the risk of thromboembolic events.

DIF: Cognitive Level: Remember/Knowledge REF: p. 450 Genetics Box OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse understands that when clots break down in a patient with a hematological disorder, which value will increase? a. Hemoglobin b. White blood cell count c. Vitamin K d. Fibrin split products ANS: D When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation but are seen in some hematological disorders as well as with thrombolytic therapy. Vitamin K is necessary for synthesis of factors II, VII, IX, and X, which are needed for clotting to occur. Hemoglobin may decrease if the patient is bleeding, and WBCs are not relevant to this scenario.

DIF: Cognitive Level: Remember/Knowledge REF: p. 451 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 22. The patient is being seen for complaints of general malaise, fatigue, and shortness of breath since having a cold 6 weeks earlier. The nurse should expect the provider to request a a. lymph node biopsy. b. differential blood count only. c. complete blood count (CBC) with differential. d. bone marrow biopsy.

ANS: C

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The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a complete blood count (CBC) with differential and a coagulation profile. The CBC evaluates the cellular components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma). A differential laboratory test is not done without the CBC first. A bone marrow biopsy is unwarranted; it would be performed only if preliminary studies indicated a hematological problem.

DIF: Cognitive Level: Understand/Comprehension REF: p. 452 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues, is known as a. polycythemia. b. anemia. c. iron deficiency. d. an increase in hemoglobin.

ANS: B The term anemia refers to a r e d uNcUt iRoSnI Ni nG tThBe. CnOu M m b e r of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of tissues. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease). Iron-deficiency anemia is the most common type of anemia.

DIF: Cognitive Level: Remember/Knowledge REF: Table 17-1 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 24. The patient is admitted with reports of chronic fatigue and shortness of breath. The nurse notices that the patient is tachycardic and has multiple bruises and petechiae on the body and arms. The patient also complains of frequent nosebleeds. The nurse should evaluate the patient’s a. complete blood count. b. hemoglobin and hematocrit. c. electrolyte values. d. blood culture results.

ANS: A

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In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells.

The CBC with differential, which includes a platelet count, would allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood loss, but assessment of cause (e.g., low platelets) is more important. Electrolyte values and blood culture results are not relevant to this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 451 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 25. The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an enlarged liver. The nurse suspects that the patient has a. aplastic anemia. b. hemolytic anemia. c. sickle cell anemia. d. anemia due to acute blood loss.

ANS: B Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or l i v eNrU. R TShIeNsG e TfiBn.C diOnM gs result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products. The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis).

DIF: Cognitive Level: Understand/Comprehension REF: p. 460 | Table 17-8 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 26. The patient is complaining of severe joint pain, as well as fatigue and shortness of breath.

The nurse notices that the patient’s joints are swollen and the legs are edematous. The nurse realizes that these are symptoms of a. anemia reflective of low volume. b. aplastic anemia.

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c. hemolytic anemia. d. sickle cell anemia.

ANS: D Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development. In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because renal tissue perfusion is impaired as a result of sluggish blood flow. Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis). The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation of breakdown products.

DIF: Cognitive Level: Understand/Comprehension REF: Table 17-8 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for a. an elevated bilirubin level. b. a low reticulocyte count. c. sickled cells. d. low white blood cell and platelet counts.

ANS: A Laboratory findings in anemia include a decreased RBC count and decreased hemoglobin and hematocrit values. The reticulocyte count is usually increased, indicating a compensatory increased RBC production with release of immature cells. This patient’s jaundice is indicative of hemolytic anemia. Patients with hemolytic anemia also have an increased bilirubin level. In sickle cell disease, a stained blood smear reveals sickled cells.

In aplastic anemia, the reticulocyte, platelet, RBC, and WBC counts are decreased because the marrow fails to produce any cells.

DIF: Cognitive Level: Understand/Comprehension REF: Table 17-8 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 28. Critical to caring for the immunocompromised patient is the understanding that a. the immunocompromised patient has normal white blood cell (WBC) physiology. b. the immunosuppression involves a single element or process.

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c. infection is the leading cause of death in these patients. d. immune incompetence is symptomatic even without pathogen exposure.

ANS: C Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body and create infection.

DIF: Cognitive Level: Remember/Knowledge REF: p. 461 | Table 17-9 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 29. The nurse is evaluating the patient’s laboratory values and notes an IgG level of 240 mg/dL. The nurse realizes that this patient is a candidate for a. no change in therapy because the level is normal. b. an immunoglobulin infusion. c. gene replacement therapy. d. increased doses of immunosuppressive medications.

ANS: B Medical therapy is directed at reversing the cause of the immune dysfunction and preventing infectious complications. In primary immunodeficiencies, B-cell and T-cell defects are treated with specific replacement therapy or bone marrow transplantation. IgG blood levels of less than 300 mg/dL warrant immunoglobulin infusion. Gene replacement therapy may soon be a realistic curative treatment option for some disorders. In secondary immunodeficiencies, the underlying causative condition is treated. For example, malnutrition is corrected, or doses of immunosuppressive medications are adjusted. For this patient, immunosuppressive medications should be discontinued or doses lowered.

DIF: Cognitive Level: Remember/Knowledge REF: p. 461 | Table 17-9 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 30. The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient is immunosuppressed. The nurse should a. place the patient in a single room with a HEPA filtration system. b. tell staff that hand washing is not recommended when working with this patient. c. start as many intravenous lines as possible to provide potential antibiotics.

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d. avoid the use of antimicrobial soaps when bathing and providing perineal care.

ANS: A Nursing interventions focus on protecting the patient from infection. Research studies support the use of high-efficiency particulate air (HEPA) filtration and laminar airflow in single-patient rooms for prevention of infection with airborne microorganisms. Nurses should diligently ensure adequate hygiene measures that include general bathing with antimicrobial soaps, oral care, and perineal care. Hand washing is paramount for staff, patients, and visitors. Nursing staff members play an important role in limiting breaks in skin integrity and ensuring sterile technique when procedures are unavoidable.

DIF: Cognitive Level: Apply/Application REF: p. 463 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 31. The nurse notes that the patient’s neutrophil count is less than 500 cells/microliter. The nurse realizes that this patient is a. is at low risk for infection. b. is at mild risk for infection. c. is at moderate risk for infection. d. is at severe risk for infection.

ANS: D Neutropenia is defined as an absNoUluRtSeIN neGuTtrBo.CpO hiM l count of less than 1500 cells/microliter of blood. Neutropenia may occur as a result of inadequate production or excess destruction of neutrophils. Patients with low neutrophil counts are predisposed to infections because of the body’s reduced phagocytic ability. Neutropenia is classified based on the patient’s predicted risk for infection: mild (1000-1500 cells/microliter), moderate (500-1000 cells/microliter), and severe (<500 cells/microliter).

DIF: Cognitive Level: Analyze/Analysis REF: p. 465 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 32. The patient is admitted with neutropenia. The nurse should assess the patient frequently for a. signs of systemic infection. b. a drop in temperature from its normal set point. c. the absence of chills. d. bradycardia.

ANS: A

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There are no specific signs or symptoms of a low neutrophil count. Every body system is examined for physical findings of infection. Typical signs may not be evident. Pain such as sore throat or urethral discomfort may be indicative of an infected site. Areas of heavy bacterial colonization (e.g., oral mucosa, perineal area, and venipuncture and catheter sites) have the highest risk of infection; however, the most common clinical infections are sepsis and pneumonia. Additional signs or symptoms of systemic infection include a rise in temperature from its normal set point, chills, and accompanying tachycardia.

DIF: Cognitive Level: Apply/Application REF: p. 465 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 33. The patient’s white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil count of 65% and a band level of 5%. The absolute neutrophil count is a. 4000 cells/microliter. b. 3000 cells/microliter. c. 2800 cells/microliter. d. 2600 cells/microliter.

ANS: C The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (NpUoR lySsI;NaGlsToB.cCaOllM ed segs or neutrophils) and bands (immature neutrophils).

WBC  (segs + bands) This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia.

DIF: Cognitive Level: Apply/Application REF: p. 465 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 34. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a normal neutrophil level of 70% with 5% bands. This patient a. is at low risk for infection. b. is at mild risk for infection. c. is at moderate risk for infection. d. is at severe risk for infection.

ANS: D

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The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages (with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands (immature neutrophils).

WBC  (segs + bands) 600  (0.70 + 0.05) 600  0.75 = 450 cells/microliter This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia. Neutropenia is classified based on the patient’s predicted risk for infection: mild (1000-1500 cells/microliter), moderate (500-1000 cells/microliter), and severe (<500 cells/microliter).

DIF: Cognitive Level: Analyze/Analysis REF: p. 464 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 35. Desired patient outcomes for immunocompromised patient related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of a. less than 500 cells/microliter. b. 500 to 1000 cells/microliter. c. 1000 to 1500 cells/microliteN r.URSINGTB.COM d. 1500 cells/microliter or higher.

ANS: D Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an absolute neutrophil count of 1500 cells/microliter or higher.

DIF: Cognitive Level: Understand/Comprehension REF: p. 464 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 36. The patient is diagnosed with lymphoma but has a normal white blood cell (WBC) count.

The nurse understands that this patient a. has normal WBC function as the WBC is normal. b. will have increased bruising and bleeding. c. is at risk for infection. d. is at risk for an allergic reaction.

ANS: C

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Malignant diseases involving WBCs are termed leukemia, lymphoma, and plasma cell neoplasm (multiple myeloma). Regardless of the specific neoplastic disorder, a deficiency of functional WBCs is a common problem. Despite normal serum cell counts, WBC activity is always impaired, and infection is the most common complication of all these disorders.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 465-466 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 37. The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the symptom most unique to this disease is a. fever. b. night sweats. c. bone pain. d. lymph node enlargement.

ANS: C Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias, activity intolerance, and night sweats are nonspecific indicators of immune disease.

INoGmTpBr.C DIF: Cognitive Level: UndersNtaUnRdS/C ehOeMnsion REF: p. 468 | Table 17-10 OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus, thrombocytopenia, and disseminated intravascular coagulation.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

38. Cases of primary immunodeficiency are usually related to a. aging. b. nutritional deficiencies. c. malignancies. d. a single gene defect.

ANS: D Most primary immunodeficiencies are congenital disorders related to a single gene defect.

Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are examples of conditions that may be associated with acquired immunodeficiencies.

DIF:

Cognitive Level: Understand/Comprehension

REF: p. 469

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OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 39. The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and is concerned about acquired immune deficiency syndrome (AIDS). The patient’s blood work shows the presence of HIV antibodies. The nurse should explain that a. HIV symptoms will continue throughout the patient’s life. b. HIV is an acute disease with a short prognosis. c. HIV infection and AIDS are considered chronic diseases. d. very few people with HIV develop AIDS. ANS: C Seroconversion is manifested by the presence of HIV antibodies and usually occurs 2 to 4 weeks after the initial infection. Symptoms associated with seroconversion include flulike symptoms such as fever, sore throat, headache, malaise, and nausea and usually last 1 to 2 weeks. The earlier stages of HIV infection may last as long as 10 years and may produce few or no symptoms, although viral particles are actively replacing normal cells. AIDS is the final stage of HIV infection. It is estimated that 99% of untreated HIV-infected individuals will progress to AIDS. Treatment regimens with combined antiviral drug regimens are controlling the progression to AIDS. HIV infection and AIDS are now considered, for many infected individuals, chronic diseases.

DIF: Cognitive Level: Understand/Comprehension REF: p. 469 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs C N atUegRoSrIN y:GPThBy. CsiOoM logical Integrity 40. When caring for a patient with HIV, the nurse should a. not focus on the mouth, as infections of the mouth are rare. b. assure the patient that infections are not a major problem at this point. c. inform the patient that the disease does not affect the respiratory system. d. monitor the patient’s medication regimen.

ANS: D Nursing assessment includes evaluation of the neurological status, mouth, respiratory status, abdominal symptoms, and peripheral sensation. As with all immunosuppressed patients, those with HIV infection must be protected from infection. These patients provide additional clinical challenges because of their multisystemic, clinical complications. For unclear reasons, persons with HIV infection have a higher propensity for adverse drug reactions than other patient groups and require careful monitoring of all medication regimens.

DIF: Cognitive Level: Apply/Application REF: p. 470 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The nurse understands that

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all patients with bleeding disorders demonstrate active bleeding. many patients have bleeding that is not obvious. mucous membranes have a high threshold for bleeding. capillaries in mucous membranes lie deep in the membrane.

ANS: B Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding. The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in hypovolemic shock.

DIF: Cognitive Level: Understand/Comprehension REF: p. 471 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 42. The nurse is caring for a patient diagnosed with anemia. This morning’s hematocrit level is 24%. Platelet level is 200,000/microliter. The nurse can expect to a. continue monitoring the patient, as this hematocrit is normal. b. administer platelets to help control bleeding. c. give fresh frozen plasma to decrease prothrombin time. d. provide RBC transfusion because this level is below the normal threshold.

ANS: D Transfusion thresholds are established based on laboratory values and patient-specific variables. In general, a threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patient’s cardiovascular tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time and partial thromboplastin time or a specific factor deficiency.

DIF: Cognitive Level: Analyze/Analysis REF: p. 472 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 43. The patient is admitted with anemia caused by blood loss and thrombocytopenia and has a platelet count of 22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse should a. give the RBCs before the platelets. b. give the platelets before the RBCs. c. use local therapies to stop the bleeding. d. give the platelets and RBCs at the same time.

ANS: B

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When the patient’s blood does not clot because of thrombocytopenia, administration of RBCs before platelets will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition (e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue contact and initiation of a surface clot.

DIF: Cognitive Level: Apply/Application REF: p. 472 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 44. The patient has a platelet count of 9,000/microliter. The nurse realizes that a. this is a normal platelet level. b. spontaneous bleeding may occur. c. the patient is at great risk for fatal hemorrhage. d. this level is considered slightly low.

ANS: C A quantitative deficiency of platelets is termed thrombocytopenia. By definition, this is a platelet count of less than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter.

DIF: Cognitive Level: Understand/Comprehension REF: p. 474 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: NuNrUsiRnSgINPGroTcBe. sCsOSMtep: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 45. The patient’s platelet count is 35,000/microliter. The provider prescribes administration of 10 units of single-donor platelets. After transfusion, the nurse can expect the patient’s platelet count to be a. between 85,000/microliter and 135,000/microliter. b. between 50,000/microliter and 75,000/microliter. c. greater than 150,000/microliter. d. between 150,000/microliter and 185,000/microliter.

ANS: A Medical treatment of thrombocytopenia includes infusions of platelets. Patients who require multiple platelet transfusions should be evaluated for single-donor platelet products, which permit administration of 6 to 10 units of platelets with exposure to the antigens of only one person. For every unit of single-donor platelets, the platelet count should increase by 5000 to 10,000/microliter.

DIF: Cognitive Level: Apply/Application REF: p. 474 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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46. The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated coagulation (DIC). Definitive diagnosis of DIC is made by evidence of a. a decrease in fibrin degradation products. b. an increased D-dimer level. c. thrombocytopenia. d. low fibrinogen levels.

ANS: B Diagnosis of DIC is made based on recognition of pertinent risk factors, clinical symptoms, and the results of laboratory studies. Evidence of factor depletion in the form of thrombocytopenia and low fibrinogen levels is seen in the early phase; however, definitive diagnosis is made by evidence of excess fibrinolysis detectable by elevated fibrin degradation products, an increased D-dimer level, or a decreased antithrombin III level.

DIF: Cognitive Level: Remember/Knowledge REF: p. 467 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Numbers of white blood cells (WBCs) are increased in circumstances of (Select all that apply.) a. inflammation. b. allergy. c. invasion by pathogenic orgaNniUsRmSsI.NGTB.COM d. malnutrition. e. immune diseases.

ANS: A, B, C WBCs play a key role in the defense against infectious organisms and foreign antigens.

Numbers of WBCs are increased in circumstances of inflammation, tissue injury, allergy, or invasion with pathogenic organisms. Numbers of WBCs are diminished in conditions of malnutrition, advancing age, and immune diseases.

DIF: Cognitive Level: Understand/Comprehension REF: p. 444 OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. Autoimmunity can result from (Select all that apply.) a. recognition of tissue as “self.” b. injury to tissues. c. infection. d. malignancy. e. unknown causes.

ANS: B, C, D, E

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In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those tissues. Autoimmunity can result from injury to tissues, infection, or malignancy, although in many cases the cause is not known.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 446-447 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. Inflammation is initiated by cellular injury and (Select all that apply.) a. is necessary for tissue repair. b. inhibits the process called chemotaxis. c. is harmful when uncontrolled. d. is less efficient when complement proteins are present. e. occurs when mediators cause vasoconstriction.

ANS: A, C Inflammation is initiated by cellular injury, is necessary for tissue repair, and is harmful when uncontrolled. When cellular injury occurs, a process called chemotaxis generates both a mediator and a neutrophil response. Mediator substances (histamine, serotonin, kinins, lysosomal enzymes, prostaglandin, platelet-activating factor, clotting factors, and complement proteins) are released at the site of injury. These mediators cause vasodilation, increase blood flow, induce capillary permeability, and promote chemotaxis and phagocytosis by neutrophils. Inflammatory symptoms such as redness, heat, pain, and swelling are sequelae of these responses. Complement proteins enhance the antibody activity, phagocytosis, and inflammation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 448 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Exudate formation at the inflammatory site functions to (Select all that apply.) a. opsonize bacteria. b. dilute toxins. c. deliver proteins. d. attach to the target cell. e. carry away toxins.

ANS: B, C, E Exudate formation at the inflammatory site has three functions: dilute toxins produced, deliver proteins and leukocytes to the site, and carry away toxins and debris. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte’s ability to engulf the target cell.

DIF: Cognitive Level: Understand/Comprehension REF: p. 448 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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5. Causes of anemia include which of the following: (Select all that apply.) a. hypoxic states. b. blood loss. c. impaired production of red blood cells. d. increased destruction of red blood cells. e. chronic obstructive pulmonary disease.

ANS: B, C, D Causes of anemia include (1) blood loss (acute or chronic), (2) impaired production of RBCs, (3) increased RBC destruction, or (4) a combination of these. Polycythemia, a disorder in which the number of circulating RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary disease).

DIF: Cognitive Level: Understand/Comprehension REF: p. 456 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. When dealing with hematological malignancies, therapies that have significant management roles include which of the following: (Select all that apply.) a. chemotherapy. b. biotherapy. c. bone marrow transplantation. d. surgery. e. radiation.

ANS: A, B, C, E Therapy commonly includes chemotherapy and biotherapy. Bone marrow transplantation is used in selected cases. Surgery may be performed to establish a pathological diagnosis by excisional or incisional biopsy but has no other significant role in the management of hematological malignancies. Radiation may be used to treat lymphoma when the disease is limited to single nodes or node groups.

DIF: Cognitive Level: Understand/Comprehension REF: p. 468 | Table 17-10 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 7. Secondary immunodeficiency involves the loss of a previously functional immune defense system, which can be caused by (Select all that apply.) a. a single gene defect. b. AIDS. c. aging. d. nutritional deficiencies. e. immunosuppressive therapies.

ANS: B, C, D, E

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In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously functional immune defense system.

AIDS is the most notable secondary immunodeficiency disorder caused by an infection.

Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that may be associated with acquired immunodeficiencies.

DIF: Cognitive Level: Understand/Comprehension REF: p. 469 OBJ: Describe pathophysiological changes that affect hematological and immunological structure and function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient has been on multiple medications at home for various ailments. In assessing the patient’s medication list, the nurse notes medications that may alter hemostasis, including which of the following: (Select all that apply.) a. aminoglycosides. b. antiplatelet agents. c. cephalosporins. d. vasoconstrictors. e. sulfonamides.

ANS: A, B, C, E Medications that may alter hemoNsUtaRsSisI Ni G ncTlBu.dCeOaMminoglycosides, anticoagulants, antiplatelet agents, cephalosporins, histamine blockers, nitrates, sulfonamides, sympathomimetics, and vasodilators.

DIF: Cognitive Level: Remember/Knowledge REF: p. 471 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. In caring for the patient who has a coagulopathy, the nurse should (Select all that apply.) a. assess fluids for occult blood. b. observe for oozing and bleeding and remove clots that form. c. limit invasive procedures. d. take temperatures rectally to increase accuracy. e. weigh dressings to assess blood loss.

ANS: A, C, E Nursing interventions specific to the patient with a coagulopathy include the following: weigh dressings to assess blood loss, assess fluids for occult blood, observe for oozing and bleeding from skin and mucous membranes, and leave clots undisturbed. Precautions such as limiting invasive procedures, including indwelling urinary catheters or rectal temperature measurement, are also important.

DIF:

Cognitive Level: Apply/Application

REF: p. 472

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OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin.

ANS: A, B, C, D Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate.

Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparin’s antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC. DIF: Cognitive Level: Understand/Comprehension REF: pp. 476-478 OBJ: Develop plans of care for the immunocompromised host and the patient who has a bleeding disorder.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs C N atUegRoSrIN y:GPThBy. CsiOoM logical Integrity

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Chapter 18: Gastrointestinal Alterations Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously because the submucosa has no blood vessels.

ANS: B The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the major layer of the wall. The serosa is the outermost layer.

DIF: Cognitive Level: Remember/Knowledge REF: p. 480 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse is assessing the patient and notices that the oral cavity is only slightly moist and contains a scant amount of t h i c kNsUaRl i SvIaN eGvTeBn. Ct hOoMu g h the patient’s fluid intake has been sufficient. The nurses realizes that the condition of the patient’s mouth is probably caused by a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

ANS: B Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary, sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL. DIF: Cognitive Level: Understand/Comprehension REF: p. 481 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer a. H2-histamine receptor blockers. b. gastrin.

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c. vagal stimulation. d. vitamin B12.

ANS: A Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid. Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation.

Gastrin is a hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment for peptic ulcer disease.

DIF: Cognitive Level: Apply/Application REF: p. 495 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following? a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia.

ANS: A Secretion of mucus by Brunner’s glands is inhibited by sympathetic stimulation, which leaves the duodenum unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract is the site for more than 50% of peptic ulcers.

Sympathetic stimulation produces a scant output of thick saliva. Vitamin B 12 is critical for the formation of red blood cells (RBCs), and a deficiency in this vitamin causes anemia.

However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium, potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is vomiting or has GI suction.

DIF: Cognitive Level: Apply/Application REF: p. 482 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 5. After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that a. vitamin B12 is needed for the formation of red blood cells. b. vitamin B12 is needed to prevent a type of anemia. c. vitamin B12 is essential for surgical wound healing. d. vitamin B12 is always deficient in obese people.

ANS: A

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Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach. Vitamin B12 is essential in the formation of red blood cells. A deficiency of B12 does lead to anemia, but this answer is not as specific as stating the relationship of B12 to red blood cells, so it is not as informative. Vitamins A and C are more essential for wound healing. Obese people may or may not be deficient in this vitamin.

DIF: Cognitive Level: Understand/Comprehension REF: p. 482 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

ANS: C Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the surrounding organs (stomach and duodenum).

DIF: Cognitive Level: Apply/Application REF: p. 483 OBJ: Review the anatomy and physiology of the gastrointestinal system.

NpUlR SIN TOP: Nursing Process Step: Im em enGtTatBio.CnOM MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is caring for a patient with liver disease. When assessing the patient’s laboratory values, the nurse should a. disregard the level of conjugated bilirubin. b. assess the total bilirubin c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

ANS: B Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected in the indirect serum bilirubin level. In the liver, bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Cirrhosis and liver cancer decrease the liver’s ability to conjugate bilirubin. Some conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level. The direct or conjugated bilirubin is increased in liver failure. Total bilirubin is also measured and will also be increased in liver failure. There is no need to call the provider for values only slightly elevated. Unconjugated bilirubin is toxic to cells.

DIF: Cognitive Level: Understand/Comprehension REF: p. 484 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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8. The liver plays a major role in homeostasis by a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I. ANS: C The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the circulation and therefore prevents clotting in the macrovascular and microvascular.

DIF: Cognitive Level: Understand/Comprehension REF: p. 485 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The liver detoxifies the blood by a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

ANS: A Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion. This procesNs Ui sR uS sI Nu aGlTl yB .aCcOc M o m pl i s he d by conversion of the fat-soluble compounds to water-soluble compounds. They can then be excreted via the bile or the urine.

DIF: Cognitive Level: Understand/Comprehension REF: p. 485 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 10. The patient is being admitted to the hospital. At home, the patient takes an over-the-counter supplement of vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamin D is stored in the liver with a 10-month supply to prevent deficiency.

ANS: D The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce vitamin D. Over-the-counter supplements are ordered, depending on the patient’s status.

DIF:

Cognitive Level: Understand/Comprehension

REF: p. 485

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OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucous membranes for signs of dryness. d. expect decreased bowel sounds.

ANS: B Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers, or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.

DIF: Cognitive Level: Remember/Knowledge REF: p. 485 OBJ: Review the anatomy and physiology of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack. c. visceral pain often leads to tN acUhRyScIaNrG diTaBa.CnO dM hypertension. d. increasing intensity of pain is always significant.

ANS: D Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by engorged mucosa, pressure in the mucosa, distension, or spasm. Visceral pain is likely to cause pallor, perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain, especially after surgery or other intervention, is always significant and usually signifies complicating factors, such as inflammation, gastric distension, hemorrhage into tissue or the peritoneal space, or peritonitis.

DIF: Cognitive Level: Apply/Application REF: p. 489 OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath.

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d. watches for signs of pain and distension.

ANS: C The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration.

Pulsations, if they are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions, discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and hydration status, not masses.

Abdominal distension, particularly in the presence of pain, should always be investigated because it usually indicates trapped air or fluid within the abdominal cavity.

DIF: Cognitive Level: Remember/Knowledge REF: p. 490 OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. When assessing the patient’s bowel sounds, the nurse a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patient’s knees.

ANS: C Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the pat ient ’Ns Ua Rr m he. CsOi dMe s or folded at the chest is usually S IsNaGt Tt B recommended. Placing a pillow under the patient’s knees also helps to relax the abdominal wall.

DIF: Cognitive Level: Apply/Application REF: p. 489 OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 15. When assessing bowel sounds, the nurse a. uses the “bell” part of the stethoscope. b. listens at least 15 minutes. c. expects bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting “absent bowel sounds.”

ANS: D Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.

DIF:

Cognitive Level: Remember/Knowledge

REF: p. 489

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OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 16. Infection by Helicobacter pylori bacteria is a major cause of a. duodenal ulcers. b. Cushing’s ulcers. c. Curling’s ulcers. d. stress ulcers.

ANS: A Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that develop as a result of burn injury are often called Curling’s ulcers. Stress ulcers associated with severe head trauma or brain surgery are called Cushing’s ulcers.

DIF: Cognitive Level: Remember/Knowledge REF: p. 490 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to a. infection with Helicobacter N pyUlRoSriINbGacTtBe.rCiaO.M b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

ANS: D A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow, leading to ischemia. The secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers.

DIF: Cognitive Level: Understand/Comprehension REF: p. 491 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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18. The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. it is not usually associated with alcohol intake or retching.

ANS: A A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal anti-inflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the esophagogastric junction may cause massive GI bleeding, requiring surgical repair.

DIF: Cognitive Level: Understand/Comprehension REF: p. 491 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the preseN ncUeRoSfINoGccTuBl.tCbOlM eeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: A Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool with a chemical reagent (guaiac).

DIF: Cognitive Level: Remember/Knowledge REF: p. 492 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 20. The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels.

The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient’s next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

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ANS: A GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac). Stool and nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black, foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting or drainage from a nasogastric tube that yields blood or coffee-ground–like material is associated with upper GI bleeding. However, blood or coffee-ground–like contents may not be present if bleeding has ceased or if it arises beyond a closed pylorus.

DIF: Cognitive Level: Apply/Application REF: p. 492 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. All vital signs would expect to be normal. b. Oral temperature of 103°. c. Heart rate 125 beats per minute. d. Systolic blood pressure of 120 mm Hg. ANS: C As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, andNUkR idSnIN eyGsT. BH. Cy Op oMt e n s i o n is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume.

DIF: Cognitive Level: Apply/Application REF: p. 494 Clinical Alert Box OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 22. The patient is admitted with the diagnosis of GI bleeding. The patient’s heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: B

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Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a blood loss of at least 1000 mL—25% of the total blood volume. Vital signs should be monitored at least every 15 minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin, lungs, liver, and kidneys.

DIF: Cognitive Level: Analyze/Analysis REF: p. 494 Clinical Alert Box OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space, the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

ANS: C The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

DIF: Cognitive Level: Understand/Comprehension REF: p. 494 Clinical Alert Box OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 24. The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%.

ANS: C One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient’s intravascular volume status and whether the patient is actively bleeding.

DIF: Cognitive Level: Analyze/Analysis REF: p. 495 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic

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failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 25. The patient is ordered to have large-volume gastric lavage. The nurse will most likely need to a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room-temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

ANS: D Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room-temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

DIF: Cognitive Level: Apply/Application REF: p. 495 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 26. The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that a. bismuth will be added to theNcUuRrrSeInNtGtTriBp.lCeOthMerapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

ANS: A Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.

DIF: Cognitive Level: Understand/Comprehension REF: p. 495 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 27. The nurse is to assist the provider in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-Fowler’s position.

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ANS: B Because endoscopy is performed at the patient’s bedside, the nurse assists with procedures and monitors for untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern. Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory complications.

DIF: Cognitive Level: Apply/Application REF: p. 496 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 28. The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient’s abdomen is rigid. The nurse should a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid.

ANS: A Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, de p e ndi n gN oUnR St hI Ne GcTauBs.Ce OoM f the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately.

DIF: Cognitive Level: Apply/Application REF: p. 499 Clinical Alert Box OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 29. The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver’s collateral circulation.

ANS: B

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Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver’s collateral circulation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 498 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 30. The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must a. maintain as little traction as possible. b. apply external traction using a side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

ANS: D It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

DIF: Cognitive Level: Apply/Application REF: p. 300 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 31. The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumens and remove the tube. d. call the provider with an update of the patient’s condition.

ANS: C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible life-threatening complications that need to be assessed.

Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain.

In the event of any of these life-threatening emergencies, all three lumens are cut and the entire tube is removed. For this reason, scissors are kept at the patient’s bedside at all times.

Endotracheal intubation is strongly recommended to protect the airway.

DIF: Cognitive Level: Apply/Application REF: p. 500 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation

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MSC: NCLEX Client Needs Category: Physiological Integrity 32. The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

ANS: D Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

DIF: Cognitive Level: Understand/Comprehension REF: p. 500 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 33. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, “What causes this? Why does it hurt so much?” The nurse should answer: a. “Pancreatitis is extremely rare, and no one knows why it causes pain.” b. “Pancreatitis is caused by diabetes; you should be checked.” c. “Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain.” d. “The pain is localized to the pancreas. Fortunately, it will not affect anything else.”

ANS: C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

DIF: Cognitive Level: Understand/Comprehension REF: p. 501 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Integrated Process: Teaching-Learning MSC: NCLEX Client Needs Category: Physiological Integrity 34. The patient is admitted with acute pancreatitis. The nurse should a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D

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The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease, gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed, these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. C-reactive protein increases within 48 hours and is a marker of severity.

DIF: Cognitive Level: Apply/Application REF: p. 502 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 35. The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

ANS: B Patients with acute pancreatitis cNaUnRdSeIN veGlToB p.C mOilM d or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient’s chance of significant morbidity and mortality. In Ranson’s research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

DIF: Cognitive Level: Analyze/Analysis REF: Box 18-12 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 36. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. monitor the patient’s blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient’s fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

ANS: A

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In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity. Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringer’s solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250 to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and kidneys, reducing the potential for complications.

DIF: Cognitive Level: Apply/Application REF: p. 510 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 37. The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient’s calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withholds any further calcium treatments. d. places an oral airway at the bedside.

ANS: A Patients with severe hyp ocalcemNi Ua R(sSeIrNuGmTBc.aClcOiM um level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low, and replacement of calcium is expected.

DIF: Cognitive Level: Apply/Application REF: p. 504 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 38. Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery.

ANS: D

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Nasogastric suction and “nothing by mouth” status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distension, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. However, trends in nutritional management are changing. NPO status and NG suction are not used as much, especially for mild cased.

Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 504-505 Evidence Based Practice Box OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 39. Pain control is a nursing priority in patients with acute pancreatitis because pain a. increases pancreatic secretions. b. is caused by decreased distension of the pancreatic capsule. c. decreases the patient’s metabolism. d. is caused by dilation of the biliary system.

ANS: A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient’s metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 505 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 40. The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an “as needed” (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

ANS: D

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Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

DIF: Cognitive Level: Apply/Application REF: p. 505 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 41. The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst.

The nurse realizes that a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

ANS: C Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed.

Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peNr U itoRnS iI tNisG. T B. CO M DIF: Cognitive Level: Understand/Comprehension REF: p. 506 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 42. The patient is diagnosed with hepatitis. In caring for this patient, the nurse should a. administer anti-inflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-the-counter anti-inflammatory medications at home.

ANS: B No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition.

Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

DIF:

Cognitive Level: Apply/Application

REF: p. 507

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OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 43. The nurse is caring for a critically ill patient with end-stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status? a. Jugular venous distension b. Normal sinus rhythm on the cardiac monitor c. Blood pressure of 180/90 mm Hg d. Stools that are guaiac positive ANS: A Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs.

Blood pressure decreases, and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

DIF: Cognitive Level: Analyze/Analysis REF: p. 509 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs C N a tUe gRoS rI N y:GPThBy. CsiOoM l ogi c al Integrity 44. The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse’s first action should be to a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowler’s position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

ANS: B Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler’s position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler’s position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

DIF: Cognitive Level: Apply/Application REF: p. 512 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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45. Lactulose is considered the first-line treatment for hepatic encephalopathy and works by a. causing ammonia to enter the bloodstream via the colon. b. trapping ammonia in the bowel for excretion. c. causing constipation and inhibiting the excretion of ammonia. d. creating an alkaline environment in the bowel.

ANS: B Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose is given orally or via a rectal enema.

DIF: Cognitive Level: Remember/Knowledge REF: p. 513 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 46. The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse a. evaluate renal function studies daily. b. give the medication every 12 hours. c. evaluate liver studies for signs of neomycin-induced damage. d. obtain stool guaiac tests to ensure that pathogens are being destroyed.

ANS: A Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein b r e a kNdUoRwSnI NaGn Td Ba. m C OmMo n i a production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.

DIF: Cognitive Level: Apply/Application REF: p. 513 OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 47. Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks.

ANS: C Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.

DIF:

Cognitive Level: Apply/Application

REF: p. 513

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OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or hepatic failure.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess ANS: B, C, D Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.

DIF: Cognitive Level: Understand/Comprehension REF: p. 490 OBJ: Describe general assessment of the gastrointestinal system.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient’s care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. e. cholinergic drugs.

ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

DIF: Cognitive Level: Apply/Application REF: p. 491 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 3. When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss

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Hemodynamic stability Vital signs every 30 minutes Signs of hypervolemic shock Necessity for fluid resuscitation

ANS: A, B, E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

DIF: Cognitive Level: Apply/Application REF: p. 494 Clinical Alert Box OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 4. Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

ANS: A, B, E Nursing and medical priorities fN orUtRhSeINmGaTnBa.gCeOmMent of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.

DIF: Cognitive Level: Apply/Application REF: pp. 503-505 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 5. The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation ANS: B, C, E

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Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage.

Disseminated intravascular coagulation may also develop.

DIF: Cognitive Level: Apply/Application REF: Box 18-15 OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 19: Endocrine Alterations Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin pump contacts the clinic to report mechanical failure of the infusion pump.

The nurse instructs the patient to begin monitoring for signs of: a. adrenal insufficiency. b. diabetic ketoacidosis. c. hyperosmolar, hyperglycemic state. d. hypoglycemia.

ANS: B If the insulin pump fails, the patient with type 1 diabetes will have a complete interruption of insulin delivery; diabetic ketoacidosis will occur. Adrenal insufficiency would not result from insulin pump failure. Hyperosmolar, hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this patient has type 1 diabetes. Interruption of insulin delivery in type 1 diabetes would result in hyperglycemia, not hypoglycemia.

DIF: Cognitive Level: Apply/Application REF: p. 531 | Box 19-3 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Intervention MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which of the following pat i ent s Ni sU aRtStIhNeGhTiBg.hCeOsM t risk for hyperosmolar hyperglycemic syndrome? a. An 18-year-old college student with type 1 diabetes who exercises excessively b. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning c. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections d. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza ANS: D Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would result in further increases in blood sugar. Some individuals with advanced Alzheimer’s disease cannot communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate. Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis. Interruption of insulin delivery related to a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency and is associated with diabetic ketoacidosis. A patient with type 2 diabetes who is new to insulin is at risk for hypoglycemia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 524 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment

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MSC: NCLEX Client Needs Category: Physiological Integrity 3. Which of the following laboratory values would be more common in patients with diabetic ketoacidosis? a. Blood glucose >1000 mg/dL b. Negative ketones in the urine c. Normal anion gap d. pH 7.24 ANS: D A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis.

Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.

DIF: Cognitive Level: Understand/Comprehension REF: p. 526 | Figure 19-3 OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and interpretation of laboratory and other diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome? a. Activity intolerance b. Fluid volume deficient c. Hyperthermia d. Impaired nutrition, more than body requirements ANS: B Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia; therefore, fluid volume deficit is a priority nursing diagnosis. Even though activity intolerance is a potential nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions, it is not a first priority. Hyperthermia is associated with thyroid crisis. Although overweight and obesity are risk factors for type 2 diabetes, during metabolic crisis, the patient has inadequate energy available to tissues because of limited availability and poor utilization of insulin.

DIF: Cognitive Level: Analyze/Analysis REF: p. 427 | Figure 19-3 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 5. The nurse is assigned to care for a patient who presented to the emergency department with diabetic ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is ordered. The targeted blood glucose value after the first hour of therapy is a. 70 to 120 mg/dL. b. a decrease of 25 to 50 mg/dL compared with admitting values. c. a decrease of 35 to 90 mg/dL compared with admitting values.

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d. less than 200 mg/dL. ANS: C Initial insulin infusions should be administered with a target blood glucose reduction of 35 to 90 mg/dL per hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral edema; thus, controlled reduction of glucose is required.

DIF: Cognitive Level: Apply/Application REF: p. 530 OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 6. A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it is all right to withhold the medication for 3 days. What is likely to happen to this patient? a. He will go into adrenal crisis. b. He will go into thyroid storm. c. His autoimmune disease will go into remission. d. Nothing; it is appropriate to stop the medication for 3 days.

ANS: A Patients on long-term corti cost e NroUi dR St hI Ne G r aTpBy. Ca Or eMat high risk for adrenal crisis, because therapy suppresses the endogenous production of steroids. Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid therapy. Thyroid storm may occur when antithyroid medications are suddenly withdrawn. Rheumatoid arthritis is likely to exacerbate with the withdrawal of glucocorticoids. Adrenal crisis may occur shortly after withdrawal of glucocorticoids.

DIF: Cognitive Level: Remember/Knowledge REF: p. 536 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 7. The nurse is caring for a patient with a diagnosis of head trauma. The nurse notes that the patient’s urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient may be developing a. diabetes insipidus. b. diabetic ketoacidosis. c. hyperosmolar hyperglycemic syndrome. d. syndrome of inappropriate secretion of antidiuretic hormone.

ANS: A

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Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following head trauma is associated with diabetes insipidus. Even though hyperosmolar hyperglycemic syndrome results in osmotic diuresis, the cause is a deficiency in insulin in type 2 diabetes, not head trauma. SIADH may occur with head trauma but results in reduced urine output and, potentially, hypervolemia.

DIF: Cognitive Level: Analyze/Analysis REF: p. 550 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. A patient is receiving hydrocortisone sodium succinate for adrenal crisis. What other medication does the nurse prepare to administer? a. Regular insulin b. A proton pump inhibitor c. Canagliflozin d. Propranolol ANS: B Patients receiving hydrocortisone sodium succinate need to be on a regime to prevent GI bleeding. A proton pump inhibitor would be a good choice. Insulin is used in the treatment of diabetes or for glycemic control in acutely ill nondiabetics. Canagliflozin is an oral anti-hyperglycemic medication. Propranolol is a beta blocker often used in thyroid storm to blunt the effects of sympathetic nervous system stimulation.

DIF: Cognitive Level: Apply/Application REF: Table 19-5 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an intravenous (IV) solution that contains dextrose started? a. Never; normal saline is the only appropriate solution in diabetes management b. When the blood sugar reaches 70 mg/dL c. When the blood sugar reaches 150 mg/dL d. When the blood glucose reaches 250 mg/dL ANS: D Normal saline is the best initial fluid choice for management of hyperglycemic states.

However, when the glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia. Hypotonic solutions are required to replace intracellular fluid deficits, and dextrose is required to prevent hypoglycemia later when glucose levels reach initial targets. A glucose level of 70 mg/dL is suggestive of hypoglycemia and would require oral glucose replacement, a 50% dextrose bolus, or glucagon administration.

DIF: Plan OBJ:

Cognitive Level: Remember/Knowledge

REF: Nursing Care

Discuss the medical management of patients with hyperglycemic crisis,

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hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis.

Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium ANS: C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes the lowering of potassium as the electrolyte is relocated to the cellular bed.

Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 530-531 S I eNnGt ToBf . C OBJ: Discuss the medical m a nNaUg Re m p aOt M i e nt s with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 11. A patient is admitted to the oncology unit with a small-cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

ANS: D SIADH may be induced by ectopic sources of antidiuretic hormone, including small-cell lung carcinoma. The clinical presentation of a dilutional hypervolemia is consistent with SIADH. Adrenal crisis is characterized by fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss. Diabetes insipidus is characterized by increased urine output and is not typically caused by lung tumors. Myxedema coma, although characterized by facial and peripheral edema, does not result from small-cell lung carcinoma.

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DIF: Cognitive Level: Analyze/Analysis REF: p. 553 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis ANS: D In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 527 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 13. Which of the following statemenNtUs Ri sS It Nr uGeTaBb. Co Ou tMt h e medical management of diabetic ketoacidosis? a. Serum lactate levels are used to guide insulin administration. b. Sodium bicarbonate is a first-line medication for treatment. c. The degree of acidosis is assessed through continuous pulse oximetry. d. Volume replacement and insulin infusion often correct the acidosis.

ANS: D Volume replacement promotes hemodilution in the face of a hyperosmolar state. Insulin administration promotes entry of glucose into cells and relieves ketosis. As volume is replaced and glucose normalizes, the acidosis often resolves. Insulin administration, not lactate levels, is guided by blood glucose values. Sodium bicarbonate is administered only to correct severe acidosis (pH <7.1). Degree of acidosis is assessed through arterial blood gas readings and serum ketone levels.

DIF: Cognitive Level: Remember/Knowledge REF: p. 531 | Box 19-3 OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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14. An individual with type 2 diabetes who takes glipizide has begun a formal exercise program at a local gym. While exercising on the treadmill, the individual becomes pale, diaphoretic, shaky, and has a headache. The individual feels as though she is going to pass out. What is the individual’s priority action? a. Drink additional water to prevent dehydration. b. Eat something with 15 g of simple carbohydrates. c. Go to the first-aid station to have glucose checked. d. Take another dose of the oral agent.

ANS: B The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia. Hypoglycemia does not place the patient at risk for dehydration. The patient requires immediate treatment and could pass out while going to the first-aid station. It cannot be assumed that the gym has access to diabetes treatment supplies. Additional doses of oral diabetes medications should not be taken without consulting the health care team. An additional dose of glipizide could promote further hypoglycemia.

DIF: Cognitive Level: Remember/Knowledge REF: p. 530 | Box 19-7 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 15. A patient with a history of type 1 diabetes and an eating disorder is found unconscious. In the emergency department, the fNoUl l Ro SwI iNnGg Tl Ba b. C vOaMl u e s are obtained: Glucose: 648 mg/dL pH: 6.88 PaCO2: 20 mm Hg PaO2: 95 mm Hg HCO3¯: undetectable Anion gap: >31 Na+: 127 mEq/L K+: 3.5 mEq/L Creatinine: 1.8 mg/dL After the patient’s airway and ventilation have been established, the next priority for this patient is: a. administration of a 1-L normal saline fluid bolus. b. administration of 0.1 unit of regular insulin IV push followed by an insulin infusion. c. administration of 20 mEq KCl in 100 mL. d. IV push administration of 1 amp of sodium bicarbonate.

ANS: A

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After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of normal saline over 1 hour. The fluid resuscitation should begin before administration of insulin. Potassium may be added to fluid replacement bags after the first liter of normal saline has infused, provided that the serum potassium is greater than 3.3 mEq/L. Although bicarbonate replacement is indicated in this clinical situation, the bicarbonate is administered by infusion, not by IV push, until the pH exceeds 7.0.

DIF: Cognitive Level: Apply/Application REF: p. 530 | Box 19-7 OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 16. Acute adrenal crisis is caused by a. acute renal failure. b. deficiency of corticosteroids. c. high doses of corticosteroids. d. overdose of testosterone.

ANS: B An adrenal crisis occurs because of a lack of corticosteroids. This may be due to lack of endogenous cortisol production, lack of ACTH production, or inhibition of natural cortisol production by exogenous cortisol administration. Acute renal failure would not be associated with adrenal crisis. High doses of corticosteroids are associated with Cushing’s syndrome. Testosterone overdose would not be associated with adrenal crisis. Steroid hormones may possess some co N r t Ui cRoSi dI NpGr TopBe. Cr tOi eMs. DIF: Cognitive Level: Remember/Knowledge REF: p. 538 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 17. The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is a. fluid volume excess. b. hyperglycemia. c. hyperkalemia d. hypernatremia ANS: C

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Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone acts to retain sodium, resulting in water retention and potassium loss. Inadequate levels of aldosterone therefore result in hyponatremia, fluid loss, and hyperkalemia. Inadequate cortisol levels may cause weight loss, weakness, and hypoglycemia. Fluid volume deficit may accompany adrenal crisis as a result of sodium loss from decreases in cortisol and aldosterone. Hypoglycemia may accompany adrenal crisis as a consequence of inadequate amounts of cortisol, which limits gluconeogenesis.

Hyponatremia may accompany adrenal crisis because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.

DIF: Cognitive Level: Remember/Knowledge REF: p. 538 Lab Alert Box OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 18. A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to which of the following cardiac rhythms while providing care to this patient? a. Atrial fibrillation b. Idioventricular rhythm c. Junctional rhythm d. Sinus bradycardia ANS: A Increased heart rate and t a c hyd yNsrUhRySt hI NmGiTa,Bi. CncOlM udi ng atrial fibrillation, may accompany thyroid storm. Bradycardiac rhythms may be suggestive of hypothyroidism.

DIF: Cognitive Level: Apply/Application REF: p. 545 | Box 19-17 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 19. An elderly female patient has presented to the emergency department with altered mental status, hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory findings support this diagnosis? a. Elevated adrenocorticotropic hormone b. Elevated cortisol levels c. Elevated T3 and T4 d. Elevated thyroid-stimulating hormone ANS: D Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism. Elevated adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency. Elevated cortisol levels accompany Cushing’s syndrome. Elevated T3 and T4 levels are consistent with hyperthyroidism.

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DIF: Cognitive Level: Remember/Knowledge REF: Lab Alert Box Throid Disorders OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 20. A patient presents to the emergency department with the following clinical signs: Pulse: 132 beats/min Blood pressure: 88/50 mm Hg Respiratory rate: 32 breaths/min Temperature: 104.8°F Chest x-ray: Findings consistent with congestive heart failure Cardiac rhythm: Atrial fibrillation with rapid ventricular response These signs are consistent with which disorder? a. Adrenal crisis b. Myxedema coma c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) d. Thyroid storm ANS: D Tachycardia, vascular collapse, rapid cardiac rhythms, congestive heart failure, and severe hyperthermia are consistent with the clinical manifestations of the hypermetabolic state of thyroid storm. Adrenal i nsuf fi ci N e nUcRySpI Nr eGsTe Bn t. Cs OwMi t h weakness, fatigue, weight loss, anorexia, abdominal pain, and hyperpigmentation. Myxedema coma is an extreme form of hypothyroidism and is characterized by signs of hypometabolism, including bradycardia, hypotension, hypothermia, cold intolerance, and neurological sluggishness. SIADH is characterized by fluid retention, hyponatremia, and hemodilution. Heat intolerance and atrial fibrillation are not typical characteristics of the condition.

DIF: Cognitive Level: Understand/Comprehension REF: Box 19-17 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 21. Which of the following would be seen in a patient with myxedema coma? a. Decreased reflexes b. Hyperthermia c. Hyperventilation d. Tachycardia ANS: A

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Myxedema coma is characterized by a hypometabolic state, and all body functions are slowed including cardiovascular function, decreased gastrointestinal mobility, cold intolerance, and diminished reflexes. Hyperthermia is characteristic of thyroid storm.

Hyperventilation is characteristic of thyroid storm and diabetic ketoacidosis. Tachycardia is characteristic of thyroid storm.

DIF: Cognitive Level: Understand/Comprehension REF: p. 547 | Box 19-19 OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and interpretation of laboratory and other diagnostic tests.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 22. The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority to monitoring the patient carefully for which of the following? a. Congestive heart failure b. Hypovolemic shock c. Infection d. Volume overload ANS: B Pituitary surgery or manipulation of the pituitary stalk during surgery may precipitate diabetes insipidus. Profound diuresis that accompanies diabetes insipidus may result in hypovolemic shock. Fluid volume deficit, not overload, accompanies diabetes insipidus.

Increased risk of infection may accompany hyperglycemia and elevated cortisol levels.

Fluid volume overload is more characteristic of SIADH. DIF: Cognitive Level: Apply/Application REF: p. 549 OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and interpretation of laboratory and other diagnostic tests.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 23. The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition? a. Daily weight b. Fingerstick glucose c. Lung sound auscultation d. Urine osmolality ANS: D

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Diabetes insipidus may result from traumatic brain injury. It results in passage of large volumes of dilute urine. Urine osmolality is low in individuals with diabetes insipidus, and urine specific gravity assessments should be incorporated into the care of at-risk patients.

Even though daily weight monitoring is important in the assessment of fluid balance disorders, it is not specific in determining cause. Urine specific gravity measuring would be a more specific means of identifying diabetes insipidus. Blood glucose values would be abnormal in diabetes mellitus but not diabetes insipidus. Changes in breath sounds accompany fluid overload states such as SIADH. Diabetes insipidus is a hypovolemic condition.

DIF: Cognitive Level: Apply/Application REF: p. 550 | Table 19-7 OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and interpretation of laboratory and other diagnostic tests.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 24. Which of the following laboratory values would be found in a patient with syndrome of inappropriate secretion of antidiuretic hormone? a. Fasting blood glucose 156 mg/dL b. Serum potassium 5.8 mEq/L c. Serum sodium 115 mEq/L d. Serum sodium 152 mEq/L ANS: C SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur.

B .aCyOaMc c om pa ny the syndrome. Glucose elevation A low serum sodium (below 1 35N UmRESqI N/ LG)Tm is not a classic sign of SIADH. Hyperkalemia does not accompany the dilutional hyponatremia of SIADH. Serum sodium levels are typically lower in the dilutional hyponatremia that accompanies SIADH. DIF: Cognitive Level: Analyze/Analysis REF: p. 553 | Table 19-7 OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and interpretation of laboratory and other diagnostic tests.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 25. A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical management of this condition will include a. administration of 3% normal saline. b. administration of exogenous vasopressin. c. fluid restriction. d. low sodium diet.

ANS: C

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The first treatment of this condition is volume restriction; other treatments may not be needed if restrictions work. Extreme fluid restrictions (800 to 1000 mL/day) may be required in the treatment of SIADH. Hypertonic saline administration may be used to treat severe hyponatremia (serum sodium <110 mEq/L) but is not used in most cases. The administration of hypertonic saline carries significant risk. Vasopressin replacement would provide additional ADH and further complicate SIADH. Sodium replacement may be required to treat the hemodilution associated with SIADH. DIF: Cognitive Level: Apply/Application REF: p. 553 OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 26. The nurse is providing insulin education for an elderly patient with long-standing diabetes.

A prescription has been written for the patient to take 20 units of insulin glargine at 10 PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent is a. 0200. b. 0400. c. 0800. d. peakless.

ANS: D Insulin glargine is a long-acting insulin that has no specific peak in action.

S IiNt hG pT eBa. Ck O The remaining times are a s s o c i aNt eUdRw sM of other short-acting and intermediate-acting insulin products.

DIF: Cognitive Level: Apply/Application REF: Figure 19-2 OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 27. The nurse is caring for a patient who suffered a head trauma following a fall. The patient’s heart rate is 112 beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes. The patient is confused and restless. The following laboratory values are reported: serum sodium is 115 mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with which disorder? a. Cerebral salt wasting b. Diabetes insipidus c. Syndrome of inappropriate secretion of antidiuretic hormone d. Thyroid storm ANS: A

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Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma. Diabetes insipidus is characterized by clinical signs of dehydration with elevated serum sodium. SIADH is characterized by hyponatremia and fluid volume overload. Thyroid storm would not directly affect sodium levels.

DIF: Cognitive Level: Analyze/Analysis REF: p. 554 | Table 19-7 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 28. A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV) regular insulin to an intensive insulin therapy regimen of insulin glargine and insulin aspart. How should the nurse manage this transition in insulin delivery? a. Administer the insulin glargine and continue the IV insulin infusion for 24 hours. b. Administer the insulin glargine and discontinue the IV infusion in several hours. c. Discontinue the IV infusion and administer the insulin aspart with the next meal. d. Discontinue the IV infusion and administer the Lantus insulin at bedtime.

ANS: B Subcutaneous insulin should be administered 1 to 4 hours before discontinuing the intravenous infusion to allow the patient to reach adequate plasma insulin levels to prevent redevelopment of DKA. Conti n uNaUt iRoSnI NoGf Tt hBe. Ci On sMu li n infusion in conjunction with the long-acting insulin glargine would result in hypoglycemia. Discontinuation of intravenous insulin before administration of subcutaneous insulin would result in recurrence of DKA in a patient with type 1 diabetes.

DIF: Cognitive Level: Apply/Application REF: p. 519 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity MULTIPLE RESPONSE 1. Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.) a. Administer levothyroxine as prescribed. b. Encourage the intake of foods high in sodium. c. Initiate passive rewarming interventions. d. Monitor airway and respiratory effort. e. Monitor urine osmolality.

ANS: A, C, D

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Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid hormone, airway management related to respiratory depression and potential airway obstruction related to tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is monitored in conditions that affect antidiuretic hormone levels.

DIF: Cognitive Level: Analyze/Analysis REF: pp. 548-549 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.) a. ADH deficiency b. ADH excess c. ADH insensitivity d. ADH replacement therapy e. Water deprivation ANS: A, C Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic) or impaired renal response to ADH (nephrogenic). ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.

DIF: Cognitive Level: Remember/Knowledge REF: p. 549 | Box 19-21 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. A college student was admitted to the emergency department after being found unconscious by a roommate. The roommate informs emergency medical personnel that the student has diabetes and has been experiencing flulike symptoms, including vomiting, since yesterday.

The patient had been up all night studying for exams. The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this client? (Select all that apply.) a. Blood glucose: 43 mg/dL b. Blood glucose: 524 mg/dL c. HCO3—: 10 mEq/L d. PaCO2: 37 mm Hg e. pH: 7.23 ANS: B, C, E

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The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is characterized by hyperglycemia and low bicarbonate levels, low CO 2, and low pH. A blood glucose of 43 mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.

DIF: Cognitive Level: Analyze/Analysis REF: p. 527 | Box 19-3 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select all that apply.) a. Altered sleep/rest patterns b. Eating disorder c. Exposure to influenza d. High levels of stress e. Lack of financial resources ANS: A, B, D, E Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining self-care practices. Financial and time limitations may affect the ability to monitor for changes in control. Exposure to influenza is a physiological factor; it would Nn oUtRbSeI NaGpTsBy .cChOoMs o c i a l factor associated with DKA. DIF: Cognitive Level: Analyze/Analysis REF: p. 524 | Box 19-3 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Psychosocial Integrity 5. Factors associated with the development of nephrogenic diabetes insipidus include which of the following? (Select all that apply.) a. Heredity b. Medications c. Meningitis d. Pituitary tumors e. Sickle cell disease ANS: A, B, E Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte disturbances, and medications such as phenytoin and lithium carbonate. Meningitis may result in neurogenic diabetes insipidus. Pituitary tumors may result in neurogenic diabetes insipidus.

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DIF: Cognitive Level: Understand/Comprehension REF: p. 549 OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse has been assigned the following patients. Which patients require assessment of blood glucose control as a nursing priority? (Select all that apply.) a. 18-year-old male who has undergone surgical correction of a fractured femur b. 29-year-old female who is undergoing evaluation for pheochromocytoma c. 43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN) d. 62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer e. 72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic obstructive pulmonary disease (COPD) ANS: B, C, D, E Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia; obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.

DIF: Cognitive Level: Analyze/Analysis REF: Box 19-17 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs C N atUegRoS rIN y:GPThBy. CsiOoM logical Integrity 7. A patient with long-standing type 1 diabetes presents to the emergency department with a loss of consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the following? (Select all that apply.) a. Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL. b. Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia. c. Discontinue the insulin pump by removing the infusion set catheter. d. Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider. e. Perform blood glucose monitoring before exercising and driving.

ANS: B, D, E

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This patient experienced a severe hypoglycemic episode. The patient is at risk for this because of a history of autonomic neuropathy as evidenced by gastroparesis, which causes erratic gastric emptying and glucose absorption, and renal insufficiency, which can result in erratic clearance of insulin. Patients with hypoglycemia unawareness should increase blood glucose monitoring; carry a glucagon emergency kit and instruct a family member or friend on administration; monitor before high-risk activities, such as driving and exercising; and use caution with alcohol ingestion. Glucagon or 50% dextrose is administered for severe hypoglycemic episodes when a patient is unconscious or extremely uncooperative. Oral glucose replacement may be dangerous in a severe reaction because of the risk of aspiration.

Mild and moderate hypoglycemic reactions should be managed with oral glucose replacement. Insulin pump therapy may be suspended temporarily during a hypoglycemic episode but should not be discontinued. The infusion set catheter should not be removed during a hypoglycemic episode.

DIF: Cognitive Level: Apply/Application REF: Box 19-17 | Box 19-18 OBJ: Formulate plans of care for patients with critical alterations in endocrine function.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

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Chapter 20: Trauma and Surgical Management Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. Which of the following best defines the term traumatic injury? a. All trauma patients can be successfully rehabilitated. b. Traumatic injuries cause more deaths than heart disease and cancer. c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events. d. Trauma mainly affects the older adult population.

ANS: C Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors, including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals.

DIF: Cognitive Level: Understand/Comprehension REF: p. 556 OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 2. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident? a. High-speed motor vehicle crNaU s hReSsINGTB.COM b. Poisonings from prescription or illegal drugs c. Violent or domestic traumatic altercations d. Work-related falls ANS: B People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in those 65 years and older. Domestic violence is not well defined as an age-related trauma incident.

DIF: Cognitive Level: Understand/Comprehension REF: p. 556 OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center? a. Level I b. Level II c. Level III d. Level IV

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ANS: A Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower-level trauma centers.

DIF: Cognitive Level: Remember/Knowledge REF: p. 558 | Table 20-1 OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection? a. A fall from a 6-foot ladder onto the grass b. A shotgun wound to the abdomen c. A knife wound to the right chest d. A motor vehicle crash in which the driver hits the steering wheel ANS: B The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible folNloUwRiSnIgNG anTBin.CjuOrM y in which the patient hits the steering column.

DIF: Cognitive Level: Analyze/Analysis REF: p. 563 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED a. includes a cervical spine x-ray study to determine the presence of a fracture. b. involves turning the patient from side to side to get a look at his back. c. is done quickly in the first few minutes to get a baseline assessment and establish priorities. d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

ANS: C The primary survey is a systematic rapid assessment of the patient’s airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities.

DIF:

Cognitive Level: Remember/Knowledge

REF: p. 563

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OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony.

The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate? a. Insert an oral airway to prevent aspiration and to protect the airway. b. Offer the patient an emesis basin so that you can measure the amount of emesis. c. Prepare to suction the oropharynx while maintaining cervical spine immobilization. d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

ANS: C Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis, and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 566 | Table 20-2 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 7. Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fraNcUtuRrSeI?NGTB.COM a. Insertion of a nasotracheal tube b. Insertion of an indwelling urinary catheter c. Endotracheal intubation d. Placement of an oral airway ANS: A Nasotracheal tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.

DIF: Cognitive Level: Remember/Knowledge REF: p. 566 | Table 20-2 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration? a. Placement of an intraosseous catheter b. Placement of a central line c. Insertion of a femoral catheter by a trauma surgeon

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d. Rapid transfer to the operating room ANS: A Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.

DIF: Cognitive Level: Remember/Knowledge REF: p. 568 OBJ: Describe prehospital care, emergency care, and resuscitation of the trauma patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 9. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by a. cardiac contusion. b. cardiogenic shock. c. hypovolemia. d. pericardial tamponade.

ANS: C Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss.

Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often.

Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.

DIF: Cognitive Level: AnalyzNeU /ARnSaIN lyGsTisB.CROEMF: p. 567 OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 10. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients’ needs. d. have the nurse assist with transport of patients to procedural areas.

ANS: A A nurse in the medical records department is a knowledgeable health care provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to the medical records department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.

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DIF: Cognitive Level: Analyze/Analysis REF: pp. 560-561 OBJ: Describe a system approach to trauma care.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 11. A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority? a. Place the patient on a cardiac monitor b. Prepare for rapid intubation c. Seal the wound with occlusive dressings d. Start 2 large bore IVs ANS: D A patient with a hemothorax will need blood transfusions and a chest tube placement for treatment. The nurse should start 2 large bore IVs with crystalloid solution. A cardiac monitor is also necessary, but active measures to treat the patient should be done first. The patient may or may not need intubation and mechanical ventilation. An occlusive dressing is not necessary.

DIF: Cognitive Level: Apply/Application REF: p. 572 | Table 20-4 OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 12. The need for fluid resuscitation Nc aUnR bS IeNaGs Ts eBs. sCeOdMb e s t in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels ANS: D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by underperfusion (under resuscitation).

DIF: Cognitive Level: Understand/Comprehension REF: p. 569 Lab Alert Box OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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13. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse’s assessment, the oxygen saturation drops to 80%. The patient’s blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates a. administration of lactated Ringer’s solution (1 L) wide open. b. chest x-ray study to determine the etiology of the symptoms. c. endotracheal intubation and mechanical ventilation. d. needle thoracostomy and chest tube insertion.

ANS: D These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray would delay treatment and is not needed before emergent intervention. Administration of IV fluids would not assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be necessary after the tension pneumothorax is relieved to assist with the patient’s ventilation.

DIF: Cognitive Level: Analyze/Analysis REF: p. 572 | Table 20-4 OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 14. Which of the following p a t i e nt s NhUa RveS ItNh Ge TgBre.CaO teM st risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury? a. A patient who has a closed head injury with a decreased level of consciousness b. A patient who has a fractured femur and is currently in traction c. A patient who has received large volumes of fluid and/or blood replacement d. A patient who has underlying chronic obstructive pulmonary disease ANS: C During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third-spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would not be related to fluid resuscitation and excessive inflammation associated with traumatic injury.

DIF: Cognitive Level: Remember/Knowledge REF: p. 569 Lab Alert Box OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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15. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome? a. Absence of pulse in affected extremity b. Pallor in the affected area c. Paresthesia in the affected area d. Severe, throbbing pain in the affected area ANS: D Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity.

DIF: Cognitive Level: Remember/Knowledge REF: p. 576 OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 16. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent a. disseminated intravascular coagulation. b. multisystem organ dysfunction. c. septic shock. d. wound infection.

ANS: B Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g., hand hygiene).

DIF: Cognitive Level: Apply/Application REF: p. 560 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 17. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent a. catheter-associated infection. b. venous thromboembolism. c. fat embolism. d. nosocomial pneumonia.

ANS: B

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Prevention of venous thromboembolism is essential in the management of trauma patients.

If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g., heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patient’s overall hydration, and ensure sequential compression devices are used properly. Prevention of catheter-associated infections is also important through interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation, along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures and early recognition of this complication is essential to treatment.

DIF: Cognitive Level: Remember/Knowledge REF: p. 576 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 18. Which of the following interventions is a strategy to prevent fat embolism syndrome? a. Administer lipid-lowering statin medications. b. Intubate the patient early after the injury to provide mechanical ventilation. c. Provide prophylaxis with low–molecular weight heparin. d. Stabilize extremity fractures early.

ANS: D Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not B . bCoOeMm b o l i s m prophylaxis. prevent fat embolism; it is for v eNnUoRuSs I Nt hGr oT m DIF: Cognitive Level: Remember/Knowledge REF: p. 576 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 19. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of: a. 30 mL/hr. b. 50 mL/hr. c. 100 mL/hr. d. 300 mL/hr.

ANS: C Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis.

DIF: Cognitive Level: Remember/Knowledge REF: p. 576 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation

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MSC: NCLEX Client Needs Category: Physiological Integrity 20. Which of the following statements about mass casualty triage during a disaster is true? a. Priority treatments and interventions focus primarily on young victims. b. Disaster victims with the greatest chances for survival receive priority for treatment. c. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims. d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

ANS: B Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention. Age is not a determination in rendering interventions. Patient survival and severity of injury are the priority assessment for triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to principles of ethical care.

Color-coded systems are frequently used during disasters to signify patients in greatest need of assistance, with red indicating worse severity of injury and green being most stable.

DIF: Cognitive Level: Understand/Comprehension REF: p. 561 OBJ: Describe a system approach to trauma care.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 21. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment d a t aNsUuRgSgIeNsGt Tt hBe. CpOa tMi e nt suffered tissue damage consistent with a blast injury? a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min b. Crackles (rales) on auscultation of bilateral lung fields c. Responsive only to painful stimuli d. Irregular heart rate and rhythm ANS: B Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood pressure and corresponding tachycardia are more suggestive of hypovolemia. Lack of response to stimuli suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the heart (e.g., cardiac contusion).

DIF: Cognitive Level: Analyze/Analysis REF: p. 563 OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

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MULTIPLE RESPONSE 1. Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.) a. 5% Dextrose is recommended for rapid crystalloid infusion. b. IV fluids may need to be warmed to prevent hypothermia. c. Massive transfusions should be avoided to improve patient outcomes. d. Only fully crossmatched blood products are administered. e. Hypertonic saline solutions are often used during initial resuscitation.

ANS: B, C Lactated Ringer’s and normal saline are the crystalloids of choice in trauma resuscitation.

Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Crossmatched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency. Isotonic solutions are used predominantly during fluid resuscitation.

DIF: Cognitive Level: Remember/Knowledge REF: p. 571 | p. 576 | Table 20-2 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.) a. Indwelling urinary catheters are a source of infection. b. Patients often develop infectNioUnRaSnINdGsTeBps.CisOsMecondary to central line catheters. c. Pneumonia is often an adverse outcome of mechanical ventilation. d. Wounds require sterile dressings to prevent infection.

ANS: A, B, C Prevention of infection is essential in the care of trauma and postsurgical patients.

Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care.

DIF: Cognitive Level: Remember/Knowledge REF: p. 579 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse’s suspicion of a pulmonary contusion? (Select all that apply.) a. Chest wall ecchymosis b. Diminished or absent breath sounds c. Pink-tinged or blood secretions d. Signs of hypoxia on room air

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e. Paradoxical chest wall movement ANS: A, C, D Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung. Paradoxical chest wall movement is indicative of flail chest.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 572-573 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.) a. ARDS b. Coagulopathies c. Dysrhythmias d. Myocardial dysfunction e. Fat embolism ANS: B, C, D Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a com pli cNatUi oRnS IaNsGsoTcBi.aCt Oe dMwi t h excessive inflammation and overresuscitation. Fat embolism is often seen with long bone fractures.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 576-577 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.) a. Crush injury to right arm b. Gunshot wound to the abdomen c. Lightning strike of the left arm and chest d. Pulmonary contusion and rib fracture e. Penetrating wound to both legs ANS: A, C Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension. Acute kidney injury would not have a direct cause associated with a pulmonary contusion or penetrating wounds.

DIF: OBJ:

Cognitive Level: Remember/Knowledge REF: p. 576 Formulate a plan of care for the trauma patient, including prevention of

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complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. Which interventions can the nurse implement to assist the patient’s family in coping with the traumatic event? (Select all that apply.) a. Establish a family spokesperson and communication system. b. Ask the family about their normal coping mechanisms. c. Limit visitation to set times throughout the day. d. Coordinate a family conference. e. Determine how the family perceives the event ANS: A, B, D, E The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the health care team and family. Other interventions include exploring the family’s perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patient’s and family’s expectations for care. Limiting visitation will not assist the patient or the family’s ability to cope with the traumatic event.

DIF: Cognitive Level: Apply/Application REF: p. 580 OBJ: Describe assessment and management of common traumatic injuries.

TOP: Nursing Process Step: Assessment | Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.) a. Prevention of hypothermia b. c. d. e.

Administration of fresh frozen plasma as ordered Administration of potassium as ordered Administration of calcium as ordered Monitoring CBC and coagulation studies

ANS: A, B, D Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation. Monitoring lab values does not prevent an event from occurring although it can allow the nurse to notice it sooner.

DIF: Cognitive Level: Remember/Knowledge REF: p. 569 Lab Alert Box OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Assessment | Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Psychosocial Integrity 8. Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.)

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Mean arterial pressure 48 mm Hg Elevated serum blood alcohol level Nonreactive pupils Respiratory rate of 10 breaths/min Open skull fracture

ANS: A, C, D, E Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; nonreactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An open skull fracture leaves the patient extremely vulnerable to infection in the brain. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

DIF: Cognitive Level: Apply/Application REF: p. 570 OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.) a. Whole blood b. Universal donor blood only c. Red blood cells d. Platelets e. Plasma ANS: C, D, E The 1:1:1 transfusion protocol is an evidence-based practice consisting of transfusions of red blood cells, platelets, and plasma for optimal outcomes. Whole blood and universal donor blood exclusively are not included.

DIF: Cognitive Level: Remember/Knowledge REF: Evidence Based Practice Box OBJ: Formulate a plan of care of the trauma patient, including prevention of complications.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. The trauma nurse understands which information related to the older trauma patient? (Select all that apply.) a. Falls are the leading cause of death in the older population. b. Physiologic capacity is an important predictor of outcome. c. Hypotension in the elderly can appear as normotension. d. Chronic diseases do not have much effect on the older trauma patient. e. Fractures to bones other than hips are uncommon from trauma.

ANS: A, B, C

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Falls are the leading cause of death in the elderly and frequently result in fractures to many different bones, not just hips. Decreased physiologic reserve leads to poorer outcomes.

Hypertension can mask hypotension by the blood pressure appearing to be normal. That is just one example of how chronic disease can complicate the picture of an older trauma patient.

DIF: Cognitive Level: Remember/Knowledge REF: p. 578 Lifespan considerations TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Health Promotion and Maintenance

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Chapter 21: Burns Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium.

ANS: C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs.

Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status.

DIF: Cognitive Level: Remember/Knowledge REF: Box 21-1 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 2. In patients with extensive burns, edema occurs in both burned and unburned areas because of a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier.

ANS: C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing).

Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.

DIF: Cognitive Level: Remember/Knowledge REF: p. 592 | Table 21-4 OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Tissue damage from burn injury activates an inflammatory response that increases the patient’s risk for a. acute kidney injury. b. acute respiratory distress syndrome.

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c. infection. d. stress ulcers.

ANS: C The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic inflammatory response syndrome (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the causes of stress ulcers.

DIF: Cognitive Level: Remember/Knowledge OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: pp. 593-594

4. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to administer what amount of fluid in the first 24 hours? a. 2800 mL b. 7000 mL c. 14 L d. 28 L ANS: C 154 pounds/2.2 = 70 kg 4  70 kg  50 = 14,000 mL, or 14 liters.

DIF: Cognitive Level: Apply/Application REF: p. 603 | Box 21-1 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm.

A priority in the plan of care is a. to keep the extremity in a dependent position. b. active or passive range-of-motion exercises every hour. c. to prepare for an escharotomy as a prophylactic measure. d. to splint the forearm.

ANS: B

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Special attention is given to circumferential (completely surrounding a body part) full-thickness burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds may impair blood flow to underlying and distal tissue.

Therefore, extremities are elevated to reduce edema. Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation. Splinting is not as important as providing range of motion. If done, splinting must keep the affected extremity in a functional position.

DIF: Cognitive Level: Remember/Knowledge REF: p. 604 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only surgical intervention needed to close his wound. The nurse’s best response would be: a. “Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close the wound.” b. “An autograft is a biological dressing that will eventually be replaced by your body generating new tissue.” c. “Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.” d. “Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be necessary to close the wound.”

ANS: C The autograft is the only permanent method of grafting, and it uses the patient’s own tissue to cover the burn wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin, and is a temporary graft.

DIF: Cognitive Level: Understand/Comprehension REF: p. 614 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 7. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse should explore the mechanism of burn injury possibly related to a. excessive alcohol use. b. methamphetamine use. c. posttraumatic stress disorder. d. subacute delirium.

ANS: B A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance withdrawal should alert the nurse to a potential methamphetamine-related injury.

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DIF: Cognitive Level: Remember/Knowledge REF: p. 609 OBJ: Compare types of burn injuries.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the nurse assesses the patient for which of the following? a. Central nervous system deficits b. Contractures c. Infection d. Stress ulcers ANS: A Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than with other causes of burn injury.

DIF: Cognitive Level: Understand/Comprehension REF: p. 586 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 9. The nurse is managing the pain of a patient with burns. The provider has prescribed opiates to be given intramuscularly. The nurse contacts the provider to change the prescription to intravenous administration because a. intramuscular injections cause additional skin disruption. b. burn pain is so severe it r e q uNi rUeRs SrIeNl iGe Tf Bb.yCO thM e fastest route available. c. hypermetabolism limits effectiveness of medications administered intramuscularly. d. tissue edema may interfere with drug absorption of injectable routes.

ANS: D Edema and impaired circulation of the soft tissue interfere with absorption of medications administered subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication effectiveness but is not the rationale for administering opioids intravenously.

DIF: Cognitive Level: Understand/Comprehension REF: p. 611 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 10. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the

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airways.

ANS: B In inhalation injury, the airway may become edematous quickly, making intubation difficult.

Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but a patient with carbon monoxide poisoning may not need to be intubated.

Management of secretions is not an indication for intubation. Dysfunction of the cilia is not a reason for intubation.

DIF: Cognitive Level: Understand/Comprehension REF: p. 601 Clinical Alert Box OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for a. acute kidney injury. b. acute respiratory distress syndrome. c. intra-abdominal hypertension. d. disseminated intravascular coagulation disorder.

ANS: C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, d e cNrUe aRsSeI dN Gu rTi Bn .eC oOuMt p u t , and worsening pulmonary function.

Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular coagulation disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.

DIF: Cognitive Level: Understand/Comprehension REF: p. 605 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 12. An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was “too hot” and that the “patient sat in the water too long.” What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient’s burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred.

ANS: B

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In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver.

While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury); however, examining the patient away from the caregiver is a priority.

DIF: Cognitive Level: Apply/Application REF: p. 609 OBJ: Compare types of burn injuries.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 13. Silver is used as an ingredient in many burn dressings because it a. stimulates tissue granulation. b. is effective against a wide spectrum of wound pathogens. c. provides topical pain relief. d. stimulates wound healing.

ANS: B Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of common pathogens. Silver does not stimulate tissue granulation, nor does it provide pain relief or stimulate wound healing processes.

DIF: Cognitive Level: Understand/Comprehension REF: Table 19-5 OBJ: Formulate a plan of c a r e Nf Uo rR tShI Ne G pTatBie.CnOt M with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partial-thickness burn wounds to do which of the following? a. Maintain a closed wound system to decrease the risk of infection b. Remove excessive wound fluid and promote moist wound healing c. Increase patient mobility with large burn wounds d. Quantify wound drainage amount for more accurate output assessment ANS: B Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but may not prevent infection. Patients are less mobile because the system needs an electrical source to function. Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary indication for the therapy.

DIF: Cognitive Level: Understand/Comprehension REF: p. 613 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

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Sole: Introduction to Critical Care Nursing,8E

15. The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical injury are at a high risk for acute kidney injury secondary to a. hypervolemia from burn resuscitation. b. increased incidence of ureteral stones. c. nephrotoxic antibiotics for prevention of infection. d. release of myoglobin from injured tissues.

ANS: D Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury. Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause acute kidney injury but are not associated with the electrical injury.

DIF: Cognitive Level: Understand/Comprehension REF: p. 603 | Table 21-4 OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to a. remove the patient’s clothes and flush the area with water. b. apply saline compresses. c. contact a poison control center for directions on neutralizing agents. d. remove all jewelry.

ANS: A As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to remove the patient’s clothes, brush loose chemical away from the skin and apply water for at least 30 minutes. Water needs to washed away from the body, not applied as compresses. Contacting poison control may be helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority intervention.

Jewelry should be removed, but this is not as high a priority as removing the chemical and stopping the chemical burning process through continuous flushing with water.

DIF: Cognitive Level: Apply/Application OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 609

17. Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to have a sheet graft applied? a. Arm b. Face c. Leg d. Chest ANS: B

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Sole: Introduction to Critical Care Nursing,8E

A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal. Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest).

DIF: Cognitive Level: Understand/Comprehension REF: p. 614 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound treatment. A primary nursing diagnosis is a. altered nutrition, less than body requirements. b. body image disturbance. c. decreased cardiac output. d. fluid volume deficit.

ANS: B Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional support is started early in management of the patient with burns, and there is no indication that this patient has a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound closure phase of burn wound management by grafting.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 616-617 OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.

TOP: Nursing Process Step: PlNaUnnRiSnI gN GT B. COM MSC: NCLEX Client Needs Category: Physiological Integrity 19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which statement indicates the nurse’s knowledge of nutritional goals? a. “Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.” b. “Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.” c. “It is important to choose foods such as bread and pasta that are high in carbohydrates. These foods will give you energy and help you to heal faster.” d. “Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of toxins from the body that interfere with healing.”

ANS: B Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the body. Oral diets should be high in calories and high in protein to meet the demands of the body.

DIF: Cognitive Level: Apply/Application REF: pp. 615-616 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity

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Sole: Introduction to Critical Care Nursing,8E

20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse should consult with the provider to further assess the patient for a. acute delirium. b. posttraumatic stress disorder. c. suicidal intentions. d. bipolar disorder.

ANS: B Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn patients who demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as bipolar disorder or schizophrenia.

DIF: Cognitive Level: Apply/Application REF: p. 610 | p. 617 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 21. The nurse is planning care to meet the patient’s pain management needs related to burn treatment. The patient is alert, oriented, and follows commands. The pain is worse during the day, when various treatments are scheduled. Which statement to the provider best indicates the nurse’s knowledge of pain management for this patient? a. “Can we ask the music therapist to come by each morning to see if that will help the patient’s pain?” b. “The patient’s pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids around the clock.” c. “The patient’s pain is often unrelieved. It would be best if we can schedule the opioids around the clock.” d. “The patient’s pain varies depending on the treatment given. Can we try patient-controlled analgesia to see if that helps the patient better?”

ANS: D Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing independence with pain management strategies. Nonpharmacological pain strategies may provide helpful adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put the control of pain management with the patient.

DIF: Cognitive Level: Apply/Application REF: p. 610 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment? a. “Do you live alone?”

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Sole: Introduction to Critical Care Nursing,8E

b. “Do you have any drug or food allergies?” c. “Do you have a heart condition or heart failure?” d. “Have you had any surgeries?”

ANS: C Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status, nutritional status, and comorbid diseases, especially heart failure.

Assessment questions should include, as a priority, information about the patient’s cardiovascular status, including heart failure. Obtaining food or drug allergy information is also important, along with other past medical history, including past surgeries. Information on the patient’s living arrangements is an important safety consideration for discharge planning.

DIF: Cognitive Level: Apply/Application REF: Lifespan considerations box OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 23. A 63-year-old patient is admitted with new-onset fever; flulike symptoms; blisters over the arms, chest, and neck; and red, painful oral mucous membranes. The patient should be further evaluated for which possible non–burn-injured skin disorder? a. Toxic epidermal necrolysis b. Staphylococcal scalded skin syndrome c. Necrotizing soft tissue infection d. Graft-versus-host disease ANS: A Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present with acute-onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours; skin and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from rapidly invasive bacterial infections. Graft-versus-host disease is not logical given the clinical information provided.

DIF: Cognitive Level: Understand/Comprehension REF: p. 619 OBJ: Review the anatomy and physiology of the integumentary system.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 24. A(An) often produces a superficial cutaneous injury but may cause cardiopulmonary arrest and transient but severe central nervous system deficits. a. chemical burn b. electrical burn c. heat burn d. infection ANS: B

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Sole: Introduction to Critical Care Nursing,8E

Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac dysrhythmias.

DIF: Cognitive Level: Understand/Comprehension OBJ: Describe the pathophysiology of burns.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 586

MULTIPLE RESPONSE 1. Which of the following statements about the pain management of a burn victim are true?

(Select all that apply.) a. Additional pain medication may be needed because of rapid body metabolism. b. Pain medication should be given before procedures such as debridement, dressing changes, and physical therapy. c. Patients with a history of drug and alcohol abuse will require higher doses of pain medication. d. The intramuscular route is preferred for pain medication administration. e. Patients with a history of drug and alcohol abuse should not need as much pain medication as other patients.

ANS: A, B, C The rapid metabolism associated with burn injury may require additional pain medication.

Many of the procedures associated with burn wounds are painful, such as dressing changes.

Adequate pain medication should be given before the procedures. Edema in burned patients alters the absorption of m edicatiNoUnsRSthI NatGaTrBe . CinOjeMcte d intramuscularly; therefore, drugs must be administered by the IV route. A history of drug and/or alcohol abuse does not change the pain experience for this patient; they will need as much pain medication as other burn patients and in fact may need more due to increased tolerance to the effects of the medication.

DIF: Cognitive Level: Remember/Knowledge REF: p. 610 OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 2. Which of the following factors increase the burn patient’s risk for venous thromboembolism? (Select all that apply.) a. Burn injury less than 10% b. Bed rest c. Burns to lower extremities d. Electrical burn injury e. Delayed fluid resuscitation ANS: B, C, E

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Sole: Introduction to Critical Care Nursing,8E

Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bed rest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA. DIF: Cognitive Level: Apply/Application REF: p. 605 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity 3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to include which of the following? (Select all that apply.) a. Applying splints that maintain the extremity in an extended position b. Implementing passive or active range-of-motion exercises c. Keeping the limbs as immobile as possible d. Wrapping fingers and toes individually with bandages e. Administering muscle relaxants around the clock ANS: A, B, D It is important to avoid immobility in patients with burns of the hands, feet, or major joints.

Measures must be taken to maintain the function of the hands, feet, and major joints.

Nursing interventions to maintain range of motion, applying splints to keep the extremities in a position of function, and individually wrapping fingers and toes are necessary to maintain function of the hands, fNeUe Rt , SaI nNdG jToBi .nCt O s. ME f fe ct i ve pain management is necessary to encourage mobility.

DIF: Cognitive Level: Apply/Application REF: p. 608 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Planning MSC: NCLEX Client Needs Category: Physiological Integrity 4. Which of the following infection control strategies should the nurse implement to decrease the risk of infection in the burn-injured patient? (Select all that apply.) a. Apply topical antibacterial wound ointments/dressings. b. Change indwelling urinary catheter every 7 days. c. Daily assess the need for central IV catheters. d. Restrict family visitation. e. Maintain strict aseptic technique during burn wound management.

ANS: A, C, E Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and restricting family is not an intervention related to infection prevention.

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Sole: Introduction to Critical Care Nursing,8E

DIF: Cognitive Level: Apply/Application REF: pp. 610-611 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 5. Which complications may manifest after an electrical injury? (Select all that apply.) a. Long bone fractures b. Cardiac dysrhythmias c. Hypertension d. Compartment syndrome of extremities e. Dark brown urine f. Peptic ulcer disease g. Acute cataract formation h. Seizures ANS: A, B, D, E, G, H Electrical injuries vary in severity of injury by the intensity of energy exposed to the body.

Manifestations and complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis, rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct consequences of electrical burn injuries.

DIF: Cognitive Level: Remember/Knowledge REF: Box 21-2 OBJ: Compare types of burn injuries.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity 6. An autograft is used to optimally treat a partial- or full-thickness wound that (Select all that apply.) a. involves a joint. b. involves the face, hands, or feet. c. is infected. d. requires more than 2 weeks for healing. e. involves very large surface areas.

ANS: A, B, D Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization. Grafting is not done while a burn is infected. There may not be enough healthy skin to graft large areas.

DIF: Cognitive Level: Understand/Comprehension REF: p. 614 OBJ: Formulate a plan of care for the patient with a burn injury.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity ORDERING 1. The correct priority order of actions in prehospital primary survey for burn injuries is: , , , .

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Sole: Introduction to Critical Care Nursing,8E

a. assess ABCs and cervical spine b. provide oxygen therapy if smoke inhalation is suspected c. make rapid head-to-toe assessment to rule out additional trauma d. stop the burning process and prevent further injury ANS: D, A, B, C Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine. Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.

DIF: Cognitive Level: Apply/Application REF: pp. 598-599 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management.

TOP: Nursing Process Step: Implementation MSC: NCLEX Client Needs Category: Physiological Integrity