| Cardiac | Respiratory | GI/GU | Neuro | Endocrine |
|---|---|---|---|---|
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D. Confirm that the rhythm is actually ventricular fibrillation.
Rationale: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the clients chest and before discharge, which intervention is a priority?
A. Ensure that the client has been intubated. B. Set the defibrillator to the "synchronize" mode. C. Administer an amiodarone bolus intravenously. D. Confirm that the rhythm is actually ventricular fibrillation. |
D. Assess for kinks or dependent loops in the tubing.
Rationale: The least invasive nursing action should be performed first to determine why the drainage has diminished (D). (A) is completed after assessing for any problems causing the decrease in drainage. (B) is no longer considered standard protocol because the increase in pressure may be harmful to the client. (C) is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing. |
C. Dehydration
Rationale: Dehydration results in concentrated serum, causing laboratory values to increase because the blood has normal constituents but not enough volume to dilute the values to within normal range or possibly lower.
The client is admitted to a nursing unit from a long-term care facility with a hematocrit of 56% and a serum sodium level of 152 mEq/L. Which condition is a cause for these findings?
A. Overhydration B. Anemia C. Dehydration D. Renal failure |
C. Initiating range-of-motion exercises 48 hours after the injury
Rationale: Contractures develop rapidly with immobility and muscle paralysis. The exercises can be implemented within 48 to 72 hours after the injury. The exercises should ideally be preformed five times a day. Repositioning alone will not prevent contractures.
A patient is admitted to the Neuro ICU with a spinal cord injury. In writing the care plan the nurse plans that contractures can be prevented by what?
A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises 1 week following the injury C) Initiating range-of-motion exercises 48 hours after the injury D) Performing range-of-motion exercises once a day |
A. Administer 50% dextrose IVP
Rationale: The nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client.
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
A. Administer 50% dextrose IVP B. Notify the health-care provider C. Move the client to the ICU D. Check the serum glucose level |
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D. Check responsiveness
Rationale: VT is associated with a significant decrease in cardiac output. Assessing for unresponsiveness determines whether the client is affected by the decreased cardiac output. Therefore, the first action is to determine responsiveness of the client. Then the nurse should check the client's pulse to determine the next treatment strategy.
The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first?
A. Heart rate B. Blood pressure C. Respiratory rate D. Check responsiveness |
D. Encourage coughing and deep breathing
Rationale: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing (D). This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. (C) should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. (A) should not be withheld. (B) should not be applied because the fractures are clearly visible on the chest radiograph.
Which nursing action is necessary for the client with a flail chest?
A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing |
C. The PCA allows the patient to administer smaller
amounts of pain medication more frequently, which helps to get more effective pain relief. Rationale: PCA is the preferred method of pain management. It allows the patient more control and provides more effective pain relief.
A patient, admitted to the ICU with a diagnosis of acute pancreatitis, is prescribed pain medication through a PCA pump. What will the nurse include when teaching the patient and family about the proper use of the pump?
A. The patient should only use the PCA pump when the pain is severe. B. The family may help by "pushing the button" when they feel the patient is in pain. C. The PCA allows the patient to administer smaller amounts of pain medication more frequently, which helps to get more effective pain relief. D. The PCA delivers pain medication every time the button is pushed. |
B. Bradycardia and hypertension
Rationale: Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved. This makes options A, C, and D incorrect.
A nurse is caring for a patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
A) Tachycardia and hypotension B) Bradycardia and hypertension C) Tachycardia and hypertension D) Bradycardia and hypotension |
C. Bronze pigmentation, hypotension, and anorexia.
Rationale: Bronze pigmentation of the skin, particularly of the knuckles and other areas of skin creases, occurs in Addison’s disease. Hypotension and anorexia also occur with Addison’s disease.
The nurse is admitting a client diagnosed with primary adrenal cortex insufficiency (Addison’s disease). Which clinical manifestations should the nurse expect to assess?
A. Moon face, buffalo hump, and hyperglycemia. B. Hirsutism, fever, and irritability. C. Bronze pigmentation, hypotension, and anorexia. D. Tachycardia, bulging eyes, and goiter. |
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B. Cardiac rhythm
Rationale: Amiodarone is an antidysrhythmic used to treat life-threatening ventricular dysrhythmias. The client requires continuous cardiac monitoring, with infusion of the medication by an intravenous pump. Although the other assessments are not incorrect, monitoring of cardiac rhythm is the priority nursing action.
The nurse has a prescription to give amiodarone intravenously to a client. What is the priority assessment during administration of this medication?
A. Blood pressure B. Cardiac rhythm C. Skin color and dryness D. Oxygen saturation level |
A. Tidaling of water in water seal chamber
Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed (A) to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. (B) may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. (C) usually indicates an infection, which may not be related to the chest tube. (D) is an expected finding.
The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is
removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101° F D. Absence of chest tube drainage for 2 days |
A. Regular Insulin
Rationale: Regular insulin, along with glucose, will drive potassium into the cells, thereby lowering serum potassium levels temporarily.
The client diagnosed with ARF is experiencing hyperkalemia. Which medication
should the nurse prepare to administer to help decrease the potassium level? A. Regular Insulin B. Calcium gluconate C. Erythropoietin D. Osmotic diuretic |
B. Level of consciousness
Rationale: The Glasgow Coma Scale (GCS) examines three responses related to level of consciousness: eye opening, best verbal response, and best motor response.
A nurse is precepting a student nurse on the Neuro ICU. The nurse is explaining to the student about using the Glasgow Coma Scale (GCS) to gather information regarding what parameter?
A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement |
C. Instruct the client to never abruptly discontinue
the medication. Rationale: The primary medical treatment of Addison's disease is replacement of corticosteroids and mineralcorticoids, accompanied by increased sodium in the diet. The client needs to know the importance of maintaining a diet high is sodium and low in potassium. Medications should never be discontinued abruptly because crisis can ensue. Oral forms of the drug are given with food in Cushing's disease.
Which of the following nursing implications is most important in a client being medicated for Addison's disease?
A. Administer oral forms of the drug with food to minimize its ulcerogenic effect. B. Monitor capillary blood glucose for hypoglycemia in the diabetic client. C. Instruct the client to never abruptly discontinue the medication. D. Teach the client to consume a diet that is high in potassium, low in sodium, and high in protein. |
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C. By intravenous infusion
Rationale: If bleeding occurs, the health team intervenes quickly to control it by combining vasoactive medications with endoscopic therapies. Vasoactive medications reduce portal pressure. Vasopressin is a synthetic antidiuretic hormone. Administration of this hormone reduces bleeding. It acts directly on gastrointestinal smooth muscle as a vasoconstrictor. To take advantage of these effects, it should be administered via continuous intravenous infusion. It can also be administered via the subcutaneous route. Therefore, the remaining options are incorrect.
Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route?
A. Orally B. By inhalation C. By intravenous infusion D. Through a Sengstaken-Blakemore tube |
C. End tidal CO2 monitoring
Rationale: End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.
A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement?
A. Chest X-Ray B. Pulse oximetry reading of 95% C. End tidal CO2 monitoring D. Auscultation of breath sounds |
A. Place the solution on an IV pump at the
prescribed rate. B. Monitor blood glucose every six (6) hours. E. Monitor intake and output every shift. Rationale: TPN is a hypertonic solution with enough calories, proteins, lipids, electrolytes, and trace elements to sustain life. It is administered via a pump to prevent too-rapid infusion. TPN contains 50% dextrose solution; therefore, the client is monitored to ensure the pancreas is adapting to the high glucose levels.The client is weighed daily, not weekly, to monitor for fluid overload. The IV tubing is changed with every bag because the high glucose level can cause bacterial growth. Intake and output are monitored to observe for fluid balance.
The client is NPO and is receiving total parenteral nutrition (TPN) via a subclavian
line. Which precautions should the nurse implement? Select all that apply. A. Place the solution on an IV pump at the prescribed rate. B. Monitor blood glucose every six (6) hours. C. Weigh the client weekly, first thing in the morning. D. Change the IV tubing every three (3) days. E. Monitor intake and output every shift. |
D. Lower the head of the bed immediately
Rationale: For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client’s vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which
action should the nurse implement? A. Notify the health-care provider ASAP. B. Calm the client down by talking therapeutically. C. Increase the IV rate by 50 mL/hour. D. Lower the head of the bed immediately. |
A. Explain it will take up to a month for symptoms of
hyperthyroidism to subside. Rationale: Radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three (3) to four (4) weeks until the euthyroid state is reached.
The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive
iodine therapy. Which interventions should the nurse discuss with the client? A. Explain it will take up to a month for symptoms of hyperthyroidism to subside. B. Teach the iodine therapy will have to be tapered slowly over one (1) week. C. Discuss the client will have to be hospitalized during the radioactive therapy. D. Inform the client after therapy the client will not have to take any medication. |
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C. Prepare to administer amiodarone.
D. Prepare to administer epinephrine. E. Provide cardiopulmonary resuscitation (CPR). Rationale: Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as epinephrine and amiodarone and others.
The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply.
A. Prepare for cardioversion. B. Prepare to administer digoxin C. Prepare to administer amiodarone. D. Prepare to administer epinephrine. E. Provide cardiopulmonary resuscitation (CPR). |
D. Add 5 cm positive end-expiratory pressure (PEEP).
Rationale: Adding PEEP (D.) helps improve oxygenation while reducing FiO 2 to a less toxic level. (A, B, and C) will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (V T ) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; andFiO2, 0.80. Which intervention should the nurse implement first?
A. Increase the ventilator V(T) to 850 mL. B. Decrease the ventilator IMV to a rate of 8 breaths/min. C. Reduce the FiO 2 to 0.70 and redraw ABGs. D. Add 5 cm positive end-expiratory pressure (PEEP). |
C. Changes in mental status
Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.
The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?
A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lung |
B. Administer stool softeners daily.
C. Ensure that pulse oximeter reading is higher than 93%. E. Administer mild sedatives. Rationale: Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% ensures oxygenation of the brain tissues; decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the client’s agitation; strong narcotics would not be administered because they decrease the client’s level of consciousness.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing
interventions should the nurse implement? Select all that apply. A. Maintain the head of the bed at 60 degrees of elevation. B. Administer stool softeners daily. C. Ensure that pulse oximeter reading is higher than 93%. D. Perform deep nasal suction every two (2) hours. E. Administer mild sedatives. |
C. To report weight loss, anxiety, insomnia, and
palpitations. Rationale: Weight loss, anxiety, insomnia and palpitations are signs of hyperthyroidism. An adjustment in dose would need to be obtained in order to reach a therapeutic level of levothyroxine (Synthroid) in the patient with hypothyroidism.
In the administration of a drug such as levothyroxine (Synthroid), the nurse should teach the client:
A. That therapy typically lasts about 6 months. B. That weekly laboratory tests for T4 levels will be required. C. To report weight loss, anxiety, insomnia, and palpitations. D. That the drug may be taken every other day if diarrhea occurs. |
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