Murray final

final

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted?

Elevated systemic vascular resistance (SVR).

When evaluating a 62 yr old patient with a central venous catheter, the nurse observes that the insertion site is red and tender to touch and the patient's temperature is 101.8° F. What should the nurse prioritize to do next?

Discontinue the catheter and culture the tip.

A recently admitted 36 yr old patient who has sustained multiple traumas develops a low CVP pressure. Which of the following interpretations will alert the nurse of this change?

Hypovolemia

Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

The right hand feels cooler than the left hand

What action by a new intensive care unit staff nurse would indicate that the nurse educator’s teaching about arterial pressure monitoring has been effective?

Positions the zero-reference stopcock line level with the phlebostatic axis.

The nursing student is asked to demonstrate the Allen test on a fellow student. Which of the following best describes the Allen test?

Test used to determine patency of the radial and ulnar arteries.

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?

Arterial blood gas analysis

Which of the following is a hallmark characteristic of acute respiratory distress syndrome (ARDS)?

Refractory Hypoxemia

A nurse is caring for a client who has the following arterial blood gas results: pH 7.49, HCO3- 20 mEq/L, and PaCO2 28 mm Hg The nurse recognizes the client is experiencing which of the following acid base imbalances?

Respiratory alkalosis, partially compensated

A 28-year-old trauma patient in the ICU has a respiratory arrest event, and resuscitation is started. Family members are present in the room during the event. Which action by the nurse is best?

Ask family members if they wish to remain in the room during the resuscitation.

Four hours after mechanical ventilation is initiated, a patients arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3 of 23 mEq/L (23 mmol/L). What change should the nurse anticipate to the ventilator settings?

Decrease the respiratory rate.

The nurse notes premature ventricular contractions (PVCs) while suctioning a patients endotracheal tube. Which next action by the nurse is indicated?

Stop and ventilate the patient with 100% oxygen.

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Endotracheal intubation and positive pressure ventilation.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

The patients PaO2 is 45 mm Hg.

A 58 yr old patient who has been in the ICU for 6 days has disturbed sensory perception from sleep deprivation. Which actions should the nurse include in the plan of care?

Select all that apply

Cluster nursing activities.

Providing uninterrupted rest periods will minimize sleep-cycle disruption

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine?

Respirations are unlabored.

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

"DIC is caused by abnormal coagulation involving fibrinogen."

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Increased heart rate

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCs

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

Epinephrine

A nurse is providing care for a group of clients in the emergency department. Which of the following clients is at risk for developing neurogenic shock?

The client who has Guillain-Barr syndrome

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the client’s burns?

Location of the burn

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client.

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body surface area (TBSA)?

54 percent

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

The burned area is red in color with eschar present.

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Administer IV fluids.

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

"Large incisions will be made in the eschar to improve circulation and promote wound healing."

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Difficulty swallowing

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the emergent resuscitation of phase of injury?

Maintain the airway.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Hyperkalemia

A client who is having burn debridement states, “You are the worst nurse I have ever seen. All you do is hurt me.” Which of the following responses should the nurse make?

"Tell me more about that."

A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing?

One cup of lentils

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the Rule of Nines, the nurse should estimate that the client has burned what percentage of body surface area?

(Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

31.5

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

The Registered Nurse is caring for a patient and notes the following rhythm on the cardiac monitor. The nurse correctly identifies this rhythm as:

Supraventricular tachycardia

The Registered Nurse is caring for a patient and notes the following rhythm on the cardiac monitor. The nurse correctly identifies this rhythm as:

Sinus tachycardia

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

The P wave falls before the QRS complex.

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

Different apical and radial pulses.

A nurse is assisting a client who has a spinal cord injury with bathing. Which of the following actions should the nurse take?

Give the client a long-handled sponge.

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting?

“I have modified my home to make it more accessible.”

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Place the client in a high-Fowler’s position.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decerebrate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Extension and external rotation of the upper extremities

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

Pushes the painful stimulus away

When repositioning a patient with a suspected spinal cord injury, which nursing intervention is most appropriate?

Log-roll the patient with the assistance of another healthcare provider.

A nurse is assessing a client with a T6 spinal cord injury. Which of the following findings would the nurse expect?

Bilateral loss of sensation and motor function of the lower extremities

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse’s priority?

The client experiences sudden weakness of one arm and leg.

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Confusion

What is the appropriate nursing intervention for the RN to include in the planning phase for a client who has presented to the emergency department with sudden onset of slurred speech, left arm weakness, and facial drooping 25 minutes ago?

Activate the stroke team and prepare for rapid assessment and possible administration of IV alteplase

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringers solution that the nurse will give during the first 8-hours?

(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

600

A client who has hepatitis B surface antigen (HBsAg) in the serum is being discharged with pain medication after knee surgery. Which medication order should the nurse question because it is most likely to cause hepatic complications?

Hydrocodone with acetaminophen (Vicodin)

A nurse is assessing a client who has thyrotoxicosis after taking too high of a dose of levothyroxine. Which of the following manifestations should the nurse expect?

Tachycardia

A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

Mannitol 25%

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, feeling cool, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?

Hypoglycemia

A nurse in the PACU is caring for a client with an ET tube in place and observes the absence of left-sided chest wall expansion with respirations. This finding indicates which of the following post-operative complications has occurred?

Movement of the ET tube into the right main bronchus

A nurse is reviewing the client’s laboratory values who is receiving total parenteral nutrition (TPN) has the following lab values:

glucose = 72 mg/dL (70 to 99 mg/dL);

chloride = 98 mEq/L (98 - 106 mEq/L);

sodium = 138 mEq/L (135 - 145 mEq/L);

and potassium = 3.0 mEq/L (3.5 - 5.0 mEq/L).

Which of the following should the nurse implement?

Administer IV potassium replacement.

An 82-year-old patient presented to the ED with confusion and a suspected urinary tract infection. The patient was admitted with a diagnosis of sepsis and is now showing signs of multiple organ dysfunction syndrome (MODS). The nurse assesses the patient and observes the following: T: 39C, HR 118, RR 38, crackles on auscultation in all lung fields, and altered mental status. Which of the following cues is indicative of MODS?

Respiratory distress

Which of the following statements best describes the difference between SIRS and sepsis?

SIRS is a systemic inflammatory response syndrome, while sepsis when the patient has a systemic inflammatory response to an infection.

Which of the following findings on an ECG tracing would be consistent with a pacemaker?

Pacer spikes prior to the QRS complex

An RN is providing discharge education to a patient with cirrhosis. Which of the following cues may indicate impaired clotting for this patient?

Unusual bleeding or bruising

A 26 year old patient presents to the Emergency Room with confusion. Blood glucose on admission is 562. They are admitted to the hospital with hyperosmolar hyperglycemic state (HHS). An insulin drip was started and the patient was transferred to the ICU. The patient's blood glucose is now 290. Which of the following actions should the RN prioritize for fluid administration for this patient?

Administer 0.9% Sodium Chloride with Dextrose 5%

A patient with a history of diabetes mellitus presents to the emergency department with symptoms of excessive thirst, frequent urination, and fruity breath odor. The nurse recognizes these cues as possible indications of which condition?

Diabetic ketoacidosis (DKA)

A patient with hyperthyroidism is experiencing thyroid storm. Which intervention should the RN prioritize?

Administering a beta-blocker to reduce heart rate and blood pressure.

A client calls a travel advice nurse to inquire about the recommended vaccinations before their upcoming trip to a country with a high prevalence of hepatitis. The nurse educates the client about the importance of hepatitis vaccination. Which of the following statements by the nurse is correct?

Hepatitis A and B vaccination is highly recommended for all travelers to countries with a high prevalence of hepatitis.

A nurse on the day shift is preparing to change a client’s total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take?

Hang dextrose 10% in water (D10W) until the TPN solution is delivered.

A patient with a L3 spinal cord injury is admitted to the unit. The nurse is assessing the patient's muscle strength and tone. Which of the following findings would the nurse expect to observe?

Flaccid paralysis in the lower extremities

When communicating with the family of a patient with liver failure who is not a candidate for transplant, which statement by the nurse demonstrates therapeutic communication?

"It must be difficult to accept that your loved one is not eligible for a transplant. How can I support you during this time?"

A patient with jaundice has been prescribed lactulose. Which of the following statements by the patient indicates a correct understanding of the medication?

"I will drink plenty of water while taking lactulose to prevent dehydration."

A client presents with symptoms of hypovolemic shock. Which of the following hemodynamic measurement findings would be expected in this client?

Decreased CVP and increased heart rate

A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the rule of nines to determine the total body surface area of the burn injury. What percentage of body surface area should the nurse estimate the client has burned?

54 percent

A patient is transported to the emergency department via ambulance with full thickness burns covering the anterior and posterior aspect of the right arm and the anterior and posterior aspect of the right leg. Calculate the estimated total percentage of surface area of the burns using the Rule of Nines.[Image not available for print]

27

A patient presents with the following arterial blood gas results: pH 7.28, PaCO2 60 mmHg, HCO3- 30 mEq/L. What is the most accurate interpretation of these results?

Partially compensated respiratory acidosis

A patient's arterial blood gas results show a pH of 7.40, PaCO2 of 30 mmHg, and HCO3- of 18 mEq/L. What is the interpretation of these results?

Fully compensated respiratory alkalosis

While on the phone, the RN hears stridor coming from a patient who is mechanically ventilated. What is the RN's priority intervention?

Quickly end the phone call and assess the patient's airway.

An ICU nurse is caring for a patient with sepsis who is receiving an IV infusion of norepinephrine to maintain the mean arterial pressure (MAP). Why is it important to maintain a MAP of 65 mmHg?

To maintain adequate tissue perfusion to vital organs

A diabetic patient is admitted to the hospital with sepsis related to a wound infection of the toes. The patient has developed a new onset of crackles in all lung fields, has circumoral cyanosis, is sitting in a tripod position, and has a respiratory rate of 44. The rapid response team is activated and the provider plans to mechanically ventilate the patient. The nurse recognizes that this client is likely experiencing which condition related to the sepsis?

Acute respiratory distress syndrome (ARDS)

A patient presents to the emergency department with kussmaul respirations and wearing a medical alert bracelet identifying them as a type I diabetic. The nurse suspects the patient is experiencing:

Diabetic ketoacidosis (DKA)

When planning care for a patient with acute pancreatitis, what is the RN's priority?

Administering pain medication as ordered

A client with acute pancreatitis is placed on NPO status and receiving parenteral nutrition. The client asks the nurse why they cannot eat or drink. Which of the following responses by the nurse is most appropriate?

"Eating or drinking can worsen the inflammation in your pancreas. We need to let your pancreas rest"

Which of the following heart rhythms should be evaluated immediately due to its life-threatening nature?

Ventricular fibrillation