Test Bank High Acuity Nursing 6th Edition, Kathleen Wagner
The patient who had surgery yesterday reports his chest feels tight. Assessment reveals respiratory rate of 29, inspiratory wheezes, stridor, and an oxygenation saturation of 80%. The nurse would consider this patient to be which priority for transfer to the intensive care unit (ICU)?
1. Priority 1
2. Priority 2
3. Priority 3
4. Priority 4
The daughter of a patient who is dying questions the placement of her father on the medical–surgical care unit (MSCU). She requests he be placed in the intensive care unit (ICU) because of concern her father may not receive close observation on a busy hospital unit. Which action is indicated by the nurse?
1. Notify the intensive care unit of an impending transfer.
2. Tell the daughter that her father does not meet criteria for placement in the more expensive ICU.
3. Discuss the care that can be provided on the unit with the family member.
4. Contact the physician.
A nurse who is contemplating taking a position in an intensive care unit is reviewing her strengths and weaknesses. Which characteristics of the nurse will be of the greatest benefit in the intensive care environment?
1. Feels comfortable in ever changing situations
2. Closely evaluates the pros and cons of each decision for a long period of time before making a decision
3. Is quiet and introverted
4. Is excited about all new experiences
The registered nurse is working as charge nurse on a busy high-acuity care unit. Unexpectedly, a coworker becomes ill and needs to leave. There is a period of time in which the unit is short staffed while the ill coworker’s replacement travels in to work. What action by the charge nurse is indicated?
1. Make no changes until the replacement nurse arrives.
2. Assign the less acute patients to be cared for by the unlicensed assistive personnel.
3. Assign the unlicensed assistive personnel to watch the monitors and call for help if a patient “gets into trouble.”
4. Contact the house supervisor and ask for a float nurse to be sent to the unit.
A recent nursing school graduate reports having an interview with a magnet hospital. When preparing for the interview, the graduate nurse researches the concept of magnet status. Which perceptions by the nurse indicate an adequate understanding?
1. Magnet status is an accreditation from the National League for Nurses.
2. Magnet status facilities pay substantial recruitment bonuses.
3. Magnet status facilities promote the interests of professional nursing.
4. Magnet status hospitals must establish nurse-to-patient ratios.
A team of nurses would like to research outcomes of intensive care that expand beyond those that are normally studied. This team would recognize which outcome as most commonly studied?
1. Patient comfort
2. Patient perceived quality of life
3. Functional status
A newly employed nurse is working with an experienced registered nurse. During the shift, the experienced nurse routinely uses her personal digital assistant. How would the nurse explain the use of this device to the novice nurse?
1. “I use my PDA as a reference tool several times every day.”
2. “I can access my patient’s old medical records on this PDA.”
3. “I use my PDA to let the pharmacy know when I need medications.”
4. “I use my PDA to write nursing notes.”
A nurse says, “I worry that all of these machines in the intensive care unit interfere with my ability to to establish a therapeutic relationship with my patients.” What response by the nurse manager is indicated?
1. “Technology improves our patient outcomes.”
2. “I completely understand how you feel.”
3. “There are ways to increase your interaction with your assigned patients.”
4. “These feelings may be a sign that this is not the work environment for you.”
A recently hired nurse has been overheard saying she does not need to check as closely on her assigned patients as there are many machines that will “just do it for you.” What action by the nurse manager is indicated?
1. The nurse manager should plan a skills check off for the nurse.
2. The nurse should have a notation placed in her file indicating a lack of due care to assigned patients.
3. The manager should issue a verbal warning to the nurse.
4. The nurse manager should discuss assessment priorities with the nurse.
The nurse who transferred to the intensive care environment 6 months ago tells the nurse manager that she feels “burned out.” The nurse voices curiosity about how this could happen after such a short time in the unit. The charge nurse’s response should contain which information?
1. Burnout is not limited to long-term exposure to a work environment.
2. Burnout cannot be predicted.
3. The nurse most likely is not a good candidate for the intensive care unit.
4. The nurse is having a delayed response to change in work environment.
The spouse of a patient recently diagnosed with terminal cancer has voiced concerns about her husband’s continual denial of his disease. What should the nurse consider when planning a response to this concern?
1. It may be helpful for the patient’s emotional state at this time to be in a state of denial.
2. Denial is abnormal and the patient needs to have a consultation with a therapist.
3. It will be helpful to plan an intervention to force the patient to acknowledge his disease.
4. There is a limited amount of time left in the patient’s life so the denial must be rapidly worked through.
A patient in Suchman’s awareness stage has become argumentative and demanding. The nursing staff is becoming frustrated with the behaviors. What actions by the nurse are indicated?
1. The nurse should accept the behaviors and attempt to open the lines of communication.
2. Rotate the nursing assignments frequently to limit each nurse’s exposure to the behaviors.
3. Confront the patient about his demeanor.
4. Consolidate care so the nurse is in the room for shorter periods.
A patient says, “I’ve been hearing about aromatherapy as part of treatment for serious illness. What do you think about me trying it?” Which nursing responses are indicated?
1. “Some studies have shown that using lavender oil can reduce anxiety.”
2. “I would focus my energy on more traditional forms of healing.”
3. “Other than jasmine oil, you are probably safe using aromatherapy.”
4. “You should discuss this plan with your physician before purchasing anything.”
5. “I know that some massage therapists use essential oils.”
A newly licensed nurse has overheard a nurse telling a patient a joke. The nurse tells the preceptor, “I don’t think that nurse is being respectful of the patient’s diagnosis by telling jokes.” What response by the preceptor is indicated?
1. “When you have more experience you will understand the value of a good joke.”
2. “We try not to eavesdrop on other nurse’s conversations with patients.”
3. “Some times that nurse’s jokes do get old.”
4. “Sometimes laughing and joking can help us connect better with the patient.”
A patient is being kept on bedrest during treatment for deep vein thrombosis. The patient is uncomfortable because being in bed is stressful and has made his arthritis worse. Which complementary and alternative therapies might the nurse suggest to help treat this discomfort?
2. Therapeutic humor
4. Guided imagery
5. Music therapy
A patient is being treated for a massive myocardial infarction. His wife has just arrived in the emergency department and grabs the nurse’s arm demanding to know what is happening. Which initial nursing response is indicated?
1. “Your husband needs my full attention right now.”
2. “Someone call security.”
3. “Take your hands off of me.”
4. “Please go back to the waiting area.”
A newly licensed nurse says, “Every time I go into my trauma patient’s room his wife asks the same questions about his medication.” How should the preceptor evaluate this statement?
1. Anxiety about the husband’s condition has affected the wife’s ability to retain information.
2. The preceptor should present the information so that it is more understandable.
3. When serious injuries have occurred, new nurses often make the mistake of talking to the patient instead of the family.
4. The nurse and wife are not communicating well with one another.
The nurse is attempting to provide discharge teaching to a patient recently diagnosed with a terminal illness. The patient says, “I would rather talk to my usual nurse about my discharge.” What action by the nurse is indicated?
1. Ask the patient to sign a refusal of information form.
2. Continue to provide the information to the patient.
3. Ask the patient what efforts could be taken to make him feel more comfortable.
4. Contact the health care provider.
The nurse is conducting assessment on a patient who appears to be of Asian ancestry. Which questions are indicated?
1. “How long have you been in the United States?”
2. “How do you describe your ethnicity?”
3. “How does your culture influence your health care choices?”
4. “Do you speak English or do I need to try to find an interpreter?”
5. “Would you like for someone from your family to be in the room during your assessment?”
A nurse questions why socioeconomic status has been included in the admission assessment form. What response by the nurse manager is most appropriate?
1. Socioeconomic status helps the business office determine the likelihood of receiving payment.
2. Socioeconomic status will provide helpful information in choosing a room and roommate for the patient.
3. Socioeconomic status may provide information about previous access to care.
4. Socioeconomic status will reveal the patient’s health care priorities.
A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of “not feeling like myself.” What should the nurse consider during this assessment?
1. Aging causes sudden loss of function in organ systems.
2. In older adults diseases often present with uncharacteristic symptoms.
3. Many older adults do not participate in activities to support wellness.
4. Since the majority of 85-year-old patients live in an institutional setting they are exposed to more communicable diseases.
An older adult has been prescribed medication to control hypertension. Today she says, “I took this same medication years ago, but I’m having more side effects this time.” What should the nurse consider before replying?
1. Many antihypertensive medications have similar names so the patient could have confused the drugs.
2. Older women often decrease oral fluid intake, which would change response to the drug.
3. The older pancreas cannot supply enzymes to metabolize the drugs as early in the digestive system.
4. Changes in the blood–brain barrier may make older patients more sensitive to some side effects.
An older adult being treated for a burn on her lower leg and foot is surprised at its severity. She says, “It really didn’t hurt very badly when I did it.” What should the nurse consider before responding?
1. Patients can block out portions of painful stimuli if it is overwhelming.
2. Aging can decrease touch sensitivity to the feet and lower legs.
3. Poor circulation has probably resulted in death of the nerve endings in the patient’s legs.
4. Burns on the legs often appear very severe because the skin is so thin.
An older adult says, “I cannot believe that I have had a heart attack. I thought I had stomach flu and a backache.” What nursing response is indicated?
1. “I am also surprised that you had a heart attack. Your symptoms did not sound that severe.”
2. “Usually a patient has chest and arm pain with a heart attack.”
3. “The symptoms of heart attack change as people age and may include back pain or stomach problems.”
4. “It is rare but a backache and a stomach ache can occur as a signal of a heart attack.”
An older patient says, “I seem to get chest colds so often now.” How should the nurse respond to this report?
1. “How often do you wash your hands?”
2. “Risk for colds and infections increase as we age.”
3. “Do other people you are around have frequent colds?”
4. “Maybe you should consider taking antibiotics during the winter.”
An older adult patient remarks that he has been experiencing constipation, which has never been a problem for him before now. What questions should the nurse ask?
1. “Do you have a list of your medications?”
2. “How many fluids do you drink each day?”
3. “Do you get enough rest at night?”
4. “What kinds of fruits and vegetables do you eat daily?”
5. “How often do you have a bowel movement?”
The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence. Which symptoms, atypical in a younger adult, would the nurse assess for in this patient?
4. Flank pain
A 70-year-old patient had a pneumonia vaccination 10 years ago. Which information should the nurse provide about this vaccination?
1. ”A booster vaccination is warranted.”
2. “As long as your kidney function is good you do not need a second immunization.”
3. “You will never need another pneumonia vaccination.”
4. ”You should plan to get a pneumonia vaccination every year after September.”
After being medicated for postoperative pain an older patient becomes agitated and combative. Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition?
3. Drug toxicity
An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status. The patient is having progressive difficulty with normal self-care activities. The nurse should monitor this patient for which condition?
A patient complains of a dull, aching sensation in the lower back after long periods of sitting. The nurse anticipates the administration of medication to suppress pain impulse transmission in which fibers to treat the patient’s complaint?
1. A delta fibers
2. C fibers
3. Myelinated fibers
A patient has received a pain medication that blocks pain signals from the spinal cord. The nurse anticipates the effects of this medication will result in which level of pain?
1. 0 on a scale from 0–10
2. 8 on a scale from 0–10
3. 5 on a scale from 0–10
4. 2 on a scale from 0–10
The intensive care nurse plans to test nociception in the patient with a closed-head injury. Which nursing action is indicated?
1. Move an object across the patient’s visual field.
2. Place a container of ground coffee close to the patient’s nostrils.
3. Ask the patient to squeeze and release the nurse’s hand.
4. Press the patient’s nail bed.
The nurse observes the patient during a major abdominal dressing change. Which facets of pain can be observed by the nurse during this procedure?
1. Expressing behaviors
Admission vital signs for the mechanically ventilated patient in the neurosurgery intensive care unit are heart rate: 60 beats per minute, blood pressure: 110/82, and respiratory rate: 20 breaths per minute. Which statement by the nurse reflects an accurate understanding of the patient’s current pain experience?
1. “This patient’s vital signs reflect a sympathetic nervous system response to pain.”
2. “Since the vital signs are normal; the patient is not experiencing pain.”
3. “This patient needs further assessment to determine if pain is present.”
4. “Since the patient is mechanically ventilated, pain is unlikely.”
A patient tells the nurse that his back has not “bothered” him for months but now that he’s in the intensive care unit, his back is “killing” him. The nurse considers which cause of this pain when designing interventions?
1. Lack of mobility due to hospitalization
2. Worsening of the disease process that caused the hospital admission
3. An undiagnosed injury to the back
4. Tolerance to pain medication
While giving an end-of-shift report, the exiting nurse describes treatment for a patient’s complaint of arm pain. The nurse receiving the report should question the validity of which statement?
1. “The patient is resting quietly in bed.”
2. “The patient’s blood pressure is normal so the pain is gone.”
3. “I administered 800 mg of ibuprofen.”
4. “I also applied a hot pack to the arm at the patient’s request.”
A trauma patient has just been sedated, intubated, and placed on mechanical ventilation. The nurse documents the patient’s pain level as 9 on the 1–10 scale. How should this action be interpreted?
1. The patient should receive the highest dose of analgesic medication ordered.
2. The nurse has inappropriately scaled the patient’s pain.
3. The nurse should wait until the patient has adapted to the mechanical ventilator before scaling the level of pain.
4. Pain will decrease now that the patient does not have to work to breathe.
The nurse prepares to administer a nonsteroidal anti-inflammatory drug to the patient with postoperative knee pain. The nurse should consider which pharmacological properties of NSAIDs?
1. NSAIDs inhibit the manufacture of bradykinins.
2. NSAIDs bind with opioid receptors throughout the nervous system.
3. NSAIDs exert peripheral effects.
4. NSAIDs inhibit the formation of prostaglandins.
5. NSAIDS exert CNS effects.
A semi-conscious patient with pancreatic cancer requires pain management. After multiple attempts, the oncology nurses are unable to establish venous access. What is the best alternative route for pain medication administration until venous access can be obtained?
1. Rectal suppository
2. Injection in deltoid muscle
3. Subcutaneous injection in abdominal tissue
4. Oral liquid
An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated?
1. Increase vigilance for dehiscence.
2. Talk to the family about trimming the patient’s hair.
3. Use a protein-based shampoo.
4. Increase the patient’s oral fluid intake.
A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?
1. Support elevated nutrient needs.
2. Maintain on intravenous fluids and clear liquids.
3. Limit food and fluid intake to three mealtimes daily.
4. Begin a weight-reduction program immediately.
A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring?
1. Blood pressure 170/104 mm Hg
2. Elevated blood glucose level
3. Serum potassium of 5.4 mEq/L
4. Increase in body temperature
The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated?
1. Encourage the patient to eat as much as possible during each meal.
2. Plan to increase the patient’s calorie intake to goal in 2 or 3 days.
3. Limit the patient’s intake of fluids so to encourage a normal appetite.
4. Each day offer foods that provide 20kcal/kg of the patient’s actual body weight.
The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient’s nutritional needs?
1. Monitor carbohydrate intake to reduce body carbon dioxide levels.
2. Encourage fat intake.
3. Minimize vitamin supplements.
4. Limit protein.
The nurse is caring for a patient diagnosed with chronic renal failure and being treated with hemodialysis who weighs 100 kg. What would be an appropriate intake of protein for this patient?
1. 120 g per day
2. 75 g per day
3. 240 g per day
4. 60 g per day
A patient, being treated for multiple injuries in the intensive care unit, had been NPO for several days. Clear liquids are started today, but the patient only takes a few sips before refusing additional fluids and then vomiting. The patient’s temperature is also elevated. The nurse would assess for findings associated with which disorder?
1. Gastric ulcer
2. Gut failure
3. Electrolyte imbalance
4. Diabetes insipidus
The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient’s nutritional needs?
1. Supply with balanced nutrients to meet current body weight needs.
2. Complete a nutritional assessment and supply with high-calorie, high-protein supplements.
3. Provide high dose therapy of vitamins C and B.
4. Supply with high-fat and high-carbohydrate supplements.
The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient’s nutritional needs?
1. Provide adequate calories in the form of carbohydrates and fats.
2. Ensure adequate protein intake to maintain a positive nitrogen balance.
3. Plan to implement parenteral nutrition as soon as possible.
4. Increase dietary supply of cortisol.
A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds. What should be included in to the plan to support this patient’s nutritional needs?
1. Maintain NPO status.
2. Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition.
3. Determine best enteral feeding approach and plan implementation.
4. Begin oral feeding with a diet as tolerated as soon as bowel sounds return.
A patient in the emergency department (ED) becomes suddenly unresponsive. CPR is initiated. Arterial blood gas results reveal pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76 percent. The nurse would prepare for which priority intervention?
1. Call for a rapid response team.
2. Auscultate the patient’s lungs.
3. Place the patient on a 50 percent humidified mask.
4. Administer endotracheal intubation.
An adult patient has suffered a respiratory arrest and requires endotracheal intubation. The nurse should obtain which equipment for this procedure?
1. Topical anesthetic
2. Magill forceps
3. Cuffless endotracheal tube
4. Oxygen cannula
5. Water-soluble lubricant
A patient aspirated while eating and suffered a respiratory arrest. A code blue was called, the obstruction was removed, but the patient required endotracheal intubation. Postintubation the nurse hears breath sounds bilaterally, but the carbon dioxide monitor indicates a higher than expected level. Which patient history could account for this discrepancy?
1. The patient’s original admittance diagnosis was dehydration.
2. The patient’s wife reports, “We were talking and laughing when he choked.”
3. The patient has history of calcium deficiency requiring dietary supplementation.
4. The patient’s wife says, “He had some heartburn earlier, so the nurse had given him a lemon-lime soda to drink with his supper.”
The nurse manager teaches newly hired nurses about findings associated with barotrauma. The manager would include that this complication is most common in which type of mechanical ventilation?
The nurse notes these ventilator setting change orders. What nursing intervention is indicated?
1. Carry out the orders as written.
2. Verify the respiratory rate.
3. Verify the mode.
4. Verify the tidal volume.
The nurse caring for a patient who is ventilated via the assist-control mode monitors for which complication specifically related to this intervention?
4. Respiratory alkalosis
The nurse is admitting a patient who sustained a traumatic brain injury and who is now deeply sedated. The nurse would anticipate managing which mode of ventilation during this patient’s initial care?
1. Pressure support ventilation
2. Assist-control ventilation
3. Pressure support ventilation (PSV)
4. Synchronized intermittent mandatory ventilation (SIMV)
The nurse is preparing to care for a patient returning from elective surgery who will require mechanical ventilation for a few more hours. The nurse would initiate which ventilator setting orders without question?
1. SIMV with a rate of 12, tidal volume 750 mL, FIO2 0.60
2. Assist-control with a rate of 16, tidal volume 1,000 mL, FIO2 0.40
3. Assist-control with a rate of 20, tidal volume 1,200 mL, FIO2 0.60
4. SIMV with a rate of 4, tidal volume 1,200 mL, FIO2 0.60
A patient’s ventilator settings are going to be modified to include positive end expiratory pressure (PEEP). What nursing action is most important?
1. Suction the patient before and after the change.
2. Monitor vital signs frequently.
3. Notify the physician of abrupt increases in oxygenation.
4. Monitor breath sounds at least every 15 minutes.
The nurse responds to a ventilator pressure alarm by going to the patient’s room. What should be the nurse’s first action?
1. Turn off the ventilator alarm to help calm the patient.
2. Administer intravenous sedation according to prn prescription.
3. Assess for the cause of the alarm.
4. Manually bag the patient until the cause of the alarm is detected.
The nurse is preparing to use a patient’s pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated?
1. Zero the transducer at the phlebostatic axis.
2. Place the patient in Trendelenburg position.
3. Warm cardiac output injectate fluid to body temperature.
4. Prepare 20 mL of injectate.
The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?
1. Inflating the pressure bag to 300 mm Hg
2. Infusing a vasoactive drug through the proximal injectate port
3. Obtaining a pulmonary artery wedge pressure reading through the distal port
4. Using iced normal saline to obtain a cardiac output
While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patient’s cardiac output remains at 6.0 liters per minute. What would the nurse expect the patient’s blood pressure to be?
4. Initially decreased, and then increased
The nurse is reviewing the results of a patient’s cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate?
1. A low cardiac output
2. Poor injection technique
3. Incorrect placement of the catheter
4. A high cardiac output
The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate?
1. Jugular vein distention
2. Weak, thready pulse
3. Presence of rales and rhonchi
4. Poor skin turgor
A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient’s right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions?
1. Internal hemorrhage
2. Fluid loss during surgery
3. Vasodilation from drugs administered during surgery
4. Left heart failure
5. Cardiac tamponade
While evaluating a patient’s pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated?
1. Assist the patient to a left side-lying position.
2. Notify the physician for repositioning.
3. Increase intravenous fluids.
4. Nothing, since this is an expected occurrence.
A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?
1. A pulmonary artery wedge pressure of 16 mm Hg
2. Pulmonary artery pressure of 34/16 mm Hg
3. Systemic vascular resistance of 1,400 dynes/sec/cm-5
4. A right atrial pressure of 5 mm Hg
The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?
1. Systemic vascular resistance of 900 dynes/sec/cm5
2. Appearance of an “a” wave on the pulmonary artery waveform
3. Pulmonary artery wedge pressure of 10 mm Hg
4. Spontaneous development of a pulmonary artery wedge pressure waveform
A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention?
1. Pulmonary artery wedge pressure of 2 mm Hg
2. Heart rate of 112
3. Urine output of 25 mL/hr
4. Presence of rales at both lung bases
A patient has been diagnosed with premature ventricular contractions. The nurse realizes that this dysrhythmia can result from a weaker than normal stimulus during which action potential period?
1. Absolute refractory period
2. Relative refractory period
3. Supranormal period
4. Subnormal period
A patient’s electrocardiogram ST segment tracing is deflected from baseline. The nurse would conduct assessment for which condition?
1. Ventricular muscle injury
2. Atrial muscle injury
3. Respiratory acidosis
A patient’s heart rate averages 86 beats per minute. If this patient is to have continuous electrocardiogram monitoring the nurse will set the rate alarms at which level?
1. Low 76, high 96
2. Low 66, high 106
3. Low 60, high 100
4. Low 80, high 100
The nurse has determined that the patient has a bundle branch block. In order for this determination which condition must exist?
1. The PR interval must be longer than 0.20 seconds.
2. The ST segment must be elevated.
3. QRS segment should not be longer than 0.128 seconds.
4. The PR interval lengthens with each beat.
The nurse interpreting a patient’s electrocardiogram has just examined the P waves. What is the nurse’s next step?
1. Determine if each P wave is followed by a QRS complex.
2. Measure the PR interval.
3. Diagnose the rhythm.
4. Examine and measure the QRS complex.
A patient is diagnosed with hypermagnesemia. The nurse would assess for which changes on the patient’s cardiac rhythm strip?
1. Prolonged QT interval
2. Flattened T waves
3. Tall peaked T waves
4. Short QT interval
5. Prolonged PR interval
A patient’s admission vital signs were blood pressure 128/64 mm Hg; HR 86 bpm, respirations 16, and temperature 98.6°F. The patient has spiked a temperature of 101.6°F. Which change in heart rate would the nurse anticipate?
1. Increase to 116 bpm
2. Increase to 100 bpm
3. Decrease to 76 bpm
4. Increase or decrease of no more than 5 bpm
A patient presents to the emergency department and says, “I am so dizzy that it is scaring me.” Monitoring reveals the patient’s blood pressure is 78/52 mm Hg and heart rate is 50 beats per minutes. Which nursing intervention is indicated?
1. Administer anti-anxiety medication.
2. Administer atropine.
3. Instruct the patient to cough forcefully.
4. Monitor the patient while contacting the primary care provider.
A patient in the emergency department has a heart rate of 140 bpm. Which nursing interventions are indicated?
1. Assess the patient’s temperature.
2. Administer atropine.
3. Present a calm demeanor.
4. Assess the patient for pain.
5. Prepare for intubation.
A patient’s cardiac monitor reveals a regular rhythm with a rate of 240 bpm. No P waves are distinguishable. The patient is alert and says, “My heart is racing.” What nursing intervention is indicated?
1. Gather equipment to begin anticoagulant therapy.
2. Defibrillate the patient.
3. Prepare the patient for immediate cardioversion.
4. Ask the patient to bear down as if moving the bowels.
Assessment of the patient’s sternal surgical incision reveals that the skin between sutures is opened. There is a small amount of drainage present on the dressing. The nurse would anticipate caring for this wound as it heals in which manner?
1. Tertiary intention
2. Primary intention
3. Secondary intention
4. Recurrent surgical debridement
A patient is to receive pulsatile lavage treatments for a chronic ulcer on the left heel. Which explanation would the nurse provide for this treatment?
1. “This treatment is a form of autolytic debridement to remove dead tissue from your heel.”
2. “Your foot will be submersed in a whirlpool tub for this treatment.”
3. “This treatment will help cleanse the wound bed.”
4. “This treatment will inject medications into the deep crevices of your wound.”
The surgical wound of a patient recovering from an appendectomy has several steri-strips across it with a small amount of dried blood over the incision line. How would the nurse dress this wound?
1. Hydrocolloid dressing
2. Wet-to-dry dressing
3. Alginate dressing
4. Dry, sterile dressing
A patient presents to the emergency department with a large leg wound. The nurse identifies which factors as increasing this patient’s risk of complications with wound healing?
1. The patient smokes eight cigarettes a day.
2. The patient has peripheral artery disease.
3. The patient has osteoarthritis in his knees.
4. The patient’s average blood sugar measurements are over 200mcg/dL.
5. The patient lost some blood during the injury but the loss was not excessive.
There is dead tissue throughout the patient’s nonhealing abdominal wound. The nurse prepares for which intervention needed to encourage this wound to heal?
1. Diet analysis for protein adequacy
2. Keeping the wound covered to increase oxygen to the wound bed
3. Debridement of devitalized tissue
4. Introduction of air into the wound for drying
The nurse caring for a patient with a pressure ulcer notes the wound is increasing in redness and has more swelling around the wound edges. Which nursing intervention is indicated?
1. Encourage the patient to ingest more fluids.
2. Assess for pain and warmth.
3. Cover the wound with a sterile dry dressing.
4. Dress the wound as prescribed.
The nurse manager has noted an increase in wound infections in a postoperative unit. What instruction to the unit staff is the most important?
1. Wear gloves at all times.
2. Administer antibiotics as prescribed.
3. Assess patients for infection risk upon admission.
4. Follow hand washing protocols.
A patient has a wound on his thigh that is swollen and red. The nurse assesses that the surrounding tissue has a dusky blue color with a few small dark blisters. Which other assessment findings would cause the nurse to alert the health care provider about possible necrotizing fasciitis (NF)?
1. Blood pressure is 140/90 mm Hg.
2. The patient reports recently taking steroids for a severe ear infection.
3. The patient works in an elementary school.
4. The patient reports pain as a 9 on the 1 to 10 pain scale.
5. The patient’s body mass index is 31.
A male patient tells the nurse that he has “excruciating pain” in his perineal region that started a few days after having an indwelling urinary catheter removed. Upon inspection, the nurse sees a dime-sized reddened area on the patient’s perineum below the scrotal sac. What nursing intervention is priority?
1. Have the wound further evaluated for possible Fournier’s gangrene.
2. Apply ice to the region.
3. Give the patient prn acetaminophen.
4. Place a scrotal support on the patient.
A patient being treated for necrotizing fasciitis has signs of granulation tissue appearing in a large abdominal wound. The nurse anticipates providing which care for this patient’s wound?
1. Irrigating the wound twice daily before applying dry dressing
2. Caring for a split thickness skin graft
3. Applying wet-to-dry dressings
4. Caring for a suture line created by surgical closure of the wound
The nurse is assessing a patient with an endotracheal tube and notes decreased breath sounds on the left with normal sounds on the right. Which condition may cause this?
1. Pressure from a right pneumothorax
2. Misplacement of the endotracheal tube
3. High pulmonary pressures
4. Partial obstruction of the endotracheal tube
5. A large infiltrate in the left lung
A patient with pulmonary edema has a respiratory rate of 28 per minute. The nurse plans care for this patient based on which change in the lungs?
1. Decreased work of breathing
2. Reduced muscle activity
3. Dehydration of lung tissues
4. Decreased compliance
The patient has been diagnosed with early stage pneumonia. The nurse would anticipate which laboratory results?
1. Increased PaO2 and increased PaCO2
2. Decreased PaO2 and normal PaCO2
3. Normal PaO2 and elevated PaCO2
4. Decreased PaO2 and increased PaCO2
The nurse is assessing an 80-year-old patient who has no underlying respiratory pathology but whose carbon dioxide level is slightly elevated. The nurse would contribute this increase to which changes associated with normal aging?
1. Increase in alveolar–capillary membrane thins
2. Increase in total lung surface area
3. Increase in size of the airways
4. Increase in air trapping
5. Overgrowth of alveoli
The arterial blood gases of a patient with a large mass in the right lung show increasing hypoxemia and the patient will be intubated for placement on a mechanical ventilator. In which position should the nurse place this patient until intubation is begun?
1. Flat in bed lying on the left side
2. Flat in bed lying on the right side
3. Lying on the left side with the head of the bed elevated to 30 degrees
4. Lying on the right side with the head of the bed elevated 30 degrees
A patient, diagnosed with diabetic ketoacidosis, presents with Kussmaul respirations at a rate of 28. A newly licensed nurse asks the patient to try to slow his breathing. What instruction should the preceptor provide?
1. “Keep trying to slow the patient’s respirations because breathing so fast is hard on his heart.”
2. “If he keeps breathing like that he will develop respiratory acidosis.”
3. “Let the patient set his respiratory rate as rapid breathing helps to compensate for his acidosis.”
4. “The patient is breathing deeply to help offset diabetes-induced hypoxemia.”
A postoperative patient’s nasogastric drainage has been 500 mL in the last 8 hours. The nurse would assess this patient for findings associated with which acid–base imbalance?
1. Metabolic alkalosis
2. Metabolic acidosis
3. Respiratory acidosis
4. Respiratory alkalosis
A patient was extubated in the postanesthesia recovery room prior to transfer to the intensive care unit (ICU). Upon admission to the ICU the patient is sedated, but will arouse when stimulated. Blood pressure is 106/68 mm/Hg, heart rate is 68 and regular, temperature is 97.8 F, and respirations are 12 bpm. The nurse would monitor this patient for which changes in arterial blood gases?
1. Increase in pH and decrease in PaCO2
2. Increase in pH and increase in HCO3
3. Decrease in pH and increase in PaCO2
4. Decrease in pH and decrease in HCO3
A patient’s arterial blood gases (ABGs) are as follows:
pH 7.30, PaCO2 30 mm Hg, HCO3 14 mEq/L, and PaO2 50. The nurse evaluates these ABGs as representing which acid–base imbalance?
1. Uncompensated respiratory alkalosis with moderate hypoxemia
2. Compensated metabolic acidosis with severe hypoxemia
3. Partially compensated metabolic acidosis with moderate hypoxemia
4. Partially compensated respiratory alkalosis with mild hypoxemia
A patient’s PaO2 level is 76 mm Hg. The nurse would be least concerned regarding this finding in which patient?
1. The patient is 83 years old.
2. The patient is recovering from anesthesia.
3. The patient is a smoker.
4. The patient is intubated.
A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?
1. Prolonged expiratory time
2. Increased lung compliance
3. Reduced tidal volume
4. Hyper-inflated lungs
A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?
1. Decreased total lung capacity
2. Progressive respiratory alkalosis
3. Increased PaCO2
4. Increased forced expiratory volume (FEV)
A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a “high pitched noise” in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?
The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?
1. The patient is now able to rest and sleep.
2. The patient’s condition has significantly deteriorated.
3. The patient’s condition shows some slight improvement.
4. The patient’s condition has stabilized significantly.
A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?
1. The patient has ventilation failure.
2. Without treatment the patient’s oxygen saturation is likely to drop rapidly.
3. The patient has decreased airflow.
4. The patient is at risk for respiratory muscle fatigue.
5. Acute respiratory failure is present.
The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication?
1. A patient who sustained a severe chest contusion.
2. A patient hospitalized for treatment of drug overdose.
3. A patient who sustained severe head trauma.
4. A patient hospitalized for treatment of pneumonia.
5. A patient diagnosed with sepsis.
The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing?
1. Increased lung compliance
2. Decrease in heart rate
3. Hypoxemia refractory to oxygen therapy
4. Respiratory acidosis
A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?
1. Obstructed endotracheal tube
2. Increased severity of ARDS
3. Decreased cardiac output
The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?
1. Administer pain medication as ordered.
2. Increase intravenous fluids.
3. Evaluate the patient’s oxygen saturation.
4. Help the patient assume a more comfortable position.
The patient’s Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?
1. Monitor daily D-dimer levels.
2. Strictly measure all intake and output.
3. Encourage ambulation.
4. Instruct the patient on use of antiembolism stockings.
5. Prevention of leg injury
A patient’s cardiac index will be calculated. What nursing interventions are necessary before this calculation is completed?
1. Assure that there is an accurate current weight on the medical record.
2. Compare fluid input and output for the last 12 hours.
3. Measure the patient’s height.
4. Figure the patient’s age in years and months.
5. Obtain the patient’s current heart rate.
A patient is scheduled for an echocardiogram with measurement of ejection fraction. The nurse explains to the patient that this test will provide the most information about which cardiac characteristic?
1. The amount of blood the heart pumps every minute
2. The strength of the heartbeat
3. The amount of resistance the heart beats against
4. The amount of blood in the heart before it beats
Testing indicates that a patient has a high preload. What changes would the nurse expect in this patient’s cardiac function?
1. Heart rate will decrease.
2. Afterload will increase.
3. Stroke volume will decrease.
4. Stoke volume will increase.
5. Blood pressure will decrease.
A patient, with a steadily increasing preload, was experiencing a corresponding increase in stroke volume but it has now begun to decrease. Which rationale would the nurse provide for this occurrence?
1. This fluctuation will occur until maximum preload has been reached.
2. The patient’s heart rate is increasing, which causes a drop in stroke volume.
3. The patient’s preload has reached a critical point and now stroke volume will decrease.
4. It is necessary to assess for a secondary pathophysiological event causing the stroke volume to decrease.
A patient is diagnosed with septic shock and has a decrease in afterload. The nurse would expect which initial changes in the patient’s cardiac status?
1. Increase in cardiac output
2. Increase in blood pressure
3. Decrease in cardiac output
4. Decrease in blood pressure
5. No change in blood pressure or cardiac output
It is determined that a patient has poor cardiac contractility. The nurse would anticipate administering which type of drugs to improve contractility?
1. Cardiac glycosides
2. Loop diuretics
3. Sympathomimetic agents
4. Phosphodiesterase inhibitors
A patient is admitted with the complaint of chest pain. Questions about which history will best help the nurse determine if the pain is from cardiac or pulmonary origin?
1. Deficits in movement, timing of the pain, and dietary changes in the last 24 hours
2. What precipitated the pain, what it feels like, and where it is located
3. Changes in dietary habits, smoking history, and presence of cough
4. What home remedies were tried, activity level, and fluid intake changes
Which assessment techniques will the nurse use to evaluate the patient’s cardiac output?
1. Inspection of color changes in the periphery
2. Strength of pulses
3. Percussion of heart borders
4. Auscultation of heart sounds
5. Pulse pressure determination
A patient has been admitted with chest pain and generalized discomfort. Which assessment is essential in order for the nurse to set realistic goals for patient therapy and education?
1. The patient’s functional status prior to illness
2. Family history of disease, diet history, and prior medical history
3. Demographic data including age, sex, race, and weight of patient
4. Cardiovascular risk factors, such as history of smoking and stress level
The nurse has auscultated the patient’s heart sounds and has measured vital signs. Which finding would the nurse evaluate as indicating greatest need for additional assessment?
1. Pulse pressure of 38 mm Hg
2. Bounding, vigorous pulse
3. Split of S2
4. Apical pulse of 66
Which clinical manifestation would the nurse evaluate as most significant in a patient with mitral valve stenosis?
1. Edema of the lower extremities
2. A heart rate of 110 beats per minute
3. Altered deep tendon reflexes
4. Bounding peripheral pulse
When conducting a health history on a patient with aortic valve stenosis, which question would be most important for the nurse to ask?
1. “Do you have a family history of coronary artery disease?”
2. “Do any of your family members have valvular problems?”
3. “Have you ever been diagnosed with rheumatic fever?”
4. “Have you ever been diagnosed with high blood pressure?”
A patient with history of mitral valve stenosis is placed on a cardiac monitor. Which arrhythmia would the nurse anticipate since it is a common rhythm for patients with this history?
1. Ventricular tachycardia
2. Third-degree heart block
3. Junctional rhythm
4. Atrial fibrillation
A patient is diagnosed with an acute myocardial infarction and ruptured papillary muscle. Which action is the highest priority for the nurse to complete?
1. Obtain an electrocardiogram.
2. Measure the patient’s cardiac output.
3. Assess the patient’s neurological status.
4. Assess respiratory status.
The nurse is collecting the health history of a patient hospitalized for possible infective endocarditis. Which findings would the nurse evaluate as supporting this presumptive diagnosis?
1. The patient reports having rheumatic heart disease as a child.
2. The patient has asthma.
3. The patient had a routine screening colonoscopy 1 month ago.
4. The patient is maintained on hemodialysis.
5. The patient has developed osteoarthritis over the last 2 years.
The nurse has completed discharge teaching with a patient who had a mechanical valve replacement. Which patient behavior would the nurse evaluate as indicating additional teaching is necessary?
1. The patient asks his wife to purchase a blood pressure monitor from their pharmacy.
2. The patient tells the nurse of his plans to visit Rome next year.
3. The patient orders a pasta salad with broiled salmon for lunch.
4. The patient makes plans to stay with his daughter in her three story condominium for a few weeks after discharge.
A patient is admitted for treatment of heart failure. The nurse would attribute which patient complaint to this diagnosis?
1. “I often have headaches early in the morning.”
2. “I have some numbness in my feet.”
3. “I wake up a lot at night.”
4. “I find I bruise more easily now.”
A patient diagnosed with heart failure makes the following comments. Which statement requires additional assessment by the nurse?
1. “I still sleep better in a recliner.”
2. “I do pretty well as long as I don’t try to do too much at one time.”
3. “My heart rate runs around 60 to 64 most of the time.”
4. “I’ve gained 4 pounds since yesterday.”
A patient has been diagnosed with dilated cardiomyopathy. The nurse would provide which instruction?
1. “It will be necessary for you to rest more and to limit exercise.”
2. “In some cases, this condition is treated with a surgical procedure to remove part of the ventricular septum.”
3. “You will need to take calcium channel blockers exactly as prescribed for the rest of your life.”
4. “A common treatment for your condition is the implantation of a cardioverter-defibrillator.”
A patient with heart failure tells the nurse that she is “allergic” to ACE inhibitors because they make her cough “all of the time.” What does this information suggest to the nurse?
1. The patient should not take an angiotensin receptor blocker because of the ACE inhibitor allergy.
2. The patient’s asthma has been exacerbated by the use of an ACE inhibitors.
3. The patient experienced a side effect of the ACE inhibitor, which is a cough.
4. The patient’s cough is due to long-standing heart failure.
A patient is diagnosed with atherosclerosis. How would the nurse explain the area injured by this inflammatory disorder?
1. “Your arteries have three layers that are all damaged by atherosclerosis.”
2. “Atherosclerosis damages the lining of your arteries.”
3. “Atherosclerosis is also called ‘hardening of the arteries’ because it damages the outside layer, making it hard for your artery to stretch.”
4. “The middle layer of the wall of your arteries is injured by atherosclerosis, which allows plaque to build up.”
A lipid panel has been drawn on a patient who has a family history of atherosclerosis. The nurse would explain that which value on the panel is most implicated in development of atherosclerosis?
1. High-density lipoprotein
2. Total cholesterol level
3. Triglyceride level
4. Low-density lipoprotein
The nurse is performing a cardiovascular assessment. Which patient findings would indicate significant risk factors for the development of atherosclerosis?
1. The patient is diabetic.
2. The patient tends to become anemic.
3. The patient’s mother and sister had myocardial infarctions before age 50.
4. The patient has high levels of low-density lipoproteins.
5. The patient is a 50-year-old male.
The nurse is assessing a patient whose body mass index is 28 kg/m2. Which nursing diagnosis is appropriate for this patient?
1. Imbalanced Nutrition: More than Body Requirements
2. Altered Health Maintenance
3. Imbalanced Nutrition: Less than Body Requirements.
4. Risk for Exercise Intolerance
A patient tells the nurse that he smokes two packs per day, works 10-hour work days most days of the week, eats out twice a day when working, and has no time to exercise. Which nursing diagnosis is appropriate for this patient?
2. Ineffective Coping
3. Altered Health Maintenance
4. Imbalanced Nutrition: More than Body Requirements
The nurse has completed teaching regarding cardiac risk factor reduction. Which patient statement would best indicate an understanding of the instructions?
1. “I am going to start walking my dog for 30 or 40 minutes every day.”
2. “I will substitute vegetables for some of the fruit I have been eating.”
3. “I will increase weight bearing activities.”
4. “I will avoid becoming dependent upon laxatives.”
The nurse is providing medication education for a patient who has been prescribed atorvastatin (Lipitor). Which information should be included?
1. This is one of the few medications that will not need to be monitored with periodic blood tests.
2. Contact your physician if you develop muscle pain.
3. It will take about 6 months before this medication will improve your low density lipoprotein level.
4. This medication helps your liver break down LDL.
A patient tells the nurse that he had chest pain into his left arm while moving a heavy trash can that lasted for about 10 seconds and stopped when he put the trash can down. This information would be included in which aspects of the PQRST assessment for chest pain?
A patient tells the nurse that he has been experiencing a “pain in the chest” for the last 3 hours. What does this information suggest to the nurse?
1. The pain is of non-cardiac origin.
2. The patient is in the midst of an acute myocardial infarction.
3. The patient is going to have a myocardial infarction within hours.
4. The patient is having continuous angina.
A patient is diagnosed with Prinzmetal’s angina. Which assessment findings would the nurse attribute to this diagnosis?
1. The patient experiences lightheadedness that occurs at rest.
2. The patient has chest pain that lasts several hours.
3. The patient can predict the level of activity that will cause the pain.
4. The patient is awakened from sleep by chest pain.
5. The patient has chest pain that is not related to physical activity.
A patient, admitted with the diagnosis of stroke, has left hemiparesis involving the face, arm, and leg. The nurse explains that this stroke most likely involves which artery?
1. Right vertebral
2. Left posterior communicating
3. Left middle cerebral
4. Right middle cerebral
A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position?
1. The brain will compress the cerebral veins less in this position.
2. The ventricles of the brain will drain better in this position.
3. This position allows for less pain for the patient.
4. The cerebral spinal veins are valveless and drain by gravity.
The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow?
The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must be accompanied by which other change if intracranial pressure is to remain stable?
1. There will be an increase in the blood flow to the brain.
2. There is a decrease in the blood–brain barrier.
3. There must be a decrease in another of the intracranial compartments.
4. There will be an increase in the production of cerebrospinal fluid.
A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention?
1. 12 mm Hg
2. 22 mm Hg
3. 25 mm Hg
4. 30 mm Hg
A nurse is providing care for a patient with increased intracranial pressure and is monitoring cerebral perfusion pressure. The nurse compares measurements to which critical normal value?
1. 50 mm Hg
2. 70 mm Hg
3. 120 mm Hg
4. 30 mm Hg
A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient?
1. 50 mm Hg
2. 90 mm Hg
3. 70/40 mm Hg
4. 40/70 mm Hg
A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status?
1. The patient cannot remember where he is.
2. The patient’s pupil size is increased.
3. The patient’s blood pressure has increased.
4. The patient exhibits decorticate posturing when stimulated.
A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose?
The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient’s pupils to be pinpoint and nonreactive to light. The nurse takes into consideration that this finding can be due to which situations?
1. The patient was given atropine sulfate for bradycardia.
2. The patient has increased blood glucose.
3. The patient may have taken an opioid drug overdose.
4. The patient has sustained compression of the oculomotor nerve.
5. The patient has sustained damage to the pons.
A patient is demonstrating confusion and difficulty focusing. Which assessment findings would the nurse evaluate as supporting a diagnosis of delirium rather than dementia?
1. The confusion cleared when the patient was rehydrated.
2. The patient does not recognize her daughter.
3. The patient’s daughter reports that her mother has been becoming increasingly confused over the last 6 months.
4. The patient’s mentation was clear yesterday.
5. The patient does not recognize that she is confused.
A patient being treated with haloperidol for symptoms of delirium has a blood pressure reading of 190/110 mm Hg. Which nursing action is priority?
1. Encourage the patient to drink at least 240 mL of fluids.
2. Contact the prescriber about an increase in the haloperidol dosage.
3. Place the patient on seizure precautions.
4. Hold the haloperidol dose and collaborate with the prescriber.
A ventilator-dependent patient has been in a coma for several weeks. Which finding would the nurse evaluate as indicating there is possibility of reversing this coma state?
1. Testing indicates that the patient has brain function.
2. The patient has clear breath sounds with no indications of pneumonia.
3. The patient cardiac rhythm strip reveals normal sinus rhythm.
4. The patient’s urinary output has remained adequate throughout the coma state.
A patient is admitted to the intensive care unit accompanied by a family member who says, “He suddenly started acting funny and couldn’t remember where he was.” The nurse would anticipate that first assessment efforts would focus on which condition?
1. Hypovolemic shock
2. Cerebral infection
3. Ischemic stroke
4. Drug overdose
A patient in the intensive care unit has pulled out his peripheral intravenous line twice and continually picks at his abdominal dressing. How should the nurse describe this behavior?
1. As hyperactive dementia
2. As hyperactive delirium
3. As hypoactive delirium
4. As mixed dementia
An elderly patient in the intensive care unit recovering from an abdominal aortic aneurysm repair begins to show signs of decreased responsiveness. The nurse realizes that which situation is the most likely cause of this change in mentation?
1. The patient’s intravenous line is infiltrated.
2. The patient has been NPO for an extended period of time.
3. The patient’s oxygen saturation has dropped from 96% to 90%.
4. The patient was started on a PCA pump with morphine.
From the use of the CAM-ICU assessment tool, a patient is found to have hypoactive delirium. Which nursing intervention is indicated?
1. Use the prn order for morphine to control the patient’s pain.
2. Use wrist restraints to maintain monitoring devices and lines.
3. Restrict visitors to times when the patient’s mentation is clearest.
4. Reorient the patient to the environment as needed.
A patient diagnosed with delirium has a history of adverse reaction to haloperidol. Which medication would the nurse anticipate using instead of haloperidol?
A patient who was in a coma for one week after surgery is unable to tell the nurse where he lives or what he did for a living. The nurse evaluates this condition as suggesting which change resulting from the coma?
1. The patient now has a learning deficit.
2. The patient has instability of emotions.
3. The patient’s cognition is impaired.
4. The patient was near brain death before the coma resolved.
An elderly patient is admitted to the intensive care unit with acute respiratory injury from aspiration. The nurse monitors this patient very carefully to avoid onset of polyneuropathy because the patient has history of which disorder?
2. Type 2 diabetes mellitus
3. Urinary urgency
4. Congestive heart failure
The nurse is providing community education regarding stroke. Which information should be included?
1. Stroke is caused by interruption of blood flow to the brain.
2. Stroke is the third-leading cause of death in the United States.
3. Stroke usually occurs simultaneously with myocardial infarction.
4. Rapid recognition of stroke symptoms can help decrease poor outcomes.
5. Stroke causes neurological defects.
A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient?
1. If the patient has high blood pressure
2. If the symptoms are still present
3. If this is a recurrent problem
4. If the patient fell
When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?
2. Use of anticoagulants
3. History of atherosclerosis of cerebral arteries
4. Atrial fibrillation
When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management?
1. Restoration of cerebral blood flow and limiting the size of the infarcted area of the brain
2. Keeping the blood pressure under control pharmacologically
3. Transferring the patient for rehabilitation as soon as medically stable
4. Reestablishing blood flow to the infarcted area surgically
Diagnostic testing reveals that a patient has areas of cerebral focal infarctions. The nurse plans care with the realization that which outcome is likely?
1. The patient will likely deteriorate into multiple system organ failure.
2. These areas of ischemia will likely extend into the brainstem.
3. The patient’s symptoms will likely resolve with treatment.
4. The patient’s symptoms will progress rapidly.
A patient with cerebral infarction is experiencing an acceleration of symptoms indicating death of cerebral tissue. The nurse would explain this acceleration as due to which pathophysiology?
1. Increased concentration of sodium, chloride, and calcium in the brain cells
2. Reduced ability of the macrophages to reach the site of injury
3. Reduced concentration of magnesium and phosphorus in the brain cells
4. Increased concentration of potassium in the brain cells
The nurse is instructing a patient on stroke prevention. Which patient statement would the nurse evaluate as indicating understanding of the presence of a nonmodifiable risk factor for stroke development?
1. “I have hypertension just like my mom and her family.”
2. “Lots of people of my ethnicity suffer strokes.”
3. “I have tried several times to quit smoking, but I just can’t seem to do it.”
4. “It is going to be hard to give up eating red meat and my favorite family meals just to lower my cholesterol.”
The nurse is assessing a newly admitted older patient for modifiable risk factors for stroke development. The nurse would include teaching about which findings?
1. Blood pressure is consistently above 95 diastolic.
2. The patient has had two recent hospital admissions to treat dehydration.
3. The patient reports drinking a glass of wine with dinner every evening.
4. The patient uses smokeless tobacco.
5. Testing has previously indicated the patient has hypercholesterolemia.
The nurse is triaging a patient who just presented to the emergency department. Which cluster of assessment findings would the nurse evaluate as indicated the greatest possibility that this patient is having a stroke?
1. Radicular pain, decreased deep tendon reflexes, loss of bladder control
2. Dysphagia, hemianopsia, hemiparesis
3. Dystonia, dysphagia, dysarthria
4. Paresthesia, priaprism, loss of reflexes
A patient, admitted with syncope, is diagnosed with an 80% stenosis of the left carotid artery. In addition to assessing the patient’s speech, the nurse should focus the assessment on the presence or development of which other findings?
1. Vertigo and cranial nerve palsies
2. Monocular blindness and left-sided sensory loss
3. Double vision and ataxia
4. Right sided hemineglect, sensory and motor loss
A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition?
1. Acute subdural hematoma
2. Subacute subdural hematoma
3. Epidural hematoma
4. Chronic subdural hematoma
The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon?
1. Urine output has dropped from 100 mL each hour to 60 mL per hour.
2. The patient’s hand grasps are weak bilaterally.
3. Fine crackles can be auscultated in the lung bases bilaterally.
4. The pupil on the side of the injury has become fixed and dilated.
The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide?
1. Symptoms of the concussion will continue for most of the patient’s life.
2. The concussion might be healed; however, the patient will not recover from the symptoms.
3. Symptoms of the concussion will come and go depending upon the patient’s health status.
4. Symptoms of a concussion can last 3 months or more.
A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings?
1. The accident causing this injury occurred several weeks ago.
2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion.
3. There is dilation of the pupils for several hours post injury.
4. There is presence of coma that may last for an extended period of time.
A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient?
1. Electrolyte replacements
2. Maintain adequate fluid volume.
3. Supporting nutritional needs
4. Maintain stable cerebral perfusion pressure.
A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal?
1. Reducing cerebral swelling
2. Confining inflammation to one area
3. Supporting absorption of debris from neuronal death
4. Limiting ischemic tissue injury
A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter?
1. Assessing of color of the cerebral spinal fluid
2. Assessing of the amount of cerebral spinal fluid
3. Instillation of hyperosmolar therapy via the catheter
4. Draining CSF
5. Directly monitoring the ICP
A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention?
1. High-dose barbiturate therapy
2. High-volume intravenous fluids
3. Hyperbaric oxygen therapy
4. Hyperosmolar therapy
A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would evaluate which findings as indicating this therapy is having its desired effects?
1. ICP is increasing
2. Serum sodium is 148 mEq/L
3. Serum osmolality is 300 mOsm
4. Osmotic gap is 12
A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient?
1. “We will let this patient rest between his bath and changing his linens.”
2. “We are going to bath this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon.”
3. “Be certain that we don’t raise this patient’s head above 10 degrees during his bath.”
4. “You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds.”
A patient is admitted for a lumbar laminectomy. The nurse reinforces teaching that which portion of the vertebra will be removed?
1. Roof of the arch
2. Cartilage inside the vertebra
3. Pedicles that attach the arch to the body
4. Spinous process
A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae. How would the nurse describe this injury?
1. As life threatening
2. As stable
3. As minor
4. As unstable
A patient is diagnosed with damage to the spinothalamic tract of the spinal cord. Which assessment finding would the nurse attribute to this damage?
1. The patient reports an unusual amount of pain.
2. Muscle spasms are occurring in the patient’s right leg.
3. The patient has ataxia.
4. The patient is complaining of vertigo.
The nurse is caring for a patient with a fractured sacrum. The nurse would assess for which changes as a result of this fracture?
1. Altered sympathetic responses
2. Alteration in pain responses
3. Alteration in position sense
4. Altered parasympathetic responses
A patient is diagnosed with central cord syndrome. Which assessment finding would the nurse anticipate from this injury?
1. Complete paralysis of lower extremities
2. Loss of bladder and bowel function
3. Motor function intact in upper extremities
4. Variable motor function in lower extremities
A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind. The nurse will assess this patient for findings associated with which type of injury?
1. Ankylosing spondylitis
2. Axial loading
A patient was admitted this morning after sustaining an acute spinal cord injury. This afternoon his neurological assessment shows some deterioration of function. How would the nurse explain this to the patient’s family?
1. “Injured cells release potassium that causes destruction of the covering of nerves in the area injured.”
2. “Decreased blood flow increases the size of the affected area.”
3. “The body’s inflammatory response has caused blood vessels in the area to dilate.”
4. “Injury to nerves impairs the body’s healing responses.”
A patient suffered an acute T6 spinal cord injury. Family has been told that the patient will likely be paraplegic. However, this morning the patient has limited use of his arms. How should the nurse explain this change?
1. “There must be a second area of fracture higher in the spine.”
2. “The spinal cord is probably swollen above the area of original injury.”
3. “These changes are due to the low blood pressure he had before he got to the hospital.”
4. “This is a sign that he is dehydrated and will go away as we give him more IV fluids.”
A patient is admitted with a fractured mandible and several fractured ribs. Which priority intervention would the nurse anticipate?
1. Providing pain medication
2. Determining lung function by chest x-ray
3. Maintaining spinal cord injury precautions
4. Stabilizing the rib fractures
It is suspected that a patient admitted with spinal cord injury has severe cord injury. The nurse would prepare the patient for which diagnostic test to determine the extent of this edema?
2. Somatosensory-evoked potentials
3. CT scan
A patient is diagnosed with esophageal reflux. The nurse explains to the patient that there is an impairment in which structure?
2. Duct of Wirsung
3. Cardiac sphincter
A patient is diagnosed with a gastric ulcer located on the antrum. The nurse is aware that the ulcer may also affect the function of which adjacent structure?
1. Sphincter of Oddi
3. Pyloric sphincter
4. Lower esophageal sphincter
A patient has been diagnosed with deficiency of the hormone cholecystokinin (CCK). The nurse would expect this patient to have difficulty digesting which nutrients?
A patient is demonstrating hepatic encephalopathy due to buildup of ammonia. The nurse anticipates intervention to support which function of the liver?
1. Protein metabolism
2. Vitamin synthesis
3. Fat metabolism
4. Carbohydrate metabolism
A patient is diagnosed with duodenal ulcers caused by a highly acidic gastrointestinal environment. The nurse explains that this condition may be related to deficiency in which hormone?
A patient is diagnosed with a splenic artery aneurysm. The nurse would assess for dysfunction in which organs?
4. Transverse colon
The nurse is caring for a patient with an injury to cranial nerve X. Which assessment finding would the nurse attribute to that injury?
1. Rectal bleeding
2. Dry mouth
3. A metallic taste in the mouth
4. Decreased bowel sounds
A patient tells the nurse that after eating some food that tasted “off” he experienced a severe stomachache. However, after a few hours the discomfort was gone and he felt fine. Which information should the nurse consider when formulating a response to this report?
1. Decreased production of mucous in the duodenum likely propelled the organism through the system in a few hours.
2. The duodenal pH of 4.0 killed the offending organism.
3. The acidic stomach environment likely killed any offending organisms in the ingested food.
4. Chyme blocked the offending organism from attaching to the walls of the GI tract.
A patient with a history of tonsillectomy and appendectomy is admitted with a possible infection. Which etiological factor would the nurse select for the nursing diagnosis Infection, Risk for?
1. Decreased prostaglandin production
2. Impairment of gut-associated lymphoid tissue
3. Decrease in mucosa-associated lymphoid tissue
4. Degradation of superficial epithelial cells
The nurse is planning care for a patient at risk for developing an infection because of an interruption in the intestinal mucosa. Which patient history would the nurse evaluate as most likely to exacerbate this risk?
1. The patient has a history of type 2 diabetes mellitus.
2. The patient was hospitalized 2 months ago for congestive heart failure.
3. The patient was hospitalized for treatment of severe trauma sustained in a motor vehicle accident.
4. The patient has been treated for hypertension for the last 10 years.
AND MUCH MORE