Chapter 26 Kidney Disorders and Therapeutic Management, Chapter 35- Burns, Chapter 29- Gastrointestinal Disorders and Therapeutic Management, Chapter 37 Critical Care Nursing- Urden, Chapter 25: Kidney Clinical Assessment and Diagnostic Procedures, C...

An elderly patient is in a motor vehicle accident and sustains a significant internal

hemorrhage. The nurse knows the patient is at risk for developing what type of acute kidney

injury (AKI)?

a. Intrinsic

b. Postrenal

c. Prerenal

d. Intrarenal

c. Prerenal

Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration decreases, and consequently urine output decreases. Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal AKI. Any obstruction that hinders the flow of urine from beyond the kidney through the remainder of the urinary tract may lead to postrenal AKI.

A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which

laboratory value would the nurse find helpful in evaluating patient's renal status?

a. Serum sodium

b. Serum creatinine

c. Serum potassium

d. Urine potassium

b. Serum creatinine

Serum creatinine is the most reliable predictor of kidney function. In the acutely ill patient, small changes in the serum creatinine level and urine output may signal important declines in the glomerular filtration rate and kidney function.

A patient has developed acute kidney injury (AKI) secondary to hemorrhage shock. Which

intravenous solution would the nurse expect to be ordered for this patient?

a. Dextrose in water

b. Normal saline

c. Albumin

d. Lactated Ringer solution

b. Normal saline

Prerenal acute kidney injury (AKI) is caused by decreased perfusion and flow to the kidney. It is often associated with trauma, hemorrhage, hypotension, and major fluid losses. If contrast dye is used, aggressive fluid resuscitation with normal saline is recommended.

One therapeutic measure for treating hyperkalemia is the administration of dextrose and

regular insulin. Which statement regarding how this treatment works is accurate?

a. Glucose and insulin force potassium out of the cells, lowering it on a cellular level.

b. Glucose and insulin promote higher excretion of potassium in the urine.

c. Glucose and insulin bind with potassium, lowering available amounts.

d. Glucose and insulin force potassium into the cells, lowering it on a serum level.

d. Glucose and insulin force potassium into the cells, lowering it on a serum level.

Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.

A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous

solution should the nurse question if it were ordered for this patient?

a. D5W

b. 0.9% NaCl

c. Lactated Ringer solution

d. 0.45% NaCl

c. Lactated Ringer solution

Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.

To assess whether or not an arteriovenous fistula is functioning, what must the nurse do and

why?

a. Palpate the quality of the pulse distal to the site to determine whether a thrill is

present; auscultate with a stethoscope to appreciate a bruit to assess the quality of

the blood flow.

b. Palpate the quality of the pulse proximal to the site to determine whether a thrill is

present; auscultate with a stethoscope to appreciate a bruit to assess the quality of

the blood flow.

c. Palpate gently over the site of the fistula to determine whether a thrill is present;

listen with a stethoscope over this site to appreciate a bruit to assess the quality of

the blood flow.

d. Palpate over the site of the fistula to determine whether a thrill is present; check

whether the extremity is pink and warm.

c. Palpate gently over the site of the fistula to determine whether a thrill is present;

listen with a stethoscope over this site to appreciate a bruit to assess the quality of

the blood flow.

The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula.

To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood

and a negative hydrostatic pressure is applied to the dialysate bath. What is this process

called?

a. Ultrafiltration

b. Hemodialysis

c. Reverse osmosis

d. Colloid extraction

a. Ultrafiltration

To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and results in fluid extraction, known as ultrafiltration, from the vascular space.

A patient with chronic kidney disease was admitted with severe electrolyte disturbances. The

patient had been ill and missed several hemodialysis sessions. The patient is disoriented,

dizzy, cold, clammy, and complains of severe abdominal cramping. The patient's

electrocardiogram appears normal. Which electrolyte disturbance would the nurse suspect the

patient may be experiencing?

a. Hyponatremia

b. Hypokalemia

c. Hypercalcemia

d. Hypochloremia

A. Hyponatremia

Hyperkalemia, hypocalcemia, hyponatremia, hyperphosphatemia, and acid-base imbalances occur in kidney disease. Signs of hyponatremia include disorientation, muscle twitching, nausea, vomiting, abdominal cramps, headaches, dizziness, cold, clammy skin, tachycardia, and seizures.

A patient who receives peritoneal dialysis is admitted after a 3-day history of flulike

symptoms. The patient reports muscle cramps and is noted to have a low blood pressure and

tachycardia. The nurse suspects the patient may be experiencing what condition?

a. Dehydration

b. Peritonitis

c. Fluid obstruction

d. Hernias

a. Dehydration

This patient has dehydration. This patient is showing signs and symptoms of muscle cramps and low blood pressure.

A patient was admitted with an infection that had to be treated with gentamicin, an

aminoglycoside antibiotic. After 3 days of administration, the patient developed oliguria, and

an elevated blood urea nitrogen and creatinine levels. The nurse suspects the patient has

developed what type of kidney injury?

a. Prerenal

b. Intrarenal

c. Anuric

d. Postrenal

b. Intrarenal

Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the contrast dye used in radiologic diagnostic studies.

A patient was admitted with an infection that had to be treated with an aminoglycoside

antibiotic. After a few days the patient developed oliguria and elevated blood urea nitrogen

and creatinine levels. The patient's vital signs are stable. The nurse would anticipate the

practitioner ordering which dialysis method for this patient?

a. Peritoneal dialysis

b. Hemodialysis

c. Continuous renal replacement therapy

d. Intermittent ultrafiltration

b. Hemodialysis

As a treatment, hemodialysis separates and removes from the blood excess electrolytes, fluids, and toxins by means of a hemodialyzer. Hemodialysis would be the first choice for managing this patient with medication toxicity.

A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on

continuous renal replacement therapy (CRRT). The nurse knows that fluid that is removed

each hour is charted as what on the CRRT flowsheet?

a. Convection

b. Diffusion

c. Replacement fluid

d. Ultrafiltrate

d. Ultrafiltrate

The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the bloodstream with it.

What is the most common site for short-term vascular access for immediate hemodialysis?

a. Subclavian artery

b. Subclavian vein

c. Femoral artery

d. Radial vein

b. Subclavian vein

Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same catheterized vein. A dual-lumen venous catheter is most commonly used.

The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive

to diuretics. Which type of dialysis would the nurse anticipate being started on this patient?

a. Intermittent ultrafiltration

b. Continuous venovenous hemofiltration (CVVH)

c. Continuous venovenous hemodialysis (CVVHD)

d. Continuous venovenous hemodiafiltration (CVVHDF)

a. Intermittent ultrafiltration

Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with acute decompensated heart failure when the kidneys are unresponsive to diuretics.

The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with

acute kidney injury. The patient needs both the removal of fluids and a moderate amount of

solutes. Which type of CRRT would the nurse anticipate being started on this patient?

a. Slow continuous ultrafiltration (SCUF)

b. Continuous venovenous hemofiltration (CVVH)

c. Continuous venovenous hemodialysis (CVVHD)

d. Continuous venovenous hemodiafiltration (CVVHDF)

b. Continuous venovenous hemofiltration (CVVH)

Continuous venovenous hemofiltration (CVVH) is indicated when the patient's clinical condition warrants removal of significant volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 h. Removal of solutes such as urea, creatinine, and other small non-protein-bound toxins is accomplished by convection

A patient with acute kidney injury (AKI) has been started on continuous venovenous

hemodialysis (CVVHD). The nurse understands the patient should be closely monitored for

what patient-related complications of the therapy?

a. Air embolism, access failure, and blood leaks

b. Decreased inflow pressure, air bubbles, and power surge

c. Infection, hypotension, and electrolyte imbalances

d. Catheter dislodgement, decreased outflow pressure, and acid-base imbalances

c. Infection, hypotension, and electrolyte imbalances

Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte imbalances, acid-base imbalances, blood loss, hemorrhage, hypotension, and infection.

A patient with acute kidney injury (AKI) has been started on continuous venovenous

hemodialysis (CVVHD). The nurse understands that this type of continuous renal replacement

therapy (CRRT) is indicated for the patient who needs what type of treatment?

a. Fluid removal only

b. Fluid removal and moderate solute removal

c. Fluid removal and maximum solute removal

d. Maximum fluid and solute removal

d. Maximum fluid and solute removal

Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require large-volume removal of fluid and solutes.

A patient with acute kidney injury (AKI) has been started on continuous venovenous

hemodialysis (CVVHD). The nurse knows the hemodialyzer filter used in this type of therapy

is permeable to what substance?

a. Electrolytes

b. Red blood cells

c. Protein

d. Lipids

a. Electrolytes

A continuous venovenous hemodialysis filter is permeable to solutes such as urea, creatinine, uric acid, sodium, potassium, ionized calcium, and drugs not bound by proteins.

A patient with acute kidney injury (AKI) has been started on continuous venovenous

hemodiafiltration (CVVHDF). The nurse understands the patient should be closely monitored

for what circuit-related complications of the therapy?

a. Hypervolemia, hypothermia, and hyperkalemia

b. Access dislodgment, decreased outflow pressures, and bleeding

c. Filter clotting, access failure, and air embolism

d. Increased overflow pressure, dehydration, and calcium loss

c. Filter clotting, access failure, and air embolism

Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration, blood leaks, broken filter, disconnection, access failure, and catheter dislodgement

What is the recommended nutritional intake of protein to control azotemia in the patient with

acute kidney injury?

a. 0.5 to 1.0 g/kg/day

b. 1.2 to 1.5 g/kg/day

c. 1.7 to 2.5 g/kg/day

d. 2.5 to 3.5 g/kg/day

b. 1.2 to 1.5 g/kg/day

The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia (increased blood urea nitrogen level).

Laboratory results come back on a newly admitted patient: Serum blood urea nitrogen, 64

mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity, 1.002;

and urine sodium, 96 mEq/L. The patient's urine output has been 120 mL since admission 2

hours ago. These values are most consistent with which diagnosis?

a. Prerenal acute kidney injury

b. Postrenal acute kidney injury

c. Oliguric acute kidney injury

d. Intrarenal acute kidney injury

d. Intrarenal acute kidney injury

Urinary sodium less than 10 mEq/L (low) suggests a prerenal condition. Urinary sodium greater than 40 mEq/L (in the presence of an elevated serum creatinine and the absence of a high salt load) suggests intrarenal damage has occurred. The urine output does not seem to suggest oliguria. The other options do not fit the data as presented.

A patient is admitted with acute kidney injury (AKI). Which event from the patient's history

was the most probable cause of the patient's AKI?

a. Recent computed tomography of the brain with and without contrast

b. Recent bout of acute heart failure after an acute myocardial infarction

c. Twice-daily prescription of Lasix 40 mg by mouth

d. Recent bout of benign prostatic hypertrophy and transurethral resection of the

prostate

a. Recent computed tomography of the brain with and without contrast

Intravenous contrast media can be nephrotoxic, especially with the patient's preexisting cardiac disease. The other choices, although possible causes, are less likely than the intravenous contrast media.

A patient with acute kidney injury has a potassium level of 6.9 mg/dL. The patient has had no

urine output in the past 4 hours despite administration of Lasix 40 mg intravenous push. To

correct the hyperkalemia the patient is given 50 mL of 50% dextrose in water and 10 U of

regular insulin intravenous push. A repeat potassium level 2 hours later shows a potassium

level of 4.5 mg/dL. What order would the nurse expect now?

a. Sodium Kayexalate 15 g PO

b. Nothing; this represents a normal potassium level

c. Lasix 40 mg IVP

d. 0.9% normal saline at 125 mL/h

a. Sodium Kayexalate 15 g PO

Acute hyperkalemia can be treated temporarily by intravenous (IV) administration of insulin and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells. However, the potassium was not eliminated from the body; it was simply shifted intracellularly. Soon the potassium will return to the bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is not expected to work in the presence of anuria. The patient's vital signs do not support hypovolemia. In the presence of anuria, a large fluid infusion can precipitate acute heart failure.

A patient with chronic kidney disease receives hemodialysis treatments 3 days a week. Every

2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells. What is the

probable reason for this patient's frequent transfusion needs?

a. Too much blood phlebotomized for tests

b. Increased destruction of red blood cells because of the increased toxin levels

c. Lack of production of erythropoietin to stimulate red blood cell formation

d. Hemodilution secondary to fluid retention

c. Lack of production of erythropoietin to stimulate red blood cell formation

In chronic kidney disease, the kidneys do not produce sufficient amounts of erythropoietin in response to normal stimuli such as anemia or hypotension. The other choices are not reasons for frequent blood transfusions in this patient.

A patient is admitted with respiratory failure and is being mechanically ventilated. The nurse

understands there is a significant association between acute kidney injury and respiratory

failure. How does mechanical ventilation alter kidney function? (Select all that apply.)

a. Decreases blood flow to the kidney

b. Decreases glomerular filtration rate (GFR)

c. Damages the kidney tubular endothelium

d. Decreases urine output

e. Hinders flow of urine from the kidneys

a. Decreases blood flow to the kidney

b. Decreases glomerular filtration rate (GFR)

d. Decreases urine output

Mechanical ventilation can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the glomerular filtration rate (GFR), and decreases urine output. These effects are intensified with the addition of positive end-expiratory pressure (PEEP).

What is a leading cause of death in the hospitalized burn patient?

a. Smoke inhalation

b. Infection

c. Burn shock

d. Renal failure

B. infection

Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center?

a. The size and depth of burn injury and the burning agent

b. The age and present medical history of the patient

c. The depth of the burn injury and the presence of soot in the sputum

d. The medical history of the patient and the size and depth of the burn injury

D. the medical history of the patient and the size and depth of the burn injury

Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum.

a. 28%

b. 23.5%

c. 45.5%

d. 16%

B. 23.5%

The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg.

a. 2775 mL

b. 5550 mL

c. 8325 mL

d. 11,100 mL

B. 5550 mL

In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL 37 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn?

a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid.

b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema.

c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.

d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.

Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient?

a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids.

b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient.

c. Changing gloves and handwashing should be done when moving from area to area on the same patient.

d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.

c. Changing gloves and handwashing should be done when moving from area to area on the same patient.

Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient. Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps, and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers between patients.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan?

a. Continue as planned; everything looks good.

b. IV rate should be decreased and colloids started.

c. IV rate should be increased and fluid status closely watched.

d. Fluids should be switched to packed red blood cells.

C. IV rate should be increased and fluid status closely watched

Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/h; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause?

a. Blood loss associated with burns and pain

b. Hemodynamic stability related to adequate fluid resuscitation.

c. Overresuscitation related to overestimation of the burn area involved

d. Underresuscitation because of probable wound conversion

D. underresuscitation because of probable wound conversion

The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Overresuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema-inhibiting perfusion of the zone of stasis, resulting in wound conversion.

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury?

a. Rhabdomyolysis

b. Stress ulcers

c. Pneumothorax

d. Venous thromboembolism

C. pneumothorax

The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI) hemorrhage?

a. Stress ulcers

b. Peptic ulcers

c. Nonspecific erosive gastritis

d. Esophageal varices

B. Peptic ulcers

Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism?

a. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area

b. Superficial mucosal erosions because of increased stress levels

c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance

d. Inflammation and ulceration secondary to nonsteroidal anti-inflammatory drug use

A. Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area

Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop because of portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids. Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood from areas of high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen, intestines, and stomach.

A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms?

a. Metabolic acidosis and hypovolemia

b. Decreasing hemoglobin and hematocrit

c. Hyperkalemia and hypernatremia

d. Hematemesis and melena

D. hematemesis and melena

The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock; the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect the provider to order for this patient?

a. Histamine2 (H2) antagonists

b. Vasopressin

c. Heparin

d. Antacids

B. vasopressin

In acute variceal hemorrhage, control of bleeding can be accomplished by using pharmacologic agents. Intravenous vasopressin, somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the splanchnic arteriolar bed.

Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage?

a. Positioning the patient in a high-Fowler position

b. Ensuring the patient has a patent airway

c. Irrigating the nasogastric tube with iced saline

d. Maintaining venous access so that fluids and blood can be administered

B. Ensuring the patient has a patent airway

Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to achieve hemodynamic stability, correction of comorbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop bleeding, and diagnostic procedures to determine the exact cause of the bleeding.

The nurse is caring for a patient with acute liver failure. The provider asks the nurse to assess the patient for asterixis. How should the nurse assess for this symptom?

a. Inflate a blood pressure cuff on the patient's arm.

b. Have the patient bring the knees to the chest.

c. Have the patient extend the arms and dorsiflex the wrists.

d. Dorsiflex the patient's foot.

C. Have the patient extend the arms and dorsiflex the wrists

The patient should be evaluated for the presence of asterixis, or "liver flap," best described as the inability to voluntarily sustain a fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms and dorsiflexes the wrists.

A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs because of what pathophysiologic mechanism?

a. Uncontrolled hypoglycemia caused by an increased release of insulin

b. Loss of storage capacity for senescent red blood cells

c. Premature activation of inactive digestive enzymes, resulting in autodigestion

d. Release of glycogen into the serum, resulting in hyperglycemia

C. Premature activation of inactive digestive enzymes, resulting in autodigestion

In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in the patient's plan of care?

a. Monitor the patient for hypovolemic shock from plasma volume depletion.

b. Observe the patient for hypoglycemia and hypercalcemia.

c. Initiate enteral feedings after the nasogastric tube is placed.

d. Place the patient on a fluid restriction to avoid the fluid sequestration.

A. monitor the patient for hypovolemic shock from plasma volume depletion

Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous insulin may be required.

A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8. What intervention would the nurse include in the patient's plan of care to facilitate pain control?

a. Administer analgesics only as needed.

b. Administer analgesics around the clock.

c. Educate the patient and family on lifestyle changes.

d. Teach relaxation and distraction techniques.

B. Administer analgesics around the clock

Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the knee-chest position can also assist in pain control. However, the patient's pain needs to be addressed first.

A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education plan. Which topic would the nurse include in the plan?

a. Diabetes management

b. Alcohol cessation

c. Occult blood testing

d. Anticoagulation management

B. Alcohol cessation

As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol cessation program.

A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second lumen?

a. Allows for administration of tube feeding

b. Allows for testing of gastric secretions

c. Prevents the tube from adhering to the gastric wall

d. Prevents the tube from advancing

C. prevents the tube from adhering to the gastric wall

The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient's stomach and prevents the tube from adhering to the gastric wall and damaging the mucosa.

The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the nurse expect the provider to order for this patient?

a. Insulin

b. Vitamin K

c. Lactulose

d. Lorazepam

C. Lactulose

Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding. Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with acute liver failure because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.

A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an esophagectomy. The patient asks about the procedure. What is the best response by the nurse?

a. "This procedure is usually performed for cancer of the proximal esophagus and gastroesophageal junction."

b. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."

c. "This procedure is usually performed for cancer of the pancreatic head."

d. "The procedure is usually performed for varices of the distal esophagus and gastroesophageal junction."

B. "This procedure is usually performed for cancer of the distal esophagus and gastroesophageal junction."

Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.

A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an RYGBP is. What is the best response by the nurse?

a. "It is an esophagectomy performed using the transthoracic approach."

b. "It is an esophagectomy performed using a transhiatal approach."

c. "It is a combination of restrictive and malabsorption types of bariatric surgery."

d. "It is a standard operation for pancreatic cancer."

C. "it is a combination of restrictive and malabsorption types of bariatric surgery."

Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.

The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which finding would indicate this occurrence?

a. Crackles in the lung bases

b. Subcutaneous emphysema

c. Incisional bleeding

d. Absent of bowel sounds

B. Subcutaneous emphysema

The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.

The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention is the highest priority?

a. Preventing atelectasis

b. Managing pain

c. Promoting ambulation

d. Preventing infection

B. Managing pain

It is imperative to appropriately manage the patient's pain after gastrointestinal (GI) surgery. Adequate analgesia is necessary to promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump or through continuous epidural infusion of an opioid and local anesthetic (bupivacaine).

A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. What stage of hepatic encephalopathy is the patient exhibiting?

a. Stage 1

b. Stage 2

c. Stage 3

d. Stage 4

B. Stage 2

The patient is in Stage 2 hepatic encephalopathy as evidenced by lethargy, moderate confusion, marked asterixis, and abnormal electroencephalography (EEG).

A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a vasopressin drip. Which side effect is the nurse monitoring for?

a. Constipation

b. Diarrhea

c. Chest pain

d. Bleeding

C. Chest pain

A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension, acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention.

How would the nurse administer sucralfate through a gastric tube?

a. Crushed and mixed with 10 mL of water

b. Dissolved in 10 mL of water to form a slurry

c. Mixed in 15 mL of water to form a solution

d. Administered as a whole pill with a 35-mL water flush

B. Dissolved in 10 mL of water to form a slurry

Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension.

A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds, abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which condition?

a. Peptic ulcer disease

b. Esophageal varices

c. Acute liver failure

d. Acute pancreatitis

D. Acute pancreatitis

The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness, guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several days into the illness.

Which disorders or conditions are potential causes of acute liver failure? (Select all that apply, one, some, or all.)

a. Ischemia

b. Hepatitis A, B, C, D, E, non-A, non-B, non-C

c. Acetaminophen toxicity

d. Wilson disease

e. Reye syndrome

f. Diabetes

A. Ischemia

B. Hepatitis A, B, C, D, E, non-A, non-B, non-C

C. Acetaminophen toxicity

D. Wilson Disease

E. Reye syndrome

Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.

A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all that apply, one, some, or all.)

a. Calcium

b. Serum amylase

c. Serum glucose

d. Potassium

e. White blood cells

f. Serum triglycerides

B. Serum Amylase

C. Serum glucose

E. White blood cells

F. Serum triglycerides

Calcium and potassium decrease with acute pancreatitis.

A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this diagnosis? (Select all that apply, one, some, or all.)

a. Epigastric and abdominal pain

b. Nausea and vomiting

c. Diaphoresis

d. Jaundice

e. Hyperactive bowel sounds

f. Fever

A. Epigastric and abdominal pain

B. Nausea and vomiting

D. Jaundice

F. Fever

Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, Grey-Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.

A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional collaborative management plan? (Select all that apply, one, some, or all.)

a. Benzodiazepines for agitation

b. Pulse oximetry and serial arterial blood gas measurements

c. Insulin drip for hyperglycemia and hyperkalemia

d. Monitoring electrolyte blood levels

e. Assessing for signs of cerebral edema

B. Pulse oximetry and serial arterial blood gas measurements

D. Monitoring electrolyte blood levels

E. Assessing for signs of cerebral edema

The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the blood-brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.

What is the most common cause of disseminated intravascular coagulation (DIC)?

a. Sepsis caused by gram-positive organisms

b. Sepsis caused by gram-negative organisms

c. Sickle cell anemia

d. Burns

B. Sepsis caused by gram-negative organisms

Although all of these answers can cause disseminated intravascular coagulation (DIC), sepsis, particularly that caused by gram-negative organisms, can be identified as the culprit in as many as 20% of cases, making it the most common cause of DIC.

A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. What laboratory value would be valuable in definitively diagnosing the patient's condition?

a. Fibrin split products

b. D-Dimer level

c. Bleeding time

d. White blood cell count

B. D-Dimer level

D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of coagulopathy.

A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites and ecchymosis beneath the blood pressure cuff. The patient's platelet count is normal, and international normalized ratio (INR) is elevated. Which treatment goal is the highest priority?

a. Maintain adequate organ perfusion.

b. Suppress antibody response that is destroying platelets.

c. Treat life-threatening metabolic disturbances.

d. Begin hypothermic therapy to prevent cerebral hemorrhage.

A. Maintain adequate organ perfusion

The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware of the conditions that commonly contribute to the development of DIC and treating them vigorously and without delay provide the best defenses against this devastating condition. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are paramount to achieving a favorable outcome.

Which ethnic descent is the most prevalent for Sickle cell anemia?

a. West African

b. Middle Eastern

c. Pacific Islander

d. Asian

A. West African

This genetic trait is primarily found in people of West African descent. The disease has also been linked to persons of sole European or Middle Eastern ancestry; however, this is extremely rare. The disease is not prevalent in persons of Asian or Pacific Islander descent.

A patient is admitted with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has which disorder?

a. Idiopathic thrombocytopenic purpura

b. Heparin-induced thrombocytopenia

c. Sickle cell anemia

d. Disseminated intravascular coagulation

C. Sickle Cells Anemia

A variety of clinical manifestations are associated with sickle cell anemia. The patient may present with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable spleen, and pretibial ulcers.

The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse understands that this disorder has which characteristic?

a. Formation of thrombi

b. Spontaneous epistaxis

c. Elevated prothrombin times

d. Massive peripheral ecchymoses

A. Formation of thrombi

Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for thrombosis than bleeding. Vessel occlusion can result in the need for limb amputation, stroke, acute myocardial infarction, and even death. The resultant formation of fibrin platelet-rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise to its more descriptive name: white clot syndrome.

The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse knows that pulmonary embolism is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication?

a. Blanching of fingers and toes and loss of peripheral pulses

b. Chest pain, pallor, and confusion

c. Headache, impaired speech, and loss of motor function

d. Dyspnea, pleuritic pain, and rales

D. Dyspnea, pleuritic pain, and rales

The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb indicate peripheral vascular thrombi. Neurologic signs and symptoms such as confusion, headache, and impaired speech can signal the onset of cerebral artery occlusion and stroke. Acute myocardial infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure. Thrombi in the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.

The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient's plan of care to monitor for this potential complication?

a. Monitor D-dimer levels every 5 to 10 hours from day 2 to day 5.

b. Monitor prothrombin time (PT) every 5 to 14 hours from day 2 to day 12.

c. Monitor platelet count every 2 or 3 days from day 4 to day 14.

d. Monitor international normalized ratio (INR) every 5 days from day 10 to day 30.

C. Monitor platelet count every 2 or 3 days from day 4 to day 14

Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed every 2 or 3 days from day 4 to day 14. When a decrease in the platelet count is detected, heparin therapy should be discontinued immediately, and the patient should be tested for the presence of heparin antibodies.

The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing heparin-induced thrombocytopenia (HIT). Which previous medical conditions places this patient at risk for developing HIT?

a. Sepsis

b. Deep vein thrombosis

c. Cardiac arrest

d. Pneumonia

B. Deep vein thrombosis

Ascertaining a medical history that includes previous heparin therapy, deep vein thrombosis, or cardiovascular surgery that included the use of cardiopulmonary bypass can alert the nurse to potential problems.

What is the primary mechanism in the development of tumor lysis syndrome?

a. Destruction of platelets by lymphocytic antibodies

b. Destruction of malignant cells through radiation or chemotherapy

c. Formation of heparin antibodies

d. Damage to the endothelium

B. Destruction of malignant cells through radiation or chemotherapy

The primary mechanism involved in the development of tumor lysis syndrome is the destruction of massive numbers of malignant cells, either by chemotherapy or radiation. This mass destruction results in the release of large amounts of potassium, phosphorus, and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.

Which pathophysiologic event contributes to renal failure associated with tumor lysis syndrome?

a. Hypocalcemia

b. Elevated white blood cell count

c. Metabolic acidosis

d. Crystallization of uric acid in the renal tubules

D. Crystallization of uric acid in the renal tubules

When therapy is initiated, tumor cell destruction releases nucleic acids, which are metabolized into uric acid. Metabolic acidosis ensues, resulting in crystallization of the uric acid in the distal tubules of the kidneys and leading to obstruction of urine flow. Glomerular filtration rates drop as the kidneys are unable to clear the increasing amounts of uric acid. Consequently, acute kidney injury eventually occurs.

Hospital-acquired anemia is an increasing problem in critically ill patients. Which nursing interventions can be most beneficial in preventing this problem?

a. Administering fluids and inotropic agents to optimize blood pressure

b. Using blood salvage devices

c. Obtaining smaller blood samples through the use of pediatric blood tubes and point-of-care testing

d. Decreasing afterload through the use of vasodilators

C. Obtaining smaller blood samples through the use of pediatric blood tubes and point-of-care testing

Frequent blood draws in critically ill patients have been associated with the development of anemia. Blood losses correspond to actual volume of samples and discard when drawing from venous access lines. Critical care nurses can be instrumental in significantly decreasing blood loss in this arena. The use of pediatric collection tubes and point-of-care testing are techniques that yield valid diagnostic results but require smaller amounts of blood.

A patient has been admitted with sickle cell anemia and is requiring a blood transfusion. The nurse understands that transfusions should be used with caution in this patient because of what complication?

a. Fluid overload

b. Iron overload

c. Vasoocclusive crisis

d. Stroke

B. Iron overload

Transfusion therapy is used with extreme caution due to risks such as iron overload, exposure to hepatitis, HIV and other infectious agents, alloimmunization, induction of hyperviscosity, and limitations on resources. The indications for having a blood transfusion or exchange are recurrent painful vasoocclusive crises with long hospital admissions, acute chest syndrome, stroke, priapism, and leg ulcers.

A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to prevent the metabolic imbalances associated with this disorder?

a. Give sodium polystyrene sulfonate for hypokalemia.

b. Keep urine pH below 7.0.

c. Restrict all oral fluids.

d. Restrict foods containing potassium.

D. Restrict foods containing potassium

Dietary restrictions of potassium and phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid formation and to increase renal clearance. These can be accomplished through the administration of sodium bicarbonate to increase the pH of the urine to above 7.0, which increases the solubility of uric acid, preventing subsequent crystallization. Administration of intravenous fluids may be necessary early in the course of treatment if inadequate hydration exists. If potassium levels rise dangerously, Kayexalate (sodium polystyrene sulfonate) may be given orally, or if the patient is unable to tolerate oral medications because of nausea and vomiting, rectal instillation may be used.

Place these pathophysiologic mechanisms of disseminated intravascular coagulation (DIC) in the order in which they occur.

1. Activation of the fibrinolytic system

2. Breakdown of thrombi; spontaneous hemorrhage

3. Consumption of coagulation factors; failure of regulatory mechanisms

4. Endothelial damage; release of tissue factor

5. Thrombin formation; clots form along epithelial walls

a. 4, 5, 3, 1, 2

b. 4, 1, 3, 2, 5

c. 5, 1, 2, 4, 3

d. 2, 3, 1, 5, 4

A. 4, 5, 3, 1, 2

Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form, consuming coagulation factors. The fibrinolytic system is triggered to break down the clots, which leads to spontaneous hemorrhage.

A patient has been admitted with tumor lysis syndrome (TLS). Which laboratory findings would the nurse expect to note to support this diagnosis? (Select all that apply, one, some, or all.)

a. Increased calcium

b. Decreased potassium

c. Dysrhythmias

d. Elevated blood urea nitrogen (BUN)

e. Elevated creatine

C. Dysrhythmias

D. Elevated blood urea nitrogen

E. Elevated creatine

Common laboratory findings in tumor lysis syndrome (TLS) are as follows: increased potassium, phosphorus, uric acid, blood urea nitrogen (BUN), and creatine; decreased calcium, creatinine clearance, pH, bicarbonate, and PaCO2.

The nurse is caring for a patient with heparin-induced thrombocytopenia (HIT). The nurse knows the patient is at high risk for bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply, one, some, or all.)

a. Avoid intramuscular injections.

b. Use a large-gauge intravenous cannula for venipunctures.

c. Use a soft-bristled toothbrush when providing mouth care.

d. Use a draw sheet when repositioning the patient in bed.

e. Shave the patient with an electric shaver only.

A. Avoid intramuscular injections

C. Use a soft-bristled toothbrush when providing mouth care

D. use a draw sheet when repositioning the patient in bed

E. Shave the patient with an electric shaver only

Bleeding precautions include all of these options except using a large-gauge intravenous cannula for venipunctures. If necessary, only small-gauge needles or cannulas should be used.

A patient was admitted with multiple trauma who has been volume resuscitated. The nurse suspects the patient is fluid overloaded. Which assessment findings would confirm the nurse's suspicion?

a. Venous filling of the hand veins greater than 5 seconds

b. Distended neck veins in the supine position

c. Presence of orthostatic hypotension

d. Presence of a third heart sound

ANS: D

Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.

A patient has been admitted with acute kidney injury. The nurse knows the most important consideration for evaluating the patient's fluid status is what parameter?

a. Daily weights

b. Urine and serum osmolality

c. Intake and output

d. Hemoglobin and hematocrit levels

ANS: A

One of the most important assessments of kidney and fluid status is the patient's weight. In the critical care unit, weight is monitored for each patient every day and is an important vital signs measurement.

As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of what substance?

a. Ketones

b. Glucagon

c. Antidiuretic hormone

d. Potassium

ANS: C

When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to normal, and results in

more concentrated urine and an elevated urine osmolality level.

A patient was admitted with acute kidney failure. Which urinalysis value reflects a decreased ability of the kidneys to concentrate urine?

a. pH of 5.0

b. Specific gravity of 1.000

c. No casts

d. Urine sodium of 140 mEq/24 h

ANS: B

Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and substances suspended in water, the specific gravity should always be higher than that of water.

An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is accurate?

a. Airway assessment must incorporate cervical spine immobilization.

b. Hyperextension of the neck is the only acceptable technique.

c. Flexion of the neck protects the patient from further injury.

d. Airway patency takes priority over cervical spine immobilization.

A. Airway assessment must incorporate cervical spine immobilization

Airway assessment must incorporate cervical spine immobilization. The patient's head should not be rotated, hyperflexed, or hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical spinal cord injury has been definitively ruled out.

A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize secondary brain injury?

a. Hyperventilate the patient to keep PCO2 less than 30.

b. Restrict fluids to keep central venous pressure less than 6 cm H2O.

c. Maintain the patient's body temperature more than 37.5 C.

d. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg.

D. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg

Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity, or metabolic derangements. Hypoxia or hypotension, the best-known culprits for secondary injury, typically are the result of extracranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue. This increase in blood volume increases intracranial volume and raises intracranial pressure

A patient is admitted with a C5 to C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse suspects the patient may have which type of injury?

a. Posterior cord syndrome

b. Brown-Séquard syndrome

c. Diffuse axonal injury

d. Central cord syndrome

D. Central Cord syndrome

Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.

A patient is admitted with a C5 to C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing care for the patient includes which intervention?

a. Keep the room cool, dark, and quiet.

b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg.

c. Elevate the head of the bed 45 degrees.

d. Resuscitate low blood pressure by only using intravenous fluid.

B. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg

Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to 90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. The room should be kept warm to avoid hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone.

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse suspects these findings are indicative of which disorder?

a. Tension pneumothorax

b. Cardiac tamponade

c. Simple pneumothorax

d. Ruptured diaphragm

A. Tension pneumothorax

Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.

A patient with multisystem trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient's vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7 C; and central venous pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture?

a. Septic shock

b. Hemorrhagic shock

c. Cardiogenic shock

d. Neurogenic shock

A. Septic shock

The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are obtained.

A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that immobility places the patient at risk for developing which complication?

a. Pneumonia

b. Infection

c. Venous thromboembolism

d. Fat embolism syndrome

C. Venous thromboembolism

Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions to decrease and eliminate the trauma patient's risk of infection.

A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the information?

a. Check circulatory status.

b. Check electrolyte profile.

c. Insert a urinary catheter.

d. Obtain patient history.

D. Obtain patient history

During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters such as blood pressure, heart rate, and urine output is not adequate. Circulatory status is part of the primary survey.

A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method is used for during the primary survey. Which response would indicate the new graduate nurse understood the information?

a. Used to assess respiratory status

b. Used to assess circulatory status

c. Used to assess pain status

d. Used to assess level of consciousness

D. used to assess level of consciousness

The AVPU method can be used to quickly describe the patient's level of consciousness: A: alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U: unresponsive.

A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what type of trauma?

a. Spinal shock

b. Blunt thoracic trauma

c. Maxillofacial injuries

d. Penetrating thoracic injuries

B. blunt thoracic trauma

Blunt trauma to the chest most often is caused by motor vehicle crashes (MVCs) or falls. Spinal shock is a condition that can occur shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (e.g., 22-caliber gun, knife) usually damage only what is in the weapon's direct path.

A trauma patient's condition has deteriorated. The nurse notes changes in patient's condition, including trachea shift, absence of breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication?

a. Cardiac tamponade

b. Hemothorax

c. Open pneumothorax

d. Ruptured diaphragm

B. Hemothorax

Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to percussion on one side of the chest.

A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side, and 1800 mL of blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure?

a. Thoracotomy

b. Pericardiocentesis

c. Splenectomy

d. Pneumonectomy

A. Thoracotomy

Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.

The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a high risk for this complication?

a. Patients with liver trauma

b. Patients with burns

c. Patients with orthopedic trauma

d. Patients with spleen trauma

C. Patients with orthopedic trauma

Fat embolism syndrome can occur as a complication of orthopedic trauma.

Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that trauma patients are at risk due to which factors? (Select all that apply, one, some, or all.)

a. Blood stasis

b. Hypernatremia

c. Injury to the intimal surface of the vessel

d. Hyperosmolarity

e. Hypercoagulopathy

f. Immobility

A. blood stasis

C. injury to the intimal surface of the vessel

E. hypercoagulopathy

F. immobility

The factors that form the basis of venous thromboembolism (VTE) pathophysiology are blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.

A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this complication? (Select all that apply, one, some, or all.)

a. Dark tea-colored urine

b. Decreased urine output

c. Hypoxemia

d. Diminished pulses

e. Increased serum creatine kinase level

A. dark tea-colored urine

B. decreased urine output

E. increased serum creatine kinase level

Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should be monitored. Hypoxemia and diminished pulses are not associated with rhabdomyolysis.

Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients should include which preventive measures? (Select all that apply, one, some, or all.)

a. Consultation by physical therapist (PT) and occupational therapist (OT) early in the treatment of the patient.

b. Turning and repositioning the patient every 2 hours as ordered by the physician.

c. Range of motion exercises 1 month after the spine has been stabilized.

d. Removal of splints every 4 hours and at bedtime.

e. Hand splints for patients with paraplegia.

f. Hand and foot splints for patients with quadriplegia.

A. Consultation by physical therapist (PT) and occupational therapist (OT) early in the treatment of the patient.

B. Turning and repositioning the patient every 2 hours as ordered by the physician.

F. Hand and foot splints for patients with quadriplegia.

Physical therapy and occupational therapy personnel should be consulted early in the patient's course. Range-of-motion exercises are initiated as soon as the spine has been stabilized. Footdrop splints should be applied on admission to prevent contractures and prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be removed every 2 hours.