Question 1

The nurse provides discharge instructions to a client with a graft site on the right leg. Which statement, if made by the client, would indicate the need for further instruction?

Accepted Answer

The graft site must be free from pressure and should be immobilized; therefore, weight bearing must be avoided. The graft site must also be protected from harsh materials or ingredients and sunlight.

Question 2

When working the family of the patient in critical care, a nurse should use this kind of Therapeutic Communication:

Accepted Answer

When working with the family of the patient in critical care, the nurses' best method of Therapeutic Communication to use is to consider the family to be an integral part of the team and engage them in the patient's care. Therapeutic Communication involving the family as part of the team can ease anxiety, tension and frustration on the part of the family helping ensure better patient outcomes and family satisfaction.

Question 3

A patient's family begins to ask several questions about the variety of numbers on the patient's monitor. What would be the most appropriate response for the nurse to give?

Accepted Answer

The most appropriate response for the nurse to give in such a situation is "Tell me about which numbers are concerning to you." This response acknowledges the family's concerns and helps them understand the patient's condition. It is normal for families to feel helpless and powerless and the nurse has the opportunity to offer empowerment and comfort through simple but focused explanations

Question 4

Which type of seizure is characterized by brief, involuntary muscle movements and typically occurs early in the morning?

Accepted Answer

Myoclonic seizures are characterized by brief, involuntary muscle movements. They typically occur early in the morning. Myoclonic seizures

Question 5

For a patient with a massive stroke, when is the best time to begin exercises and physical therapy?

Accepted Answer

The patient who has had a stroke should begin exercises as soon as possible. Simple exercises such as range of motion for the affected and unaffected sides are important to prevent muscle atrophy and skin breakdown.

Question 6

The nurse is taking care of a patient who is has been admitted with a diagnosis of "brain dead post traumatic injury." The nurse would expect all of the following clinical manifestations except:

Accepted Answer

The nurse would expect to see no eye movement during the caloric test in a patient with a diagnosis of "brain dead." During the caloric test, cold water is instilled into the ears. Normally, the eyes would move toward the ear where the water is instilled.

Question 7

The importance of evidenced based care is gaining credibility and acknowledgement. Nurses in the critical care setting are often learning new techniques and adapting their care to reflect evidenced based outcomes. Evidence based care would be based on all the following sources except:

Accepted Answer

Evidence based care is based on formal nursing research, clinical knowledge and scientific knowledge. Cultural practices are not a basis for evidence based care. The critical care nurse has the opportunity to educate and inform the patients and their families about the best care for them based on research and knowledge.

Question 8

What teaching is important to include for women who have experienced a spinal cord injury and have questions about having children?

Accepted Answer

After a spinal cord injury, many women have questions about child bearing. They should be taught that they can still conceive and deliver children but should use a birth control measure that does not increase the risk for clot formation.

Question 9

What is the most appropriate description of a depressed skull fracture?

Accepted Answer

The most appropriate description of a depressed skull fracture is an injury that causes a contusion to the brain tissue. It is sometimes associated with a perforated scalp but that is not always the case. A localized lesion on the brain limited to the area of impact on the skull is a brain lesion.

Question 10

Which cranial nerve is tested to assess the gag reflex?

Accepted Answer

The cranial nerve that is tested to assess the gag reflex in a person is the Glossopharyngeal nerve. Assessment of the vagus nerve identifies the symmetry of the arch of the tongue (the "ahh" test). One would test the trigeminal nerve to assess the ability to swallow and bilateral facial sensation. Testing the trochlear nerve identifies the ability of the patient to move their eyes.

Question 11

The Emergency Room has transferred a thirty seven year old man to the intensive care unit after a gunshot wound. The patient has had a blood loss of approximately 900 mL. He is arousable but not alert. His vital signs are, blood pressure 88/45, heart rate of 130 and shallow respirations of 28/minute. What kind of intravenous fluids would be the most appropriate for fluid resuscitation?

Accepted Answer

The most appropriate intravenous fluids for rapid fluid resuscitation for the patient with a massive fluid loss, such as a traumatic injury are Lactated Ringer's solutions. A transfusion of red blood cells would be appropriate if the blood loss had exceeded 1500 mL Normal saline would be the additive of choice for administering blood.

Question 12

What is the main treatment for heart failure?

Accepted Answer

The main treatment for heart failure is pharmacologic therapy such as diuretics to decrease preload and positive isotropic drugs to increase the heart's ability to contract.

Question 13

What is a major side effect of beta blockers that should be included in patient education?

Accepted Answer

A major side effect of beta blockers that should be included in patient education is fatigue. Renal insufficiency and Hyperkalemia are side effects of ace inhibitors. Hypotension may occur with beta blockers. Patients who start on beta blockers often expect that the medications will help them feel better and do not expect to feel more tired after starting their new regimen

Question 14

An experienced intensive care unit nurse is teaching a class of new nurses. What would she emphasize as nursing interventions to prevent ventilator associated pneumonia?

Accepted Answer

The nursing intervention that should be emphasized to prevent ventilator associated Pneumonia is to elevate the head of the bed 30-45 degrees. Another nursing intervention to prevent ventilator associated pneumonia is to advocate for the patient to have a sliver coated Endotracheal Tube.

Question 15

Which type of ventilator is most appropriate for the patient who requires minimal ventilator support?

Accepted Answer

The type of ventilator that is most appropriate for the patient who requires minimal ventilator support is the synchronized intermittent mandatory ventilation (SIMV). Synchronized intermittent mandatory ventilation delivers a preset volume and rate and matches the patient's effort. SIMV prevents the patient and the ventilator from competing with one another

Question 16

Mr) M is two days post operation of a total right hip replacement surgery. He has been out of bed once since surgery. He suddenly becomes short of breath and states that he has mild chest pressure that gets worse as he tries to take deeper breaths. His respiratory rate is 30/ minute and his heart rate is 122. What is the most likely reason for his symptoms?

Accepted Answer

The most likely reason for Mr. M's onset of symptoms is pulmonary embolism. Shortness of breath is one of the most common clinical manifestations of pulmonary embolism, followed by cough, Hemoptysis, chest pain that gets worse w hen taking a deep breath, tachycardia and Tachypnea

Question 17

A nurse is calling the doctor to obtain an order for medication to help maintain the tissue perfusion for a patient with acute respiratory distress syndrome who is continuing to be Hypotensive. Which medication would she anticipate being ordered?

Accepted Answer

The medication that the nurse would most likely anticipate to be ordered for the patient with acute respiratory distress who is Hypotensive would be Dopamine. Dopamine can help regulate blood pressure through renal perfusion.

Question 18

What is the goal in managing peptic ulcer disease?

Accepted Answer

The main goal in managing peptic ulcer disease is to prevent gastrointestinal bleeding; a major risk for people with peptic ulcer disease. Surgical intervention may be necessary if gastrointestinal bleeding results in the patient with peptic ulcer disease.

Question 19

Which diagnostic test is considered the "gold standard" for diagnosis of gastrointestinal bleeding?

Accepted Answer

The diagnostic test considered to be the "gold standard" for diagnosis of gastrointestinal bleeding is endoscopy. It provides direct visualization of the gastric intestinal tract any sources of bleeding.

Question 20

A nurse is taking care of a patient with a gastrointestinal bleed who is receiving intravenous fluids, packed red blood cell transfusion and proton pump inhibitor medication. The nurse would assess for all the following complications of a gastrointestinal bleed except for:

Accepted Answer

The nurse would assess for all of the following complications of a gastrointestinal bleed except for myocardial infarction which is not a primary complication of a gastrointestinal bleed. If the patient's gastrointestinal bleed has been extensive, hemorrhagic shock can occur. When the erosion of the gastrointestinal tract occurs, perforation can occur.

Quiz 1: Adult