Question 1

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury. After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine. The client now develops hypotension, tachycardia, oliguria, and severe nausea. What is the client's priority nursing diagnosis (ND) at this time?

Accepted Answer

This client is exhibiting symptoms of hypovolemia, which include hypotension, tachycardia, and decreased urinary output. Therefore, the priority ND is deficient fluid volume related to active intravascular loss that is secondary to hemorrhage, gastric suction, wound drainage, and possible third spacing as evidenced by decreased urine output, hypotension, and tachycardia. The adverse effects of the epidural anesthesia can contribute to hypotension as well. This ND poses the greatest threat to survival because if not corrected, it can lead to decreased cardiac output, acute renal failure, and hypovolemic shock. (Option B) Impaired urinary elimination refers to a dysfunction in urinary elimination, such as incontinence, retention, frequency, urgency, dysuria, hesitancy, and nocturia. It is not an appropriate ND for this client. (Option C) Nausea is most likely an adverse effect of the morphine, and an antiemetic will be prescribed. It is an appropriate ND as dry heaving and vomiting can compromise the integrity of the abdominal wound incision. However, it is not the priority ND. (Option D) Clients with trauma are at risk for microbial invasion secondary to inadequate primary defense (eg, skin barrier, catheters), secondary defenses (eg, decreased blood), and environmental exposure (eg, invasive procedures). However, this is not the priority ND. Educational objective: Deficient fluid volume, nausea, and risk for infection are appropriate NDs for a client who has undergone surgery for repair of a blunt trauma intraabdominal hemorrhagic injury. However, the priority ND addresses the highest level of risk to a client: airway, breathing, circulation (eg, hypovolemia, cardiac output), and vital signs (eg, hypotension, tachycardia).

Question 2

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply.

Accepted Answer

The initial management of a near-drowning victim focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option C). Careful handling of the hypothermic client is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent turning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated (Option B). There are passive, active external, and active internal rewarming methods. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets. Active external rewarming involves using heating devices or a warm water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Options A and E). (Option D) Unless blood loss has occurred from trauma during the near-drowning incident, administration of blood products is not indicated. Educational objective: Emergency department care of near-drowning victims includes advanced airway management, aggressive oxygenation, establishing IV access and administering IV fluids (warmed if hypothermic), and monitoring for cardiac arrhythmias and fluid imbalances.

Question 3

A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client?

Accepted Answer

11ecbb05_cb04_74da_b433_85f5266fb83e_MD0009_00 Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR (Option B). In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If return of spontaneous circulation (ROSC) does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated. Delivery should occur within 5 minutes of initiating CPR. (Option A) Compressions to the right sternal border will lack effectiveness as the heart is displaced to the left side during pregnancy. (Option C) Chest compressions given below the diaphragm are not effective for ROSC and greatly increase the risk of injury to the client's uterus, spleen, or liver. (Option D) In the supine position, the vena cava and aorta are compressed by the uterus, hindering effective blood flow during CPR. The uterus should be displaced to the left to reduce pressure. Educational objective: Two important modifications for cardiopulmonary resuscitation of a pregnant client include performing chest compressions slightly higher on the sternum and displacing the uterus to the client's left side.

Question 4

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply.

Accepted Answer

Rapid response teams are formed as a means to get critical care specialists to the bedside of clients who are not in a critical care unit when acute, significant changes occur in their condition. Each institution sets its own criteria, but it usually includes acute changes in heart rate, systolic blood pressure, respiratory rate, oxygen saturation, level of consciousness, and/or urine output. Although strokes occur more commonly in adults, they can occur in children. Symptoms found in both groups can be similar, such as unilateral paralysis, which is usually found with vessel abnormalities or a hematologic complication (eg, sickle cell, cancer) (Option A). Just as in adults, emergency treatment for children should be activated. A sudden loss of consciousness is emergent in any client (Option D). (Option B) Normal heart rate for an infant (1-12 months) is 100-160/min. (Option C) Normal respiration rate for an infant (1-12 months) is 30-60/min. (Option E) A fever is ordinarily not an emergency situation that meets the criteria to activate the rapid response team. It can signal a serious condition in infants who are age <1 month or in children age <2 years who have a temperature >104 F (40 C) without a localized source (due to an immature immune system). However, in this case, it would probably be more effective to call a health care provider to prescribe appropriate diagnostic tests (eg, complete blood count, cultures) and treatment (eg, antibiotics). A fever does not usually require immediate life-saving intervention. Educational objective: Rapid response teams are formed as a means to get critical care assistance to the bedside of clients (not in intensive care) with acute significant changes in their condition. Common criteria include sudden, significant changes in pulse rate, respiration rate, systolic blood pressure, oxygen saturation, level of consciousness, and/or urine output.

Question 5

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply.

Accepted Answer

Defibrillation is indicated in clients with ventricular fibrillation (Vfib) and pulseless ventricular tachycardia. Cardiopulmonary resuscitation (CPR) should be initiated and compressions continued until the shock is ready to be delivered (Option C). Certain pulseless rhythms (asystole and pulseless electrical activity) do not need defibrillation. Steps to perform defibrillation are as follows: Turn on the defibrillator Place defibrillator pads on the client's chest (Option A) Place defibrillator pads Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option B). Deliver the shock Immediately resume chest compressions (Option D) IV sedation is not necessary for defibrillation as the client is already unconscious. It is often given prior to elective synchronized cardioversion to ease anxiety and decrease pain. (Option E) Synchronized cardioversion delivers a shock on the R wave of the QRS complex and would not be appropriate for a client in Vfib (no identifiable QRS complexes). Rhythms that are ideal for synchronized cardioversion are supraventricular tachycardia, ventricular tachycardia with a pulse, and atrial fibrillation with rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on the T wave and can cause a lethal arrhythmia (eg, Vfib). Educational objective: The steps for defibrillation are as follows: Turn on the defibrillator, place pads on the client's chest, charge defibrillator, ensure the area is "all clear," deliver the shock, then resume compressions immediately.

Question 6

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 g/dL (120 g/L). Which action should the nurse carry out first?

Accepted Answer

Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock (Option A). (Option B) Increasing the IV flow rate of the isotonic solution may be an appropriate intervention once the nurse has assessed the client, including taking a full set of vital signs. The nurse should intervene only after assessing to rule out other problems for which an increase in IV fluid intake would not be an appropriate solution (eg, Foley catheter obstruction). (Option C) The nurse will notify the health care provider to report oliguria (<0.5 mL/kg/hr) after collecting all of the data necessary (ie, vital signs). This is not the nurse's first action. (Option D) Urinary retention is possible following surgery due to the adverse effects of anesthesia, opioids, anticholinergic drugs, and immobility. However, a bladder scan is not an appropriate action in this situation as the client has a Foley catheter. Irrigating the catheter is the appropriate intervention if the nurse questions its patency. Educational objective: Third-spacing can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

Question 7

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply.

Accepted Answer

11ecbb05_cb00_0809_b433_c1ffb9f315e1_MD0009_00 Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: Excessive secretions: Obstruct the airway, increasing resistance (Option D) Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance (Options A and E) (Options B and C) Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm. Educational objective: When the mechanical ventilator high-pressure limit alarm sounds, the nurse should assess for causes of increased airway resistance in the client (eg, bronchospasm), artificial airway (eg, excessive secretions, biting the endotracheal tube), and/or ventilator system (eg, kinked tubing), as well as for causes of decreased lung compliance (eg, pneumothorax).

Question 8

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion?

Accepted Answer

The priority action after placing a subclavian central venous catheter is to check the results of the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain verification before using the catheter as perforation of the visceral pleura can occur during insertion and lead to an iatrogenic pneumothorax or hemothorax. Although these complications are rare, due to the use of ultrasound to guide insertion, if present, the TPN would infuse into the pleural space. (Option A) Filters are used during TPN infusion to remove particulate matter, precipitates, or microorganisms. Because TPN uses a hypertonic solution (eg, dextrose concentration >10%), it increases the risk for infection. Therefore, the use of a 0.22-micron filter is recommended to remove microorganisms when administering a lipid-free formula. The use of a 1.2-micron filter is recommended when administering TPN with lipids. Although this action is appropriate, it is not the priority. (Option B) The nurse should monitor the baseline blood glucose (BG) level and fingerstick BG every 6 hours while the client is receiving TPN; it should be maintained in the range of 140-180 mg/dL (7.8-10.0 mmol/L) for a hospitalized adult client. This action is appropriate, but it is not the priority. (Option D) TPN is always administered using an electronic infusion pump to ensure an accurate and consistent hourly infusion rate to help avoid fluctuations in BG levels. This action is appropriate, but it is not the priority. Educational objective: Incorrect placement of a subclavian central venous catheter can result in an iatrogenic pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that the catheter tip has been placed correctly in the superior vena cava. Other appropriate actions include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6 hours, and programming the electronic infusion device to ensure an accurate and consistent hourly infusion rate.

Question 9

An emergency department nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? Select all that apply.

Accepted Answer

11ecbb05_cb07_5b0d_b433_e330978d6c13_MD0009_00 The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options A, D, and E). A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation (Option C). (Option B) Movement of the neck/upper extremities should be avoided until cervical spine injury is ruled out with imaging, which is done after the spine is immobilized with a hard collar. Educational objective: The priorities for a client with a suspected cervical spine injury are maintaining a patent airway and spinal immobilization. Interventions include application of a rigid hard collar, placing the client on a firm surface, logrolling the client during movement and transfers, and continued assessment of need for an advanced airway.

Question 10

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately?

Accepted Answer

Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option B). (Options A and C) A client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse; and to have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain. (Option D) Hypothermia (<95 F [35 C]) is common in the immediate postoperative period due to anesthetic-induced vasodilation, decreased basal metabolic rate, and a cool environment. This can be managed by the nurse. Hyperthermia (fever) is also common due to the blood products and trauma from surgery. However, stiffness/rigidity in the presence of elevated temperature is more concerning. Educational objective: Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia.

Question 11

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply.

Accepted Answer

The rapid response team is activated to marshal additional experienced and specialized resources for an acute need to try to prevent a client from deterioration into a code/arrest situation. The team has critical care expertise to provide immediate attention to unstableclients in noncritical care units and usually consists of a respiratory therapist, a critical care nurse, and a physician or advanced practice registered nurse. Recommended criteria to consider according to the Institute for Healthcare Improvement include the following: Any provider worried about the client's condition ORAn acute change in any of the following:Heart rate <40 or >130/minSystolic blood pressure <90 mm HgRespiratory rate <8 or >28/min (Option D)Oxygen saturation <90 despite oxygenUrine output <50 mL/4 hrLevel of consciousness (Option E) Any provider worried about the client's condition OR An acute change in any of the following:Heart rate <40 or >130/minSystolic blood pressure <90 mm HgRespiratory rate <8 or >28/min (Option D)Oxygen saturation <90 despite oxygenUrine output <50 mL/4 hrLevel of consciousness (Option E) Heart rate <40 or >130/minSystolic blood pressure <90 mm HgRespiratory rate <8 or >28/min (Option D)Oxygen saturation <90 despite oxygenUrine output <50 mL/4 hrLevel of consciousness (Option E) Heart rate <40 or >130/min Systolic blood pressure <90 mm Hg Respiratory rate <8 or >28/min (Option D) Oxygen saturation <90 despite oxygen Urine output <50 mL/4 hr Level of consciousness (Option E) (Option A) The GCS is abnormal but is stable in the abnormality. A rapid response would be used for a significant deteriorating trend. (Option B) Many clients routinely run a slowed pulse rate (athletes). There is no indication that this is a new change for the client. It would be concerning if there was an effect on perfusion, accompanied by chest pain, or if the heart rate was <40/min. (Option C) Unrelieved pain is concerning, but the nurse can handle this through assessing the etiology, calling the health care provider, or adjusting the analgesia. Pain in and of itself is not an indication of client instability. Educational objective: Rapid response criteria for unstable clients in a nonacute care setting usually include sudden, significant changes that do not respond to treatment.

Question 12

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply.

Accepted Answer

11ecbb05_cb08_1e5e_b433_bbb9803ad00e_MD0009_00 The transference of kinetic energy to the client's body from an opposing force during sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse (using the rule of airway, breathing, and circulation [ABCs]) (Option A). Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury (Option D). The client should be removed and placed on a backboard after the cervical spine has been stabilized (Option E). The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment (Option B). (Option C) If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-lift maneuver may hyperextend the neck, compromising the cervical spine. Educational objective: After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.

Question 13

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.

Accepted Answer

Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: Remove clothing and jewelry to prevent constriction. Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option C). Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option E). Avoid heavy blankets or clothing to prevent tissue sloughing. Provide analgesia as the rewarming procedure is extremely painful (Option D). As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option B). Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option A). Monitor for signs of compartment syndrome. Educational objective: Care of the client with frostbite focuses on preventing further injury and reducing pain. This includes removing items that can cause constriction or sloughing; no massaging or rubbing of the injured area; providing warm water soaks and analgesia; elevating injured areas; applying loose, nonadherent, sterile dressings; and monitoring for compartment syndrome.

Question 14

The nurse is caring for a client on a mechanical ventilator.  The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change.  In anticipation of this blood draw, what intervention should the nurse implement?

Accepted Answer

Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option B) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option C) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option D) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results. Educational objective: If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.

Question 15

A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority?

Accepted Answer

Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients. (Option B) Covering the client's head is indicated to prevent heat loss; however, this can be done after the cardiac monitor has been attached. Depending on the severity of the hypothermia, the trunk should be warmed before the extremities to reduce the risk of afterdrop (core temperature drops further). This is due to cold peripheral blood returning to the central circulation. (Option C) A blood draw for laboratory testing is important but should be performed after the cardiac monitor is attached. (Option D) Two large-bore IV catheters are preferred; this can be accomplished after the cardiac monitor has been attached. Educational objective: Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

Question 16

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)?

Accepted Answer

A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (eg, noise, lighting, noxious odors, interruptions due to medical and nursing care). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic (eg, delirium, post-traumatic stress disorder, anxiety) and physiologic (eg, circadian rhythm disturbance, decreased REM sleep, increased heart rate, impaired immunity) consequences. Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure (circadian rhythm disturbance) is the priority ND. (Option A) Anxiety in the ICU client is most often associated with pain and fear of the unknown and can be an appropriate ND. However, it is not the priority ND for this client. (Option C) Powerlessness is the sense of lack of control over a situation, such as requiring critical care for a life-threatening condition, and can be an appropriate ND. However, it is not the priority ND for this client. (Option D) Risk for acute confusion is the risk for developing a rapid-onset, reversible disturbance of consciousness, attention, and perception. It can be an appropriate ND, but it is not the priority. Educational objective: Disturbed sleep pattern related to environmental factors, such as excessive noise and circadian rhythm disturbance, is an important ND for a critically ill client. Lack of adequate uninterrupted sleep can lead to negative physiologic (eg, decreased REM sleep, increased heart rate) and psychologic (eg, delirium, anxiety, powerlessness, acute confusion) consequences that can affect client outcomes.

Question 17

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?

Accepted Answer

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option B) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option C) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option D) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury. Educational objective: Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.

Question 18

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube?

Accepted Answer

11ecbb05_cb05_864b_b433_4f1af9b43e9d_MD0009_00 Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura. If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF. Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client's nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures. (Option A) A bruise is an expected finding after direct trauma. It would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (Battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak. (Option B) A headache is an expected finding after trauma. It would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased intracranial pressure. (Option D) The head is highly vascular and it is not unusual to have blood oozing after trauma. This is not as concerning as a potential CSF leak. However, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern. Educational objective: A nasogastric tube should not be inserted when a basilar skull fracture is suspected. CSF leakage is an indication of this and can be evidenced by a positive halo/ring test of the blood-tinged nasal drainage (coagulated blood surrounded by CSF).

Question 19

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items?

Accepted Answer

Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option D). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. (Option A) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not a priority. (Option B) Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease. Absence of gag reflex indicates GBS progression. (Option C) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS. Educational objective: The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course.

Question 20

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply.

Accepted Answer

11ecbb05_cb06_499c_b433_675fb1177a94_MD0009_00 Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters).Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option A).Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option C).Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option D). Perform tracheal suctioning as needed.Monitor correct endotracheal tube placement by noting insertion depth.Place emergency equipment at bedside (eg, manual resuscitation bag) (Option E). Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk (Option A). Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator (Option C). Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy (Option D). Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag) (Option E). (Option B) Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection). Educational objective: When caring for a client requiring mechanical ventilation, the nurse should monitor respiratory status and airway patency (eg, breath sounds, insertion depth of endotracheal tube), maintain an appropriate level of sedation, assess for weaning readiness, prevent ventilator-associated infection (eg, oral care with chlorhexidine, head of the bed at 30-45 degrees), and implement safety measures (eg, emergency equipment at bedside, ventilator alarms on).

Exam 3: Critical Care

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic. Based on anticipated vital signs, the nurse needs to prepare for which interventions? Select all that apply.

A client at 32 weeks gestation goes into cardiac arrest. What is the nurse's best action while performing cardiopulmonary resuscitation for this client?

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply.

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation. Which steps are essential prior to delivering a shock? Select all that apply.

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply.

An emergency department nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? Select all that apply.

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately?

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply.

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply.

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement?

A client with hypothermia has just arrived in the emergency department via ambulance. The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids. What additional intervention is a priority?

The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube?

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items?

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation? Select all that apply.