Chapter 01: Critical Care Nursing Practice
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. During World War II, what types of wards were developed to care for critically injured patients?
a. Intensive care
b. Triage
c. Shock
d. Postoperative
ANS: C
During World War II, shock wards were established to care for critically injured patients. Triage wards establish the order in which
a patient is seen or treated upon arrival to a hospital. Postoperative wards were developed in 1900 and later evolved into intensive
care units.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 2
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
2. What type of practitioner has a broad depth of specialty knowledge and expertise and manages complex clinical and system issues?
a. Registered nurses
b. Advanced practice nurses
c. Clinical nurse leaders
d. Intensivists
ANS: B
Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex
clinical and systems issues. Intensivists are medical practitioners who manage the critical ill patient. Registered nurses (RNs) are
generally direct care providers. Clinical nurse leaders (CNLs) generally do not manage system issues.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 5
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
3. What type of practitioner is instrumental in ensuring care that is evidence based and that safety programs are in place?
a. Clinical nurse specialist
b. Advanced practice nurse
c. Registered nurses
d. Nurse practitioners
ANS: A
Clinical nurse specialists (CNSs) serve in specialty roles that use their clinical, teaching, research, leadership, and consultative
abilities. They are instrumental in ensuring that care is evidence based and that safety programs are in place. Advanced practice
nurses (APNs) have a broad depth of knowledge and expertise in their specialty area and manage complex clinical and systems
issues. Registered nurses are generally direct care providers. Nurse practitioners (NPs) manage direct clinical care of groups of
patients.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 6
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
4. Which professional organization administers critical care certification exams for registered nurses?
a. State Board of Registered Nurses
b. National Association of Clinical Nurse Specialist
c. Society of Critical Care Medicine
d. American Association of Critical-Care Nurses
ANS: D
American Association of Critical-Care Nurses (AACN) administers certification exams for registered nurses. The State Board of
Registered Nurses (SBON) does not administer certification exams. National Association of Clinical Nurse Specialists (NACNS)
does not administer certification exams. Society of Critical Care Medicine (SCCM) does not administer nursing certification exams
for registered nurses.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 7
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. Emphasis is on human integrity and stresses the theory that the body, mind, and spirit are interdependent and inseparable. This
statement describes which methodology of care?
a. Holistic care
b. Individualized care
c. Cultural care
d. Interdisciplinary care
ANS: A
Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable.
Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.
Cultural diversity in health care is not a new topic, but it is gaining emphasis and importance as the world becomes more accessible
to all as the result of increasing technologies and interfaces with places and peoples. Interdisciplinary care is care a mong a variety
of health care professionals with the patient’s health as the common goal.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 12
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
6. The American Association of Critical-Care Nurses (AACN) has developed short directives that can be used as quick references for
clinical use that are known as
a. Critical Care Protocol.
b. Practice Policies.
c. Evidence-Based Research.
d. Practice Alerts.
ANS: D
The American Association of Critical-Care Nurses (AACN) has promulgated several evidence-based practice summaries in the
form of “Practice Alerts.” Evidence-based nursing practice considers the best research evidence on the care topic along with
clinical expertise of the nurse and patient preferences. Critical care protocol and practice policies are established by individual
institutions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 9
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
7. What type of therapy is an option to conventional treatment?
a. Alternative
b. Holistic
c. Complementary
d. Individualized
ANS: A
The term alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a
condition or state. The term complementary was proposed to describe therapies that can be used to complement or support
conventional treatments. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent
and inseparable. Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and
psychosocial status.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 16
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
8. Prayer, guided imagery, and massage are all examples of what type of treatment?
a. Alternative therapy
b. Holistic care
c. Complementary care
d. Individualized care
ANS: C
The term complementary was proposed to describe therapies that can be used to complement or support conventional treatments.
Spirituality, prayer, guided imagery, massage, and animal-assisted therapy are all examples of complementary care. The term
alternative denotes that a specific therapy is an option or alternative to what is considered conventional treatment of a condition or
state. Holistic care focuses on human integrity and stresses that the body, mind, and spirit are interdependent and inseparable.
Individualized care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and psychosocial status.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 16 | p. 17
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
9. What is the systematic decision-making model used by nurses termed?
a. Nursing diagnosis
b. Nursing interventions
c. Nursing evaluations
d. Nursing process
ANS: D
The nursing process is a systematic decision-making model that is cyclic, not linear. An essential and distinguishing feature of any
nursing diagnosis is that it describes a health condition. Nursing interventions constitute the treatment approach to an identified
health alteration. Evaluation of attainment of the expected patient outcomes occurs formally at intervals designated in the outcome
criteria.
PTS: 1
DIF: Cognitive Level: Understanding
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
10. What is a health condition primarily resolved by nursing interventions or therapies called?
a. Nursing diagnosis
b. Nursing interventions
c. Nursing outcomes
d. Nursing process
ANS: A
An essential and distinguishing feature of any nursing diagnosis is that it describes a health condition. Nursing interventions
constitute the treatment approach to an identified health alteration. Evaluation of attainment of the expected patient outcomes
occurs formally at intervals designated in the outcome criteria. The nursing process is a systematic decision-making model that is
cyclic, not linear.
PTS: 1
DIF: Cognitive Level: Remembering
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
11. Designing therapeutic activities that move a patient from one state of health to another is an example of which of the following?
a. Nursing diagnosis
b. Nursing interventions
c. Nursing outcomes
d. Nursing process
ANS: B
Nursing interventions constitute the treatment approach to an identified health alteration. An essential and distinguishing feature of
any nursing diagnosis is that it describes a health condition. Evaluation of attainment of the expected patient outcomes occurs
formally at intervals designated in the outcome criteria. The nursing process is a systematic decision-making model that is cyclic,
not linear.
PTS: 1
DIF: Cognitive Level: Remembering
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
12. A patient was admitted to a rural critical care unit in Montana. Critical care nurses are assisting with monitoring and care of the
patient from the closest major city. What is this type of practice termed?
a. Tele-nursing
b. Tele-ICU
c. Tele-informatics
d. Tele-hospital
ANS: B
Tele-ICU is a form of telemedicine. Telemedicine was initially used in outpatient areas, remote rural geographic locations, and
areas where there was a dearth of medical providers. Currently, there are tele-ICUs in areas where there are limited resources
onsite. However, experts (critical care nurses, intensivists) are located in a central distant site.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 19
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
13. Which core competency for interprofessional practice can be described as working with individuals of other professions to maintain
a climate of mutual respect and shared values?
a. Interprofessional teamwork and team-based care
b. Values and ethics for interprofessional practice
c. Interprofessional communication
d. Roles and responsibilities for collaborative practice
ANS: B
Values and ethics for interprofessional practice mean working with individuals of other professions to maintain a climate of mutual
respect and shared values. Roles and responsibilities for collaborative practice include using knowledge of one’s own role and the
roles of other professions to appropriately assess and address the health care needs of the patients and populations served.
Interprofessional communication includes communicating with patients, families, communities, and other health professionals in a
responsive and responsible manner that supports a team approach to maintaining health and treatment of disease. Interprofessional
teamwork and team-based care means applying relationship-building values and principles of team dynamics to perform effectively
in different team roles to plan and deliver patient population-centered care that is safe, timely, efficient, effective, and equitable.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 5 | Box 1-5 1-4 ed.9
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
14. What is the stepwise decision-making flowchart for a specific care process named?
a. Algorithm
b. Practice guideline
c. Protocol
d. Order set
ANS: A
An algorithm is a stepwise decision-making flowchart for a specific care process or processes. A practice guideline is usually
created by an expert panel and developed by a professional organization. Protocols are more directive and rigid than guidelines,
and providers are not supposed to vary from a protocol. An order set consists of preprinted provider orders that are used to expedite
the order process after a standard has been validated through analytic review of practice and research.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 22
OBJ: Nursing Process Step: Intervention TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
15. Which nursing intervention continues to be one of the most error-prone for critical care nurses?
a. Inappropriate care
b. Intimidating and disruptive clinician behavior
c. Injury to patients by falls
d. Medication administration
ANS: D
Medication administration continues to be one of the most error-prone nursing interventions for critical care nurses. Intimidating
and disruptive clinician behaviors can lead to errors and preventable adverse patient outcomes. Patient safety has been described as
an ethical imperative and one that is inherent in health care professionals’ actions and interpersonal processes; examples include
inappropriate care and injury to patients by falls.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 25
OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. What considerations are taken into account in evidence-based nursing practice? (Select all that apply, one, some, or all.)
a. Clinical expertise of the nurse
b. Availability of staff and facility equipment
c. Research evidence on the topic
d. Patient knowledge of the disease
e. Patient preference regarding care
ANS: A, C, E
Evidence-based nursing practice considers the best research evidence on the care topic along with clinical expertise of the nurse
and patient preferences. For instance, when determining the frequency of vital sign measurement, the nurse would use available
research and nursing judgment (stability, complexity, predictability, vulnerability, and resilience of the patient). Availability of
staff and facility equipment and the patient’s knowledge of the disease do not factor into evidence-based nursing practices.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 9
OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
2. The concept of diversity encompasses what thoughts and actions? (Select all that apply, one, some, or all.)
a. Sensitivity to ethnic differences
b. Openness to different lifestyles
c. Openness to different values
d. Reticence to different beliefs
e. Lack of concern regarding different opinions
ANS: A, B, C
Diversity includes not only ethnic sensitivity but also sensitivity to openness to difference lifestyles, opinions, values, and beliefs.
Reticence and lack of concern are not part of the concept of diversity.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 5
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
3. According to American Association of Critical-Care Nurses, what are the responsibilities of a critical care nurse? (Select all that
apply, one, some, or all.)
a. Respecting the values, beliefs, and rights of the patient
b. Intervening when the best interest of the patient is in question
c. Helping the patient obtain necessary care
d. Making decisions for the patient and patient’s family
e. Monitoring and safeguarding the quality of care the patient receives
f. Acting as a gatekeeper for the patient, the patient’s family, and other health care
professionals
ANS: A, B, C, E
American Association of Critical-Care Nurses (AACN) critical care nurse role responsibilities include respecting the values,
beliefs, and rights of the patient; intervening when the best interest of the patient is in question; helping the patient obtain necessary
care; and monitoring and safeguarding the quality of care the patient receives. The nurse is not to make decisions for the patient or
the patient’s family but should support their decisions. The nurse should act as a liaison, not a gatekeeper, for the patient and the
patient’s family and other health care professionals.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 5 | Box 1-1
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
Chapter 02: Ethical Issues
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is the difference between ethics and morals?
a. Ethics is more concerned with the “why” of behavior.
b. Ethics provides a framework for evaluation of the behavior.
c. Ethics is broader in scope than morals.
d. Ethics concentrates on the right or wrong behavior based on religion and culture
values.
ANS: A
Ethics are concerned with the basis of the action rather than whether the action is right or wrong, good or bad.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 12
2. A patient’s wife has been informed by the practitioner that her spouse has permanent quadriplegia. The wife states that she does not
want anyone to tell the patient about his injury. The patient asks the nurse about what has happened. The nurse has conflicting
emotions about how to handle the situation. What is the nurse experiencing?
a. Autonomy
b. Moral distress
c. Moral doubt
d. Moral courage
ANS: B
The nurse has been placed in a situation initially causing moral distress and is struggling with determining the ethically appropriate
action to take. Moral courage is the freedom to advocate for oneself, patients, and peers. Autonomy is an ethical principle. Moral
doubt is not part of the American Association of Critical-Care Nurses (AACN) framework. The 4A’s to Rise Above Moral Distress.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 12
3. By what action can critical care nurses best enhance the principle of autonomy?
a. Presenting only the information to prevent relapse in a patient
b. Assisting with only tasks that cannot be done by the patient
c. Providing the patient with all of the information and facts
d. Guiding the patient toward the best choices for care
ANS: C
Patients and families must have all the information about a certain situation to make an autonomous decision that is best for them.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 15 | p. 16
4. Which ethical principle is most important when soliciting informed consent from a patient?
a. Nonmaleficence
b. Fidelity
c. Beneficence
d. Veracity
ANS: D
Veracity is important when soliciting informed consent because the patient needs to be aware of all potential risks of and benefits to
be derived from specific treatments or their alternatives.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 15
5. The principle of respect for persons incorporates what additional concepts?
a. Confidentiality and privacy
b. Truth and reflection
c. Autonomy and justice
d. Beneficence and nonmaleficence
ANS: A
Confidentiality of patient information and privacy in patient interactions must be protected and honored by health care providers
out of respect for persons. Confidentiality is a right involving the sharing of patient information with only those involved in the
patient’s care. Privacy includes confidentiality but goes further to include the right to privacy of person and personal space, such as
ensuring that a patient is adequately covered during a procedure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 16
1
6. Which action best reflects the concept of beneficence within the critical care setting?
a. Advocating for equitable health care
b. Promoting for safe patient care
c. Ensuring equal access for those with the same condition or diagnosis
d. Confirming technologic advances are available to all in a given community
ANS: B
Advocating for patient safety is an example of beneficence. The other actions are examples of justice.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 15 | Box 2-2
7. Which statement best describes the concept of paternalism?
a. Encouraging the patient to ambulate after surgery
b. Demanding the patient get out of bed to sit in a chair
c. Following the patient’s advance directive despite family objections
d. Administering antibiotics for a viral infection
ANS: B
Encouraging the patient to ambulate after surgery is an example of beneficence. Demanding the patient get out of bed to sit in a
chair is an example of paternalism. Following the patient’s advance directive despite family objections is an example of autonomy.
Administering antibiotics for a viral infection is an example of physiologic futility.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 18
8. Which statement regarding the Code of Ethics for Nursing is accurate?
a. The Code of Ethics for Nurses is usurped by state or federal laws.
b. It allows the nurse to focus on the good of society rather than the uniqueness of
c.
d.
the patient.
The Code of Ethics for Nurses was recently adopted by the American Nurses
Association.
It provides society with a set of expectations of the nursing profession.
ANS: D
The Code of Ethics for Nursing provides a framework for the nurse to follow in ethical decision-making and provides society with
a set of expectations of the profession.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 19
9. Ethical decisions are best made by performing which action?
a. Following the guidelines of a framework or model
b. Having the patient discuss alternatives with the practitioner or nurse
c. Prioritizing the greatest good for the greatest number of persons
d. Studying by the Ethics Committee after all diagnostic data are reviewed
ANS: A
To facilitate the ethical decision-making process, a model or framework must be used so that all involved will consistently and
clearly examine the multiple ethical issues that arise in critical care.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 20
10. What is the first step of the ethical decision-making process?
a. Consulting with an authority
b. Identifying the health problem
c. Delineating the ethical problem from other types of problems
d. Identifying the patient as the primary decision maker
ANS: B
Step one involves identifying the major aspects of the patient’s medical and health problems. Consulting an authority is not always
necessary in the process. Delineating the ethical problem from other types of problems may not be necessary. Identification of the
patient as primary decision maker is not part of the process.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 20
2
11. A practitioner is suggesting treatments to a patient that are contrary to the patient’s preferences. What is this practice called?
a. Invaluable deficiency
b. Physiologic uselessness
c. Ethical futility
d. Situational insufficiency
ANS: C
Ethical futility is treatment that will not serve the underlying interests, values, and preferences of the patient such as when a
practitioner’s idea of benefit is contrary to the values and preferences of the patient.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 18
12. Institutional ethics committees (IECs) review ethical cases that are problematic for the practitioner. What is the major function of
an IEC?
a. Consultation with purely binding recommendations
b. Support and education to health care providers
c. Conflict resolution for moral dilemmas
d. Recommendations that are binding in all cases
ANS: B
The Institutional Ethics Committee (IEC) can function in a variety of ways, serving as consultants, providing education, and
helping resolve ethical conflicts or dilemmas for health care providers. Recommendations from the formal IEC may or may not be
binding and are relative to the situation at hand.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 22
13. Developing an organizational policy that supports unobstructed access to the ethics committee by health care team members is one
example of a proactive approach to dealing with what issue?
a. Moral distress
b. Surrogate decision makers
c. Paternalism
d. Patient advocacy
ANS: A
Every organization must develop policies that support unobstructed access to resources such as the ethics committees to mitigate
the harmful effects of moral distress in the pursuit of creating a healthy work environment.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 12 | p. 13 | Box 2-1
14. The nurse is using the SFNO approach to case analysis to facilitate ethical decision-making. What justification criteria may be used
to help explain the reasons for selection of one option over another?
a. Effectiveness
b. Usefulness
c. Legal ramifications
d. Economics
ANS: A
Justification criteria may be helpful in explaining the reasons for selecting one or two options as superior. These include necessity,
effectiveness, proportionality, least infringement, and proper process. Usefulness, legal ramifications, and economics are not part of
the criteria.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 21 | Box 2-8
15. The nurse is using the SFNO approach to case analysis to facilitate ethical decision-making. Which question is important to ask
when considering stakeholders?
a. Are there reasons to give priority to one stakeholder over another?
b. Will the stakeholders abide by the decision?
c. Will the stakeholders want to be present during the ethics consultation?
d. Do the stakeholders understand how to use the SFNO model?
ANS: A
In the SFNO model, questions about stakeholders include:
• Who has a stake in the decision being made? Why?
• Who will be significantly affected by the decision made? Why?
• Are there reasons to give priority to one stakeholder over another?
The other questions are not relevant to this process.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 21 | Box 2-8
3
MULTIPLE RESPONSE
1. Which is/are criteria for defining an ethical dilemma? (Select all that apply, one, some, or all.)
a. An awareness of different options
b. An issue in which only one viable option exists
c. The choice of one option compromises the option not chosen
d. An issue that has different options
e. When the healthcare team is in agreement on what to do
ANS: A, C, D
The criteria for identifying an ethical dilemma are threefold: (1) an awareness of the different options, (2) an issue that has different
options, and (3) the choice of one option over another compromises the option not chosen.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 21 | Box 2-8
2. Which situations are early signs of an ethical dilemma? (Select all that apply, one, some, or all.)
a. Disagreements among health care team members
b. Failure to discuss end-of-life issues with patient
c. Aggressive pain management
d. Belief that treatment is harmful
e. Following the patient’s advance directive despite family objections
f. Providing hope to the patient’s family
ANS: A, B, D
Disagreements among health care team members, failure to discuss end-of-life issues with patient, and belief that treatment is
harmful are early signs or indicators of an ethical dilemma.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 19 | Box 2-5
4
Chapter 03: Legal Issues
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is the legal standard of care for a nurse’s actions?
a. Minimal competency under the state Nurse Practice Act
b. The ability to distinguish what is right or wrong for the patient
c. The demonstration of satisfactory knowledge of policies and procedures
d. The care that an ordinary prudent nurse would perform under the same
circumstances
ANS: D
The legal standard of care for nurses is established by expert testimony and is generally “the care that an ordinarily prudent nurse
would perform under the same circumstances.”
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27
2. A patient is admitted with chest pain, and his electrocardiogram shows elevated ST segments. The nurse bases her plan of care on
the nursing diagnosis of pneumonia. What type of negligence may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: B
Basing nursing care on an erroneous diagnosis is a failure in planning. Standards of care include assessment, the collection of
relevant data pertinent to the patient’s health or situation; diagnosis, analysis of the assessment data in determining diagnosis and
care issues; implementation, coordinating care delivery and plan and using strategies to promote health and a safe environment; and
evaluation, evaluation of the progress of the patient toward attaining outcomes.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27 | p. 30 | Box 3-3
3. What is an injury resulting from the failure to meet an ordinary duty called?
a. Negligence
b. Malpractice
c. Assault
d. Battery
ANS: A
Injury resulting from the failure to meet an ordinary duty or standard of care is negligence. Malpractice is a specialized form of
negligence. Assault and battery are examples of intentional acts.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27 | p. 28
4. A night nurse is notified by the laboratory that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a
do-not-resuscitate order. The nurse does not notify the practitioner because of the patient’s code status. In doing so, the nurse is
negligent for what?
a. Failure to analyze the level of care needed by the patient
b. Failure to respect the patient’s wishes
c. Wrongful death
d. Failure to take appropriate action
ANS: D
Nurses caring for acutely and critically ill patients must appropriately notify physicians of situations warranting treatment actions.
Furthermore, the full no-code, do-not-resuscitate order does not exclude this patient from receiving treatment to correct the critical
laboratory value. Failure to take appropriate action in cases involving acutely and critically ill patients has included not only
physician-notification issues but also failure to follow physician orders, failure to properly treat, and failure to appropriately
administer medication.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 28 | p. 29
OBJ: Nursing Process Step: Assessment | Nursing Process Step: Implementation
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. Two nurses are talking about a patient’s condition in the cafeteria. In doing so, these nurses could be accused of what?
a. Failure to take appropriate action
b. Failure to timely communicate patient findings
c. Failure to preserve patient privacy
d. Failure to document patient information
ANS: C
Nurses have a duty to preserve patient privacy, and failure to do so is a breach of patient confidentiality and failure to preserve
patient privacy. Nurses should also refrain from having discussions about specific patients with anyone except other health care
professionals involved in the care of the patient. When discussing specific patients with other health care professionals, it is
imperative that patient-specific discussions occur in nonpublic settings. Discussions about specific patients are never appropriate in
public areas such as elevators, cafeterias, gift shops, and parking lots.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 31
6. What is negligence called when it applies to an individual who is a professional?
a. Breach
b. Malpractice
c. Duty
d. Harm
ANS: B
Whereas negligence claims may apply to anyone, malpractice requires the alleged wrongdoer to have special standing as a
professional. If a nurse caring for acutely and critically ill patients is accused of failing to act in a manner consistent with the
standard of care, that nurse is subject to liability for professional malpractice (negligence applied to a professional).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 28
7. A nurse fails to recognize an intubated patient’s need for suctioning. The endotracheal tube becomes clogged, and the patient has a
respiratory arrest. What type of negligence may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: A
Nurses have a duty to assess and analyze the care required by each patient they care for. Failure to do so puts the nurse at risk for
negligence related to failure to assess the patient’s needs.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
8. What element of malpractice is based on the existence of a nurse–patient relationship?
a. Duty
b. Breach
c. Damages
d. Harm caused by the breach
ANS: A
Duty to the injured party is the first element of a malpractice case and is premised on the existence of a nurse–patient relationship.
Breach is failure to act consistently within applicable standards of care. Harm caused by the breach occurs when the patient
sustained injuries because of the breach of duty. Damages are derived from the harm or injury sustained by the acutely or critically
ill patient and are calculated as a dollar amount.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 28
9. A patient is getting heparin by intravenous infusion. The nurse received an order to increase the heparin infusion rate and obtain a
partial thromboplastin time (PTT) in 1 hour. The PTT was drawn correctly and revealed a critically elevated level. The nurse was
busy with another patient and failed to report the critical result to the physician within 30 minutes according to the facility’s policy.
Subsequently, the patient sustained a massive intracerebral bleed. What type of negligence may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: C
Failure to communicate and document patient findings in a timely manner is a form of failure to implement appropriate action.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 30
2
10. On the way to surgery, a patient expresses doubt about proceeding with the planned procedure. The patient states that the doctor
did not explain it very well and she would like to talk to her again before starting the procedure. The nurse knows the surgery
schedule is very tight, reassures the patient that everything will be all right, and administers the preoperative sedati on. This scenario
describes what possible type of negligence?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: D
The nurse has a duty to act as a patient advocate, in this case by holding the preoperative sedation until the doctor and the patient
can speak and the patient is satisfied that she has the necessary information to make this decision.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 31
11. Which statement is accurate regarding a nurse’s job description?
a. As long as the nurse follows the American Nurses Association Standards of Care,
b.
c.
d.
the job description is irrelevant in a negligence allegation.
Job descriptions must be reflective of the accepted standard of care.
Institution-specific job descriptions are not legally acceptable.
Job descriptions should be vague in describing nursing functions to avoid claims
of negligence.
ANS: B
Although job descriptions can be institution specific, they should be reflective of the national and community standards of care. Job
descriptions are based on professional accountability as outlined by state boards of nursing and standards of practice.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 29
12. The ability to practice as a licensed professional nurse is a privilege granted by what entity?
a. Employee contract
b. State legislature
c. State boards of nursing
d. Congress
ANS: B
The very ability to practice as a licensed professional nurse is a privilege granted by the state and is a function of each state’s
authority to promote and protect the health and welfare of its citizens. State boards of nursing (BON) are administrative bodies
created by—and that operate under—state statutes, or more generally written state laws created by state legislatures and signed by
the governor. In turn, the BONs develop more specific rules (or regulations) for obtaining and maintaining licensure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 24
13. Why is restraining a competent patient against his or her wishes considered an intentional tort?
a. The nurse did not document the patient’s need for restraints.
b. The nurse failed to get a physician’s order for restraints.
c. The nurse touched the patient in an unauthorized manner.
d. The nurse does not inform the patient that the restraints were needed.
ANS: C
Assault and battery are examples of intentional torts that are frequently brought against health care providers. Battery occurs if the
health care professional actually touches the patient in an unauthorized manner. The act of restraining a patient without consent is
battery.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 32
14. What is the best action a nurse could take to prevent allegations of malpractice?
a. Carrying malpractice insurance
b. Clarifying orders with the nursing supervisor
c. Delegating care to nursing assistants
d. Providing care according to standards of practice
ANS: D
Maintaining standards of practice is the best way to reduce risk. The hallmark of risk reduction is knowledge of the professional
standards of care, delivery and documentation of that care, and consistent demonstration that the standards are met. Nurses caring
for acutely and critically ill patients may be alleged to have acted in a manner that is inconsistent with standards of care or
standards of professional practice and may find themselves involved in civil litigation that focuses in whole or in part on the alleged
failure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 24
3
15. While participating in rounds, a nurse is interrupted by the wife of a ventilated patient, who informs the nurse that her husband is
having difficulty breathing. The patient is found to be disconnected from the ventilator and unresponsive when the nurse enters the
room after rounds. The alarm mode on the ventilator had been turned off. This situation is an example of what legal situation?
a. Assault
b. Battery
c. Injury
d. Malpractice
ANS: D
All four elements of negligence are present: duty and standard of care, breach of duty, causation, and injury. If a nurse caring for
acutely and critically ill patients is accused of failing to act in a manner consistent with the standard of care, that nurse is subject to
liability for professional malpractice (negligence applied to a professional). Assault occurs if the patient fears harmful or offensive
touching. Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27 | p. 28
16. After admission a patient shares with the nurse a concern that her adult children will not be able to reach agreement on what to do if
she is no longer able to make decisions for herself. The nurse informs the patient that it is possible to grant authority to one person
to make decision through which mechanism?
a. Court-appointed guardian
b. Do-not-resuscitate order
c. Durable power of attorney for health care
d. Living will
ANS: C
A durable power of attorney for health care includes legally binding documents that allow individuals to specify a variety of
preferences, particular treatments he or she wants to avoid, and circumstances in which he or she wishes to avoid them. The durable
power of attorney for health care is a directive through which a patient designates an “agent,” someone who will make decisions for
the patient if the patient becomes unable to do so. A living will specifies that if certain circumstances occur, such as terminal
illness, the patient will decline specific treatments, such as cardiopulmonary resuscitation and mechanical ventilation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 36
17. In which situation did the nurse disregard the patient’s right to privacy?
a. Informing the physician that the patient was verbalizing suicidal thoughts
b. Notifying the health department of a patient’s tuberculosis diagnosis
c. Reporting possible dependent-adult abuse to the police
d. Warning a visitor to wear gloves when giving a back rub because the patient is
HIV positive
ANS: D
Telling a visitor of the patient’s HIV status violated the patient’s right to privacy. The nurse could have ensured the visitor’s safety
by providing gloves and explaining universal precautions.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 31
18. Which statement best describes the definition of assault?
a. An intentional act that causes the patient to believe that harm may have been done
b. A statement that causes injury to the patient’s standing in the community
c. Negligence that results in harm to a spousal relationship
d. An intentional act that brings about harm or offensive contact with the patient
ANS: A
Assault occurs if the patient fears harmful or offensive touching. Battery is defined as an intentional act that brings about harm or
offensive contact with the patient.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 32
19. During transport to the operating room for mitral valve replacement, a patient with a signed consent form says that she does not
want to go through with the surgery and asks to be returned to her room. What is the best response from the nurse?
a. “The operating room is prepared; let’s not keep the surgeon waiting.”
b. “You have the right to cancel surgery, but it could be weeks before you are
rescheduled.”
c. “You sound frightened; tell me what you are thinking.”
d. “Your preoperative medications will have you feeling more relaxed in a minute; it
will be OK.”
ANS: C
The patient has the right to withdraw consent at any time. The nurse must listen and then clarify whether that is really what the
patient desires. If it is, the surgeon should then be notified.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 34
4
20. Which situation would be considered a failure of proper implementation?
a. Not identifying and analyzing symptoms appropriately
b. Not documenting the patient’s response to pain medication
c. Not recognizing a malfunctioning chest tube
d. Not asking the patient about code or no code wishes
ANS: B
Nurses caring for acutely and critically ill patients are required not only to take appropriate action but also to accur ately document
their findings, interventions performed, and patients’ response to those interventions. Failure to thoroughly and accurately
document any aspect of care gives rise to negligence causes of action.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
21. Which agency is responsible for maintaining the expectations and limits of nursing practice?
a. State Hospital Association
b. Court system
c. State Board of Nursing
d. State Department of Health
ANS: C
State Boards of Nursing (SBONs) maintain expectations for and limits of nursing practice in each state through the licensure of
nurses and also through challenges to nonnurses engaged in professional activities that intrude upon the nursing scope of practice.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 24
OBJ: Nursing Process Step: N/A
TOP: Nurse Practice Act
MSC: NCLEX: Safe and Effective Care Environment
22. A nurse providing care for a patient with a recent tracheostomy notes the presence of an ulceration or wound at the tracheotomy
site. The nature of the ulceration or wound clearly indicates it has been present for at least several days. The nurse finds no
documentation regarding the ulceration or wound since the insertion of the tracheostomy tube 12 days earlier. This situation is an
example of what legal situations?
a. Assessment and implementation failure
b. Failure to appropriately diagnose
c. Failure to follow practitioner’s orders
d. Planning and evaluation failure
ANS: A
This situation is an example of the prior nurses’ failure to assess and implement appropriately.
Assessment and implementation failures are related to a failure to assess and analyze a care need, communicate findings to a
physician, take appropriate action, and document.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
23. The patient received a blood transfusion based on test results of critically low hemoglobin. The nurse records vital signs (VS) per
hospital protocol. One hour after the transfusion was started, the nurse records VS as temperature (T) 102° F, pulse (P) 110,
respirations (R) 24, blood pressure (BP) 136/88. The nurse continues to administer the blood. This situation is an example of what
legal situation?
a. Malpractice
b. Assault
c. Battery
d. Libel
ANS: A
To avoid liability associated with administration of blood and blood products, nurses must carefully follow organizational
procedures and protocols that govern these interventions. Battery is any intentional act that brings about actual harmful or offensive
contact with the plaintiff. Assault occurs if the patient fears harmful or offensive touching. Libel is defined as publishing false
statements that are damaging to a person’s reputation.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 33 | p. 34
MULTIPLE RESPONSE
1. What elements or criteria must be present for negligence cases to go forward? (Select all that apply, one, some, or all.)
a. Duty to another person
b. Acknowledgement of wrong doing
c. Harm that would not have occurred in the absence of the breach
d. Breach of duty
e. Damages that have a monetary value
ANS: A, C, D, E
There are four criteria or elements for all negligence cases: (1) duty to another person; (2) breach of that duty; (3) harm that would
not have occurred in the absence of the breach (causation); and (4) damages that have a monetary value. All four elements must be
satisfied for a case to go forward. Acknowledgment of wrong doing is not required.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 27 | p. 28
5
2. Which actions by a nurse demonstrate the act of battery? (Select all that apply, one, some, or all.)
a. Performing cardiopulmonary resuscitation (CPR) on a patient with a
b.
c.
d.
e.
do-not-resuscitate (DNR) order
Threatening to punch someone
Sexual misconduct with a patient
Drawing blood without the patient’s consent
Threatening to restrain a patient for not using his or her call light for mobility
assistance
ANS: A, C, D
Battery is any intentional act that brings about actual harmful or offensive contact with the plaintiff. Battery occurs if the health
care professional actually touches the patient in an unauthorized manner. Assault occurs if the patient fears harmful or offensive
touching. Assault may be alleged if the patient was aware that he or she was going to be touched in a manner not authorized by
informed consent. Threatening to punch someone and threatening to restrain a patient for not using his or her call light for mobility
assistance are examples of assault.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 32
6
Chapter 04: Genetic Issues
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is a genetic variant that exists in greater than 1% of the population termed?
a. Genetic mutation
b. Genetic polymorphism
c. Genetic deletion
d. Tandem repeat
ANS: B
When a genetic variant occurs frequently and is present in 1% or more of the population, it is described as a genetic polymorphism.
The term genetic mutation refers to a change in the DNA genetic sequence that can be inherited that occurs in less than 1% of the
population. Genetic material in the chromosome can also be deleted and new information from another chromosome can be inserted
or can be a tandem repeat (multiple repeats of the same sequence).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 43
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
2. Which type of genetic disorder occurs when there is an interaction between genetic and environmental factors such as that which
occurs with type 2 diabetes?
a. Chromosome
b. Mitochondrial
c. Multifactorial disorders
d. Allele dysfunction
ANS: C
In multifactorial disorders there is an interaction between vulnerable genes and the environment. Cardiovascular atherosclerotic
diseases and type 2 diabetes are examples of multifactorial disorders that result from an interaction of genetic and environmental
factors.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 46
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
3. Philadelphia translocation is a specific chromosomal abnormality that occurs from a reciprocal translocation between
chromosomes 9 and 22, where parts of these two chromosomes switch places. This abnormality is associated with which disease?
a. Hemophilia A
b. Chronic myelogenous leukemia
c. Obesity
d. Marfan syndrome
ANS: B
Philadelphia chromosome or Philadelphia translocation is a specific chromosomal abnormality associated with chronic
myelogenous leukemia. It occurs from a reciprocal translocation between chromosomes 9 and 22, where parts of these two
chromosomes switch places. Hemophilia A is a sex-linked inheritance. Obesity is being studied with the FTO gene on chromosome
16. Marfan syndrome is classified as a single-gene disorder.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 42
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
4. What was the goal of the Human Genome Project?
a. Identifying haplotype tags
b. Exposing untaggable SNPs and recombination hot spots
c. Producing a catalog of human genome variation
d. Mapping all the human genes
ANS: D
The Human Genome Project was a huge international collaborative project that began in 1990 with the goal of making a map of all
the human genes (the genome). The final genome sequence was published in 2003. The HapMap project was to identify haplotype
tags. The Genome-Wide Association Studies was used to expose untaggable SNPs and recombination hot spots. The 1000
Genomes project was used to map all the human genes.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 49
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. The patient is placed under general anesthesia for a carotid endarterectomy. During the surgery, the patient develops muscle
contracture with skeletal muscle rigidity, acidosis, and elevated temperature. What is a possible cause for malignant hyperthermia?
a. Polymorphism in RYR1 at chromosome 19q13.1
b. Variant in the VKOR1 gene
c. Variant in the cytochrome P450 enzyme CYP2C9 gene
d. Halothane overdose
ANS: A
Individuals with polymorphisms in the ryanodine receptor gene (RYR1) at chromosome 19q13.1 are at risk of a rare
pharmacogenetic condition known as malignant hyperthermia. In affected individuals, exposure to inhalation anesthetics and
depolarizing muscle relaxants during general anesthesia induces life-threatening muscle contracture with skeletal muscle rigidity,
acidosis, and elevated temperature. Warfarin is being researched as a variant in the VKOR1 gene and in the cytochrome P450
enzyme CYP2C9 gene.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 53 | Box 4-3
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
6. What is the study of heredity particularly as it relates to the transfer heritable physical characteristics called?
a. Chromatids
b. Karyotype
c. Genetics
d. Histones
ANS: C
Genetics refers to the study of heredity, particularly as it relates to the ability of individual genes to transfer heritable physical
characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called chromatids, which are joined
near the center. A karyotype is the arrangement of human chromosomes from largest to smallest. A specialized class of proteins
called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone cord.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 54
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
7. What is the study of all the genetic material within the cell and its impact on biologic and physical characteristics called?
a. Chromatids
b. Karyotype
c. Genomics
d. Histones
ANS: C
Genomics refers to the study of all of the genetic material within cells and encompasses the environmental interaction and impact
on biologic and physical characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called
chromatids, which are joined near the center. A karyotype is the arrangement of human chromosomes from largest to smallest. A
specialized class of proteins called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone
cord.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 39
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
8. A specialized class of proteins that organizes the double-stranded DNA into what looks like a tightly coiled telephone cord is
known which of the following?
a. Chromatids
b. Karyotype
c. Genomics
d. Histones
ANS: D
A specialized class of proteins called histones organizes the double-stranded DNA into what looks like a tightly coiled telephone
cord. Genomics refers to the study of all of the genetic material within cells and encompasses the environmental interaction and
impact on biologic and physical characteristics. Each somatic chromosome, also called an autosome, is made of two strands, called
chromatids, which are joined near the center. A karyotype is the arrangement of human chromosomes from largest to smallest.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 39
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
9. To achieve a consistent distance across the width of the DNA strand, the nucleotide base guanine (G) can only be paired with what
other genetic material?
a. Adenine (A)
b. Thymine (T)
c. Cytosine (C)
d. Sex chromosome X
ANS: C
Four nucleotide bases—adenine (A), thymine (T), guanine (G), and cytosine (C)—comprise the “letters” in the genetic DNA
“alphabet.” The bases in the double helix are paired T with A and G with C. The nucleotide bases are designed so that only G can
pair with C and only T can pair with A to achieve a consistent distance across the width of the DNA strand. The TA and GC
combinations are known as base pairs.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 40
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
10. Why are monozygotic twins separated at birth used to study the effects of genetics versus environment?
a. They share an identical genome.
b. They have different sex chromosomes.
c. They have mirror chromosomes.
d. They have identical health issues.
ANS: A
Studies of identical twins offer a unique opportunity to investigate the association of genetics, environment, and health. Identical
twins are monozygotic and share an identical genome. Monozygotic twins are the same sex. Studies occur much less frequently
today because tremendous efforts are made to keep siblings together when they are adopted. Genetics can be stable in a study
group, but the environment and health issues are dynamic even in a controlled study group.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 48
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
11. The process that is used to make polypeptide chains that constitute proteins can be written as
a. RNA → DNA → protein.
b. DNA → RNA → protein.
c. protein → RNA → DNA.
d. protein → DNA → RNA.
ANS: B
The nucleotides A, T, C, and G can be thought of as “letters” of a genetic alphabet that are combined into three-letter “words” that
are transcribed (written) by the intermediary of ribonucleic acid (RNA). The RNA translates the three-letter words into the amino
acids used to make the polypeptide chains that constitute proteins. This process may be written as DNA → RNA → protein.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 41
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
12. What are the studies called that are done on large, extended families who have several family members affected with a rare disease?
a. Genetic association
b. Genetic epidemiology
c. Kinships
d. Phenotypes
ANS: C
In genetic epidemiologic research of a rare disease, it can be a challenge to find enough people to study. One method is to work
with large, extended families, known as kinships, which have several family members affected with the disease. Genetic
association studies are usually conducted in large, unrelated groups based on demonstration of a phenotype (disease trait or
symptoms) and associated genotype. Genetic epidemiology represents the fusion of epidemiologic studies and genetic and genomic
research methods. Phenotypes are different at different stages of a disease and are influenced by medications, environmental
factors, and gene–gene interaction.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 48
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
13. What is an example of direct-to-consumer genomic testing?
a. Genetic testing through amniocentesis
b. Paternity testing from buccal swabs of the child and father
c. Biopsy of a lump for cancer
d. Drug testing using hair follicles
ANS: B
An example of direct-to-consumer testing is paternity testing from buccal swabs of the child and father. Genetic testing can be done
through biopsies and amniocentesis, but they are performed in a facility by a medical professional. Drug testing and genomic
testing are two different tests and are unrelated.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 53
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
14. What was the Genetic Information Nondiscrimination Act (GINA) of 2008 designed to prevent from happening?
a. Abuse of genetic information in employment and health insurance decisions
b. Genetic counselors from reporting results to the health insurance companies
c. Mandatory genetics testing of all individuals with certain diseases
d. Information sharing between biobanks that are studying the same genetic
disorders
ANS: A
The Genetic Information Nondiscrimination Act (GINA) of 2008 is an essential piece of legislation designed to prevent abuse of
genetic information in employment and health insurance decisions in the United States. One of the paramount concerns in the
genomic era is to protect the privacy of individuals’ unique genetic information. Many countries have established biobanks as
repositories of genetic material, and many tissue samples are stored in medical center tissue banks. Some people who may be at risk
for a disorder disease will not be tested because they fear that a positive result may affect their employability. GINA also mandates
that genetic information about an individual and his or her family has the same protections as health information.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 53
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which patients would be candidates for genetic testing for long QT syndrome (LQTS)? (Select all that apply, one, some, or all.)
a. Patients with prolonged QT interval during a cardiac and genetic work-up
b. Family history of positive genotype and negative phenotype
c. Patients diagnosed with torsades de pointes
d. Family history of sudden cardiac death
e. Family history of bleeding disorders
f. Family history of obesity
ANS: A, B, C, D
Clinical genetic testing is available for long QT syndrome (LQTS). Genetic testing is very helpful within families of patients with
LQTS. If the family member has a prolonged QTc interval, the reasonable assumption during the cardiac and genetic work-up is
that the person has the mutation. It is also important to test family members with normal QTc intervals because up to 50% have
“concealed” LQTS, meaning they have a positive genotype and negative phenotype (normal QT on the resting ECG). This is
because of a genetic concept termed penetrance, in which the same gene does not have the same phenotypic effect on everyone
who is affected. If a person carries the genetic mutation but has a normal QT interval at rest, he or she may still be vulnerable
during exercise or physiologic stress. Frequently patients are identified after a syncopal episode, a life-threatening dysrhythmia
such as torsades de pointes, or sudden cardiac death. Hemophilia A and B are associated with bleeding disorders. The FTO gene is
associated with obesity.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 51
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
2. Which disorders are classified as a single-gene disorder? (Select all that apply, one, some, or all.)
a. Down syndrome
b. Marfan syndrome
c. Cystic fibrosis
d. Type 2 diabetes
e. Sickle cell disease
f. Cardiovascular atherosclerotic diseases
ANS: B, C, E
Cystic fibrosis, sickle cell disease, hemophilia A, and Marfan syndrome are examples of single-gene disorders. Down syndrome is
a chromosome disorder (extra chromosome 21), and cardiovascular atherosclerotic disease and type 2 diabetes are examples of
complex gene disorders that result from an interaction of genetic and environmental factors.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 45 | p. 46
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
3. Hemophilia A is an inherited disease. Which statements would be determined by the family pedigree regarding hemophilia A?
(Select all that apply, one, some, or all.)
a. It is an X-linked disorder.
b. Sons have a 50% chance of having hemophilia.
c. It is a Y-linked disorder.
d. Daughters have a 50% chance of being a carrier of the trait.
e. Sons have a 25% chance of having hemophilia.
f. Daughters have a 50% chance of having hemophilia.
ANS: A, B, D
In an X-linked disorder, each son has a 50% chance of having the disorder and each daughter has a 50% chance of being a carrier.
In a family pedigree, the absence of direct male-to-male transmission makes this condition identifiable as an X-linked disorder.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 46
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
Chapter 05: Patient and Family Education
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient is scheduled for a cardiac catheterization this afternoon. The nurse wants to provide her with some basic information
before going in the room to talk about her specific procedure. Which teaching strategy is most appropriate for this situation?
a. Discussion
b. Demonstration and practice
c. Audiovisual media
d. Written
ANS: C
Media are used to educate patients on a variety of educational needs, such as medications, disease processes, procedures, symptom
management, weight monitoring, laboratory tests, diet, surgery, and health maintenance issues. Patient education videos require the
patient’s attention for only a few minutes and supply the learner with “nice-to-know” and “need-to-know” information.
Demonstration and practice is not appropriate for this procedure because the patient is not performing the cardiac catheterization.
Discussion and written material will help enhance the learning with the audiovisual media; however, this is not an interactive
media.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 67
OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
2. A nurse has been progressively working with a patient on the exercises he needs to do at home when he is discharged. The nurse
wants to ensure he will remember what to do when he is at home. Which teaching strategy is most appropriate for this situation?
a. Discussion
b. Demonstration and practice
c. Audiovisual media
d. Written
ANS: D
Written media, such as brochures, pamphlets, patient pathways, and booklets, are common in outpatient and inpatient areas of
health care. Demonstration and practice would be useful throughout the hospitalization to make sure the patient is performing the
exercises correctly. Discussion and audiovisual media would be appropriate in the assessment and intervention portion of learning;
however, written material may be reviewed by the patient after returning home.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 68
OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
3. What does the first step of the teaching–learning process involve?
a. Gathering data to assist in the assessment of learning needs
b. Identifying major learning needs for the patient
c. Identifying learning needs related to medical diagnosis
d. Evaluating the effects of prior teaching
ANS: A
The first step of the teaching–learning process is assessment, which involves gathering a database to assist the nurse in meeting the
patient’s and family’s needs. Learning needs can be defined as gaps between what the learner knows and what the learner needs to
know, such as survival skills, coping skills, and ability to make care decisions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 59
OBJ: Nursing Process Step: N/A
TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
4. Which educational content area is appropriate during the first hours of hospitalization?
a. Pathophysiology of the admitting diagnosis
b. Dietary modifications
c. Purpose of bedside equipment
d. Medication side effects
ANS: C
Initial interventions are targeted to promote comfort and familiarity with the environment and surroundings. The plan should focus
on survival skills, orientation to the environment and equipment, communication of prognosis, procedure explanations, and the
immediate plan of care. Information regarding diagnosis, dietary modifications, and medication will be addressed after the patient
is through the initial contact phase and is in the continuous care phase of education.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 72 | Table 5-2
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. How should a nurse respond when a patient asks if he or she is going to die?
a. Avoid the question by leaving the room.
b. Defer the question to the physician.
c. Answer honestly and sensitively with information that is understandable and in
d.
simple terms.
Speak with the family first before answering the patient.
ANS: C
During this time of elevated stress, the nurse may have to refocus the patient or family to help concentrate efforts on coping with
the present instead of dwelling on possibilities of the future. Not addressing these immediate concerns could result in further
anxiety, affect their ability to cope, and prevent open and honest communication.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 63 | p. 65
OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
6. Which intervention can support a learning environment in the critical care unit?
a. Providing a variety of caregivers to enhance the availability of different
b.
c.
d.
information
Allowing frequent uninterrupted rest periods to enhance obtaining structured
sleep
Providing the patient lists of facts that can enhance understanding of the disease
Teaching according to a structured plan to enhance comprehension
ANS: B
Sleep cycle alterations caused by sleep deprivation or sensory overload related to continuous noise from machines or people affect
the patient’s ability to concentrate and comprehend information. Allowing frequent uninterrupted rest periods assists the patient in
obtaining structured sleep. Assignment of multiple caregivers may negatively affect the ability of the patient and family to form a
trusting relationship with the nursing staff. Teach whatever the patient wants to learn and avoid lists of facts.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 63 | Table 5-1
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
7. A patient is admitted to the critical care unit with the onset of tuberculosis. He was diagnosed with HIV/AIDS 1 year ago. When
talking to the patient about preventing the spread of tuberculosis, the patient tells the nurse that he has not followed precautions
regarding tuberculosis for patients with HIV. Which educational objective is BEST stated for this patient?
a. Patient will know at least two ways to prevent the spread of tuberculosis within 1
week.
b. Patient will understand how HIV is spread within 3 days.
c. Patient will realize that improper precautions will spread his disease to others.
d. Patient will verbalize two methods of transmission for tuberculosis within 2 days.
ANS: D
Terms such as know, understand, realize, and appreciate are open to many interpretations and are difficult to measure. Active verbs
such as identify, state, list, and demonstrate should be used. The three components in the outcomes statement are (1) the individual
who will meet the objective, (2) a measurable or observable verb, and (3) the content to be evaluated or learned.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 66
OBJ: Nursing Process Step: Planning
TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
8. When writing goals and outcomes, what should be incorporated in the outcome statement?
a. An action oriented intervention list
b. An observable verb
c. The objectives for the nurse
d. The length of the education session
ANS: B
The three components in the outcomes statement are (1) the individual who will meet the objective, (2) a measurable or observable
verb, and (3) the content to be evaluated or learned. When goals or expected outcomes of the education encounter are clearly stated,
the teacher and the learner understand the expectations and will do their best to achieve them. These statements differ from
interventions in that they reflect what the learner is to accomplish, not what the nurse is to teach. The length of the education
session is not part of the outcome statement.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 66
OBJ: Nursing Process Step: Planning
TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
9. In which situation are group discussions most effective as a patient teaching strategy?
a. Patients have a variety of medical diagnoses.
b. Patients are in the acute phase of their illness.
c. Patients are in the hospital only 3 days or less.
d. Patients are at similar stages of adaptation.
ANS: D
Hospitalized patients with similar problems and at similar stages of adaptation can benefit from discussion groups. The patient and
each member of the family may be experiencing different stages in the adaptation process at the same time. The education
encounter may need to be modified to meet the needs of the patient and family.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 63 | Table 5-1
OBJ: Nursing Process Step: Planning
TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. According to Maslow’s hierarchy of needs, the need to know and understand information is considered what type of need?
a. High-level
b. Low-level
c. Physiologic
d. Critical
ANS: A
Experiencing the stress of a physiologic need requires immediate attention and is considered a lower level, immediate need. The
need to know and understand is a high-level need and can only be met if no lower level needs require attention.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 61
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
11. The patient is asked to complete an admission form. The patient hands the form to his spouse and asks her to complete the form,
stating, “I forgot my glasses.” What might be inferred from the patient’s actions?
a. Patient has functional health literacy.
b. Patient needs a word recognition test.
c. Patient has low health literacy.
d. Patient needs a reading comprehension test.
ANS: C
Behaviors such as handing a form to a family member to complete, claiming to be too tired, or “forgetting” one’s glasses are a few
behaviors that may be used by individuals to hide their limitations or low health literacy. Word recognition tests consist of lists of
health care terms that patients are asked to read. Reading comprehension tests assess understanding of health care information
presented but do not demonstrate the individual’s ability to apply this information. Functional health literacy tests assess the
individual’s level of comprehension and ability to put into action what he or she has learned.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 61 | p. 64 | p. 65 | Box 5-2
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
12. What are the three learning domains to be considered when developing an individualized education plan?
a. Knowledge, ability, and willingness to learn
b. Psychologic, skills, and knowledge
c. Knowledge, skills, and attitude
d. Skills, attitude, and psychologic
ANS: C
Three learning domains are considered when developing an individualized education plan: knowledge, attitude, and skills.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 65
OBJ: Nursing Process Step: N/A
TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
13. Information on what topic should be included in the educational plan of a patient who is unconscious?
a. Sensations
b. Pathophysiology
c. Rehabilitation
d. Attitudes
ANS: A
Providing information regarding environment, procedures, sensations, and time of day is benevolent and may help decrease
immediate physiologic stress.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 70
OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
14. What topic should be included in the education of a patient’s family members during their first visit?
a. When to call the practitioner
b. Availability of support groups
c. Expectations about self-care
d. What the patient may look like
ANS: D
The focus of the any education during the first visit should include what the patient may look like. When to call the practitioner,
availability of support groups, and expectation for self-care should be included into later teaching sessions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 64 | Table 5-2
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. A patient has been in the critical care unit for 20 days with a diagnosis of sepsis and acute respiratory distress syndrome. The
patient is ready for transfer to the step-down unit but is apprehensive. The patient has communicated to the nurse that he does not
want to leave the ICU because he is afraid that his needs will not be met on the step-down unit. Which educational objective would
be best to use in this situation?
a. The patient will state two reasons why he is being transferred by the end of the
day.
b. The patient will confront his fears and deal with them within 1 day of transfer.
c. The patient will state the name of his “new” nurse by the end of the day.
d. The patient will be introduced to at least two of his “new” caregivers by the time
of transfer.
ANS: D
The patient needs to trust the new caregivers on the step-down unit. Introducing the new caregivers will help decrease his anxiety
about an unfamiliar environment. Objectives must be realistic in expectation and timeline. Anxiety and fear of change will decrease
the patient’s cognitive level.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 64 | Table 5-2
OBJ: Nursing Process Step: Planning
TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
16. A 79-year-old patient received a liver transplant 3 days ago. The patient is extubated and hemodynamically stable. His spouse is
coming for a visit, and the nurse has some time to discuss immune suppression drug therapy with both of them. The patient is
hearing and sight impaired. The spouse brought the patient’s hearing aids 2 days ago and will bring the patient’s glasses today.
Which of the following teaching strategies would be least effective in the critical care unit setting?
a. Patient education channel
b. Written materials
c. Lecture
d. Discussion
ANS: C
Lecture is not the strategy of choice for this situation; it does not work well in the critical care unit. Teaching must be done at the
bedside by using as many of the senses as possible. Written material, discussion, demonstration, and use of media are common
teaching strategies used in the critical care unit.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 60
OBJ: Nursing Process Step: Intervention TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
17. During which phase do Health Insurance Portability and Accountability Act (HIPAA), advance directives, and visitation policies
occur for the patient or family members?
a. Transfer to a different level of care
b. End-of-life care
c. Initial contact or first visit
d. Continuous care
ANS: C
During preparation for the first visit, the nurse would instruct the patient or family on Health Insurance Portability and
Accountability Act (HIPAA), advance directives, and visitation policy. Transfer to a different level of care includes orientation to
the receiving unit. Continuous care includes discussion of day-to-day routines, procedures, and treatment process. End-of-life care
includes discussion of palliative care or hospice.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 64 | Table 5-2
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
18. Which of the following statements best describes the teaching–learning process?
a. It follows the distinct order of the nursing process, with each step of the process
b.
c.
d.
separate and without repetition.
It requires formal blocks of learning time that are planned during the shift.
It is a continuous activity that occurs during hospitalization and beyond.
It ends at the point of discharge.
ANS: C
In the teaching–learning process, the steps of the nursing process (assessment, diagnosis, goals, interventions, and evaluation) may
occur simultaneously and repetitively. The teaching–learning process is a dynamic, continuous activity that occurs throughout the
entire hospitalization and may continue after the patient has been discharged.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 59
OBJ: Nursing Process Step: N/A
TOP: Patient and Family Education
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
19. Which statement best describes the efficacy of group discussion as a patient teaching strategy for educating both a patient newly
diagnosed with diabetes and a patient who has had the disease for years?
a. It is an efficient use of the nurse’s time.
b. It is an efficient use of the patient’s time.
c. It is an effective strategy as both patients have identical goals.
d. It is not an appropriate teaching strategy.
ANS: D
Educational needs between the two patients will differ. Group discussion is only effective when the goals of the education plan are
the same for all patients involved. A patient newly diagnosed with diabetes will require education on topics that are potentially well
known to a patient diagnosed years ago.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 63
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
20. A mechanically ventilated patient is being weaned off sedation. The patient begins to wake up and becomes increasingly agitated,
pulling at the gown, kicking, and grimacing. What action should the nurse take next?
a. Administer additional sedation until the patient stops kicking
b. Initiate wrist restraints to prevent the patient from pulling
c. Tell the patient to stop moving around to avoid accidental extubation
d. Provide the patient with simple facts to assist with understanding of the situation
ANS: D
The need for oxygen and survival predominates over all other human needs. According to Maslow’s hierarchy of human needs,
lower level, physiologic needs must be satisfied before an individual can move on to higher level issues. Experiencing a significant
physiologic stressor may completely consume all the patient’s available energy and thoughts, affecting his or her ability to interact,
comprehend, and respond.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 65
OBJ: Nursing Process Step: Implementation
TOP: Patient and Family Education
MSC: NCLEX: Safe and Effective Care Environment
21. A lack of true understanding can often be misread by the nurse as noncompliance. Which of the following statements demonstrates
effective questioning methods to assess a patient’s understanding?
a. “Do you take your heart medication every morning?”
b. “Can you tell me what you know about your different heart medications?”
c. “Do you take all of your medications?”
d. “Do you ever miss taking your medication?”
ANS: B
Open-ended questions provide the nurse an opportunity to assess actual knowledge gaps rather than assume knowledge by
obtaining a “yes” or “no” response. These types of questions also assist the patient and family to tell their story of the illness and
communicate their perceptions of the experience. Questions that elicit only a “yes” or “no” response close off communication and
do not provide for an interactive teaching–learning session.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 70
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Acute illness disrupts the patient’s and family’s normal routines and is extremely stressful. What coping mechanisms might the
nurse expect the patient and/or family to display? (Select all that apply, one, some, or all.)
a. Denial
b. Adaptation
c. Values
d. Anger
e. Disbelief
ANS: A, D, E
Denial, disbelief, and anger are all examples of coping mechanisms that patients use to help in stressful situations. Adaptation is
the ability to break down emotional barriers that affect willingness and readiness for learning. Values are considered sociocultural
factors for coping with stress.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 60
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
2. What are sources of physiologic stress in the acutely ill patient? (Select all that apply, one, some, or all.)
a. Hypotension
b. Hypoxemia
c. Fever
d. Neurologic deficits
e. Eupnea
ANS: A, B, C, D
Physiologic alterations in heart rate and blood pressure can be measured and taken into consideration during the teaching–learning
encounter. Sources of physiologic stress in acutely ill patients include medications, pain, hypoxemia, decreased cerebral and
peripheral perfusion, hypotension, fluid and electrolyte imbalances, infection, sensory alterations, fever, and neurologic deficits.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 61
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
3. According to Malcolm Knowles’ andragogy, what are characteristics of the adult learner? (Select all that apply, one, some, or all.)
a. Autonomy
b. Experience
c. Instructor-driven assessments
d. Peer-directed motivation
e. Individualism
ANS: A, B, E
Malcolm Knowles described these principles of adult learning in a model known as andragogy. Adult learning theory stresses
concepts of individualism, self-assessment, self-direction, motivation, experience, and autonomy.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 60
OBJ: Nursing Process Step: N/A
TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
4. Which questions can a nurse use to obtain assessment information to determine the immediate need for education? (Select all that
apply, one, some, or all.)
a. “How can we help you today?”
b. “Can you tell me why you take each medication?”
c. “Are you in pain?”
d. “Are these people your main support system?”
e. “How well do you understand the directions?”
ANS: A, B, E
Generally, with practice and effort, it can be determined what educational information is needed in a brief period without much
disruption in the routine care of the patient. Questions that elicit a “yes” or “no” response close off communication and do not
provide an interactive teaching–learning session.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 60 | Box 5-1
OBJ: Nursing Process Step: Assessment TOP: Patient and Family Education
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 06: Psychosocial and Spiritual Alterations and Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. According to the transactional theories on stress, what does a person do first when confronted by stress?
a. Determines coping mechanisms to deal with the stress
b. Determines the perceived degree of threat imposed
c. Determines what the response will be to the stress
d. Denies the stress exists
ANS: B
An alarm reaction is initiated by the hypothalamus, which, upon receiving sensory and chemical information regarding the presence
of a stressor, signals the release of corticotrophin-releasing factor (CRF). During the resistance stage, the person’s systems fight
back, leading to adaptation and a return of normal functioning. If the stressors continue, exhaustion occurs, a stage in which
reserves have been depleted. Reversal of stress exhaustion can be accomplished by restoration of one’s reserves through the use of
medications, nutrition, and other stress reduction measures.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 79 | p. 80
OBJ: Nursing Process Step: Assessment TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
2. A patient has recently been weaned off mechanical ventilation after 3 weeks of treatment. The patient is now refusing to have the
ventilator removed from the room. What type of alteration is the patient experiencing?
a. Disturbed self-esteem
b. Regression
c. Hopelessness
d. Disturbed body image
ANS: D
Body image disturbances arise when disruption exists in the way individuals perceive their bodies. Patients temporarily requiring
mechanical ventilation must extend their body images to include the ventilator. When the ventilator is no longer needed, the patient
should no longer perceive the ventilator as part of the self. Illness robs a person of perspective, often leading to low self-esteem and
feelings of powerlessness, helplessness, and depression. Low self-esteem impairs one’s ability to adapt.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 78
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
3. A patient with low self-esteem may manifest which behaviors?
a. Refusal to participate in care
b. Feelings that his or her body has betrayed him or her
c. Acceptance and ownership of problems
d. Disruption in the perception of the body
ANS: A
Patients with low self-esteem may refuse to participate in self-care, exhibit self-destructive behavior, or be too compliant. Feelings
that his or her body has betrayed him or her is an example of disruption in the perception of the body.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 78
OBJ: Nursing Process Step: Assessment TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
4. Which statement regarding patients with an external locus of control is true?
a. They believe that they can influence the outcome of their illness.
b. They should be forced to take control of their discharge planning.
c. They usually start out with an internal locus of control until a major illness
d.
occurs.
They believe that events are related to chance or fate.
ANS: D
People with an external locus of control tend to believe that events are related to chance or fate. Individuals who have an internal
locus of control perceive themselves to be responsible for the outcome of events. People vary in the amount of control they prefer.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 79
OBJ: Nursing Process Step: Assessment TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. Which intervention should be included in the patient management plan for a patient with powerlessness?
a. Maintain control of the environment
b. Set limits on the behavior
c. Maintain a routine schedule so that the patient can anticipate activities
d. Prepare the patient for transfer to the medical floor
ANS: B
Interventions for patients with powerlessness include setting limits on behavior, encouraging independence and participation in
self-care, counseling, and involving family members in establishing realistic goals. Powerlessness can be manifested by a refusal to
participate in decision making, disengagement from plan of care, expressions of self-doubt, or a seeming lack of interest in
recovery.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 79
OBJ: Nursing Process Step: Intervention TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
6. Which statement regarding regression as a coping mechanism for critical care patients is accurate?
a. It is necessary to some degree to allow staff to administer care.
b. It indicates deterioration of the physical state.
c. It is adaptive when the patient calls every 15 minutes, even for trivial matters.
d. It is best avoided to ensure successful recovery.
ANS: A
Regression allows patients to give up their usual roles, autonomy, and privacy to become passive recipients of medical and nursing
care. Behaviors such as whining, clinging to staff, needing the nurse constantly at the bedside, and giving evidence of an inability
to self-modulate feelings of anxiety or fear can interfere with patient recovery and negatively impact nurse–patient relationships.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 80
OBJ: Nursing Process Step: Assessment TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
7. Which concept supports patients and helps them endure the physical and psychologic insults of their critical illness?
a. Regression
b. Denial
c. Hope
d. Trust
ANS: C
Hope is a subjective, dynamic internal process essential to life. Considered to be a spiritual process, hope is an energy that arises
out of a sense of being meaningfully connected to one’s self, others, and powers greater than the self. With hope, a person is able to
transition from a state of vulnerability to a point of being able to live as fully as possible. Regression is an unconscious defense
mechanism characterized by a retreat, in the face of stress, to behaviors characteristic of an earlier developmental level. Denial is
defined as the “conscious and unconscious attempts to disavow knowledge or the meaning of an event to reduce anxiety and fear.”
Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be
able to manage any untoward event that might occur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 79
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial Alterations
MSC: NCLEX: Psychosocial Integrity
8. Which therapeutic technique may be used to enhance coping in the critical care environment?
a. Encourage the patient to let the staff have total control of the patient’s care.
b. Encourage the patient to deny the presence of the illness.
c. Inform the patient that everything will be all right.
d. Foster trust in the interprofessional health care team.
ANS: D
Trust manifests itself in critical care patients’ belief that the people they depend on will get them through the illness and will be
able to manage any untoward event that might occur. A patient needs to trust the nurse’s competence in the physical and technical
aspects of care and rely on what the nurse says.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 79
OBJ: Nursing Process Step: Intervention TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
9. Which nursing intervention can help family members who are extremely upset?
a. Encouraging the family to visit as much as possible
b. Conveying what the patient is experiencing to the family
c. Supporting the family members away from the bedside
d. Assuring the family that the staff will take care of the technical aspects of the
patient’s care
ANS: C
If family members are so upset that they completely lose composure, a brief attempt at supporting them away from the bedside may
be adequate. In doing so, nurses may determine that family members need a consistent outside source of support and may make a
referral according to department guidelines.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 83
OBJ: Nursing Process Step: Intervention TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with
immobilization for the past week. The practitioner explains to the patient that the spinal cord has been severed and that the patient
will not be able to walk again. The patient becomes overtly hostile to everyone. What psychosocial concept is the patient
demonstrating?
a. Regression
b. Loss of autonomy
c. Ineffective coping
d. Hope
ANS: C
Ineffective coping is defined as an impairment of a person’s adaptive behaviors and problem-solving abilities when meeting life’s
demands and necessary roles. Manifestations of ineffective coping in critical illness include verbalization of an inability to cope,
anxiety, and being unable to meet basic needs. Regression is an unconscious defense mechanism characterized by a retreat, in the
face of stress, to behaviors characteristic of an earlier developmental level. Hope is a subjective, dynamic internal process essential
to life. Considered to be a spiritual process, hope is an energy that arises out of a sense of being meaningfully connected to one’s
self, others, and powers greater than the self.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 80
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
11. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with
immobilization for the past week. The practitioner has explained to the patient that the spinal cord has been severed and that the
patient will not be able to walk again. The patient states, “I can’t wait until I can get on my feet and walk again.” Which defense
mechanism is the patient exhibiting in this statement?
a. Denial
b. Posttraumatic stress disorder (PTSD)
c. Regression
d. Trust
ANS: A
Denial is an unconscious defense mechanism that reduces anxiety by eliminating or reducing the seriousness of the perceived
threat. As with stress overload, posttraumatic stress disorder (PTSD) is not a disordered response to stress resulting from a failure
of a person’s will, strength, endurance, or courage. Regression is an unconscious defense mechanism characterized by a retreat, in
the face of stress, to behaviors characteristic of an earlier developmental level. Trust manifests itself in critical care patients’ belief
that the people they depend on will get them through the illness and will be able to manage any untoward event that might occur.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 80
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
12. A patient has been admitted with a severed spinal cord injury at the T2 level. The patient has been in halo traction with
immobilization for the past week. The patient continually tries to get out of bed and states, “My legs are only sleeping.” Which
nursing diagnoses would be appropriate for the patient?
a. Disturbed body image
b. Powerlessness
c. Situational low self-esteem
d. Ineffective role performance
ANS: A
Body image disturbances arise when disruption exists in the way individuals perceive their bodies. Self-esteem refers to how well
one’s behavior correlates with a sense of the ideal self and is most closely linked to one’s sense of self-worth. Patients who have a
pervasive sense that they can do nothing to change or control their circumstances are at risk for feeling powerless.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 78
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
13. A patient is in the critical care unit having undergone surgery a week ago for multiple fractures to the legs secondary to a fall from
a rooftop. The patient refuses to participate in morning care activities such as brushing his own teeth or washing his face and hands.
The patient yells at the nurse, “You do it! Can’t you see that my legs are broken?” What psychosocial disturbance is the patient
exhibiting?
a. Self-concept
b. Self-esteem
c. Body image
d. Personal identity
ANS: B
Illness and trauma can rob the person of perspective and shrinks both the familiar world and the one of possibility, often leading to
low self-esteem and feelings of powerlessness, helplessness, and depression. A low self-regard impairs one’s ability to adapt. The
person may refuse to participate in self-care, exhibit self-destructive behavior, or be too compliant.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 78
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
14. An adult patient sustains third- and fourth-degree burns to more than 70% of her body related to a house fire. The patient begins a
pattern of behavior similar to that of a young child, in which she repeatedly whines and throws “temper tantrums” in an attempt to
keep her nurse at the bedside. What coping mechanism is the patient exhibiting?
a. Regression
b. Identity disturbance
c. Denial
d. Trust
ANS: A
Regression is a normal reaction to severe burns. The person may become childlike in interactions with staff. Behaviors such as
whining, clinging to staff, and attempting to keep the nurse at the bedside constantly are not uncommon. A personal identity
disturbance, as a type of altered self-concept, is defined as an inability of a person to differentiate the self as a unique and separate
human being from others within a social environment.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 80
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
15. A patient is admitted with the diagnosis of gunshot wound to the head due to a suicide attempt. While the patient is in the critical
care unit, the plan of care should include which intervention?
a. Limiting interaction with the patient due to antisocial behaviors exhibited by the
suicidal attempt
b. Overlooking the patient’s need to talk about the incident
c. Validating the patient’s worth and self-esteem
d. Discontinuing any psychotropic medications
ANS: C
While the patient is in the unit, primary nursing interventions include validating the patient’s worth and self-esteem and helping
him or her regulate emotional states and behaviors. Patients who have attempted suicide are often stigmatized, and caregivers can
resent caring for a person whose critical condition is self-inflicted. A suicide attempt indicates, however, that the patient was
experiencing personal and spiritual distress to the point of wanting to end his or her life. The critical care team should make every
effort to continue medications for mental health conditions during the critical care stay unless medically contraindicated. If the
patient is unable to take oral medications, the team should attempt to find an alternative route if possible.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 84
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
16. What happens when the critical illness is so severe that the patient or family becomes overwhelmed?
a. Anxiety
b. Spiritual distress
c. Stress overload
d. Hopelessness
ANS: C
Stress overload does not occur because the patient or family members have coping deficits or psychologic disorders. Rather, the
stressors of critical illness are so numerous and severe that people become overwhelmed. Anxiety, hopelessness, and spiritual
distress are examples of stress-related nursing diagnoses that occur because of an inability of coping mechanisms or strategies.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 75
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
17. Which medications are commonly used for alcohol withdrawal symptoms?
a. Chlordiazepoxide and folic acid
b. Chlordiazepoxide and lorazepam
c. Lorazepam and promethazine
d. Promethazine and thiamine
ANS: B
Commonly used medications include chlordiazepoxide and lorazepam for withdrawal symptoms and ondansetron and promethazine
for nausea. Thiamine, folic acid, and multivitamins should be added to intravenous fluids.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 84
OBJ: Nursing Process Step: Intervention TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
18. Prolonged periods of anxious waiting, disrupted sleep patterns, witnessing emergency interventions, and financial concerns could
put family members at risk for developing what problem?
a. Powerlessness
b. Hopelessness
c. Anxiety
d. Posttraumatic stress disorder
ANS: D
Family members are at risk for developing posttraumatic stress reactions related to prolonged periods of uncertainty, anxious
waiting, disrupted sleep patterns, financial concerns, witnessing emergency interventions, and confronting fears of loss and death.
Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range from a vague,
generalized feeling of discomfort to a state of panic and loss of control. Conditions that increase a person’s risk for feeling hopeless
include a loss of dignity, long-term stress, loss of self-esteem, spiritual distress, and isolation, all of which can be present in a
critical care experience. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are
at risk for feeling powerless.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 76
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
19. Anxiety can cause emotional changes in which part of the brain?
a. Hypothalamus
b. Limbic system
c. Cerebral cortex
d. Pituitary gland
ANS: B
The neurotransmitters’ complex and elusive integration of these responses within the central nervous system relies on
communication among the cerebral cortex, limbic system, thalamus, hypothalamus, pituitary gland, and the reticular activating
system. Whereas the cortex is involved with cognition, attention, and alertness, emotional responses to stress are located in the
limbic system.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 77
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
20. A patient is admitted complaining of pain from a femur fracture and is anxious and agitated. The patient is receiving steroids and
theophylline for exacerbation of asthma. What disorder should the nurse suspect the patient may be experiencing?
a. Anxiety
b. Low self-esteem
c. Regression
d. Suicidal ideations
ANS: A
Pain triggers anxiety, and increased anxiety intensifies pain experiences. This reciprocal relationship varies, depending on whether
pain is produced by disease processes or invasive procedures, is acute or chronic in nature, or if the pain is anticipated. Medications
such as theophylline, anticholinergics, dopamine, levodopa, salicylates, and steroids can also contribute to feelings of anxiety.
Self-esteem refers to how well one’s behavior correlates with a sense of the ideal self and is most closely linked to one’s sense of
self-worth. Regression is an unconscious defense mechanism characterized by a retreat, in the face of stress, to behaviors
characteristic of an earlier developmental level.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 77
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
21. A patient tells his family, “I don’t know why I was placed on this earth just to suffer from cancer all my life. I just want to die.”
What psychosocial issue is the patient experiencing?
a. Lost control
b. Spiritual distress
c. Anxiety
d. Powerlessness
ANS: B
Some individuals with spiritual distress may question their existence, verbalize their wish to die, or display anger toward religious
traditions. Patients who have a pervasive sense that they can do nothing to change or control their circumstances are at risk for
feeling powerless. Anxiety is a normal and common subjective human response to a perceived or actual threat, which can range
from a vague, generalized feeling of discomfort to a state of panic and loss of control.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 79
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
22. Through what mechanism can a nurse demonstrate caring and support to a patient?
a. Demonstrating superior clinical skills
b. Ensuring continuity of care
c. Providing empathy and physical contact
d. Organizing and prioritizing care
ANS: C
Many patients interpret a nurse’s expressions of empathy and physical contact as evidence of caring and support. Caring,
compassionate verbal and nonverbal communication patterns give substance to nursing activities that promote expert psychosocial
and spiritual care interventions. None of the top challenges have to do with technical issues of medical management. Instead, the
top challenges include inadequate patterns of communication between the critical care team and family members, insufficient staff
knowledge of effective communication, unrealistic family and provider expectations, family disagreements, lack of advance
directives, voiceless patients, and suboptimal space for having meaningful conversations.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 81
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
23. What serious concern regarding the critical care environment affects the patient’s ability to cope and heal?
a. Lack of consistent visiting policies
b. Misuse of complementary therapies
c. Deprivation of sleep
d. Mishandling of integrative therapies
ANS: C
Alterations in the physical environment of critical care units can provide a sense of calm, enhance patient coping, and facilitate
healing. Sleep deprivation is a serious concern in critical care environments. To prevent light exposures that awaken patients,
nurses should group care activities to limit nighttime interruptions and collaborate with lab personnel to decrease sleep
interruptions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 83
OBJ: Nursing Process Step: Diagnosis
TOP: Psychosocial
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. What outcomes do psychosocial and spiritual interventions have the power to employ in a patient? (Select all that apply, one, some,
or all.)
a. Hope
b. Fear
c. Will to survive
d. Energy
e. Ability to meet life’s challenges.
ANS: A, C, D, E
Psychologic and spiritual interventions have the power to engage a patient’s hope, energy, will to survive, and ability to meet life’s
challenges. Fear is a coping deficit.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 75
OBJ: Nursing Process Step: Assessment TOP: Psychosocial Alterations
MSC: NCLEX: Psychosocial Integrity
2. What actions can a critical care nurse take to decrease stressors at work? (Select all that apply, one, some, or all.)
a. Request temporary assignments in a less stressful setting
b. Use self-reflection when feeling overwhelmed
c. Maintain good physical health
d. Ignore feelings of frustration and anger
e. Use stress management techniques
ANS: A, B, C, E
Stress management techniques help to restore energy and enjoyment in caring for patients. In some instances, nurses choose to
work temporarily in less emotionally stressful settings. Nurses can maintain their physical health by eating well, exercising,
engaging in relaxing activities, laughing, and getting enough sleep. Nurses should first use self-reflection when they feel
overwhelmed, considering the possible reasons for their feelings.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 84 | p. 85
OBJ: Nursing Process Step: Intervention TOP: Psychosocial Alterations
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 07: Nutrition Alterations and Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient with poorly controlled diabetes mellitus is to be started on enteral tube feeding. What type of formula would be most
appropriate?
a. Whole proteins and glucose polymers
b. Concentrated in calories
c. Low sodium
d. High fat, low carbohydrate
ANS: D
Individuals with diabetes mellitus whose blood sugar is poorly controlled with standard formulas should be given a glucose
intolerance formula that is high in fat and low in carbohydrate. High protein is associated with polymeric formulas. Concentrated
calories is associated with renal failure. Low sodium is associated with hepatic failure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 96 | Table 7-4
2. Most of the energy produced from carbohydrate metabolism is used to form what substance?
a. Galactose
b. Glycogen
c. Adenosine triphosphate
d. Antibodies
ANS: C
Most of the energy produced from carbohydrate metabolism is used to form adenosine triphosphate (ATP), the principal form of
immediately available energy within all body cells. One gram of carbohydrate provides approximately 4 kcal of energy. Through
the process of digestion, carbohydrates are broken down into glucose, fructose, and galactose. Antibodies are produced through the
immune system.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 88
3. A patient has a new order for intermittent nasogastric feedings every 4 hours. The nasogastric tube is placed by the nurse. What is
the most accurate method for confirming the placement of the tube before initiating the feeding?
a. Obtain radiography of the abdomen.
b. Check the pH of fluid aspirated from the tube.
c. Auscultate the left upper quadrant of the abdomen while injecting air into the
tube.
d. Auscultate the right upper quadrant of the abdomen while injecting air into the
tube.
ANS: A
After the tube has been placed, correct location must be confirmed before feedings are started and regularly throughout the course
of enteral feedings. Radiographs are the most accurate way of assessing tube placement.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 98 | Table 7-5
4. How would a person with a BMI of 28 be classified?
a. Obese
b. Overweight or preobese
c. Normal weight
d. Underweight
ANS: B
A body mass index between 25 and 30 is considered overweight or preobese. The other BMIs are underweight = <18.5 kg/m 2;
normal = 18.5 to 24.99 kg/m2; overweight = ≥25 kg/m2; preobese = 25 to 29.99 kg/m2; obese class I = 30 to 34.99 kg/m2; obese
class II = 35 to 39.99 kg/m2; and obese class III = ≥40 kg/m2.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 91 | Table 7-1
1
5. What type of diet would be appropriate for a patient with hypertension after a myocardial infarction?
a. Three meals a day with two snacks
b. Low-protein diet
c. Low-salt, low-cholesterol diet
d. High-carbohydrate diet
ANS: C
Because fluid accompanies sodium, limitation of sodium is necessary to reduce fluid retention. Specific interventions include
limiting salt intake, usually to 2 g a day or less, and limiting fluid intake because appropriate meal size, caffeine intake, and food
temperatures are some of the dietary factors that are of concern. Small, frequent snacks are preferable to larger meals for patients
with severe myocardial compromise or postprandial angina.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 103
TOP: Nutrition
6. Two types of protein-caloric malnutrition are kwashiorkor and marasmus. What physiologic changes are associated with
Kwashiorkor?
a. Weight loss and muscle wasting
b. Low levels of serum proteins, low lymphocyte count, and hair loss
c. Elevated serum albumin and increased creatinine excretion in the urine
d. Hyperpigmentation and a hard, easily palpated liver margin
ANS: B
Kwashiorkor results in low levels of serum proteins, low lymphocyte count, low immunity and edema from low plasma oncotic
pressure, and hair loss. Marasmus is recognizable by weight loss, loss of subcutaneous fat, and muscle wasting.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 93
7. Biochemical and clinical data play an important role in assessing a patient’s nutritional status. What laboratory and clinical findings
may be present in the patient with cardiovascular disease?
a. Low levels of high-density lipoprotein (HDL) cholesterol and transferrin
b. Elevated low-density lipoprotein (LDL) cholesterol and decreased subcutaneous
fat
c. Elevated sodium levels and a soft, fatty liver on palpation
d. Normal triglyceride levels and the presence of S3 on auscultation
ANS: B
Laboratory and clinical findings in patients with cardiovascular disease include elevated total cholesterol and triglyce rides as well
as cardiac cachexia (muscle and subcutaneous fat wasting).
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 102 | Box 7-4
8. Proteins are energy-yielding nutrients that provide important structural and functional duties within the body. What is one
important physiologic function of proteins?
a. Maintaining osmotic pressure
b. Providing minerals in the body
c. Maintaining blood glucose
d. Providing a stored source of energy
ANS: A
Proteins are the basis for lean body mass and are important for chemical reactions, transportation of other substances, preservation
of immune function, and maintenance of osmotic pressure (albumin) and blood neutrality (buffers) in the body. Carbohydrates help
with maintaining osmotic pressure, gluconeogenesis, and providing minerals to the body. Lipids provide a source of energy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 88
9. The loss of exocrine function of pancreatitis results in what disorder?
a. Anorexia
b. Obesity
c. Malabsorption
d. Hyperglycemia
ANS: C
The loss of exocrine function leads to malabsorption and steatorrhea. In chronic pancreatitis, the loss of endocrine function results
in impaired glucose intolerance. Anorexia is the result of an inability to eat or not eating. Obesity would result from consuming
more than the recommended daily allowance of calories based on one’s body type.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 108
2
10. Which statement regarding obtaining height and weight measurements for the critically ill patient is accurate?
a. All measurements should be deferred until the patient’s medical condition
b.
c.
d.
stabilizes.
Measurements should be actually measured rather than obtained through patient
or family report.
Measurements for weight are documented in pounds and height in inches.
Measurement of weight is mandatory, but measurement of height can be deferred.
ANS: B
Height and current weight are essential anthropometric measurements that should be measured rather than obtained through patient
or family report. The most important reason for obtaining anthropometric measurements is to detect changes in the measurements
over time (e.g., response to nutritional therapy). Weight is measured in kilograms and height in meters. Body mass index (BMI)
values are independent of age and gender and are used for assessing health risk.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 90
11. A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which statement is true?
a. Excessive calorie intake can cause an increase in PaCO 2.
b. The patient’s head should remain elevated at 45 degrees to avoid aspiration.
c. Lipid intake should be maintained at greater than 2 g/kg/day.
d. TPN is preferred over the use of enteral feeding to avoid the complication of
aspiration.
ANS: A
Excessive calorie intake can raise PaCO2 sufficiently to make it difficult to wean a patient from the ventilator. A balanced regimen
with both lipids and carbohydrates providing the nonprotein calories is optimal for patients with respiratory compromise, and these
patients need to be reassessed continually to ensure that caloric intake is not excessive.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 104 | Box 7-5
12. What intervention should be included in a nutrition plan for a patient with hypertension?
a. Decreasing carbohydrates
b. Limiting salt
c. Increasing protein
d. Increasing fluids
ANS: B
For hypertensive cardiac disease, sodium chloride restriction is recommended. Some individuals are more salt sensitive than others,
and this salt sensitivity contributes to hypertension.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 103
TOP: Nutrition
13. Patients with coronary artery disease should be taught about cholesterol. Which situation is most desirable?
a. Low levels of high-density lipoprotein (HDL) cholesterol
b. Low levels of low-density lipoprotein (LDL) cholesterol
c. Hypocholesterolemia
d. Low levels of both HDL and LDL cholesterol
ANS: B
Interventions for patients with coronary artery disease are geared toward lowering the low-density lipoprotein (LDL) cholesterol to
desirable levels.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 103
14. What is one effect of malnutrition on respiratory system function?
a. Decreased surfactant production
b. Increased vital capacity
c. Decreased carbon dioxide production
d. Increased respiratory rate
ANS: A
Malnutrition has extremely adverse effects on respiratory function, decreasing both surfactant production and vital capacity.
Excessive lipid intake can impair capillary gas exchange in the lungs, although this is not usually sufficient to produce an increase
in PaCO2 or decrease in PaO2; this results in decreased respiratory function.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 110
3
15. What is the rationale for careful intake and output for patients with pulmonary alterations?
a. Fluid retention occurs with tachypnea.
b. Hemodilution may cause deleterious hypernatremia.
c. Fluid volume excess can lead to right-sided heart failure.
d. Excessive fluid losses may lead to dehydration and hypovolemic shock.
ANS: C
Pulmonary edema and failure of the right side of the heart may result from fluid volume excess, which can further worsen the status
of patients with respiratory compromise.
PTS: 1
DIF: Cognitive Level: Creating
OBJ: Nursing Process Step: Evaluation
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 104
16. A patient who has sustained a head injury has increased nutritional needs related to what physiologic mechanism?
a. Decreased metabolism as a result of coma
b. Decreased blood sugar from a lack of dietary supplementation
c. Anabolism and wound healing
d. Hypermetabolism and catabolism associated with the injury
ANS: D
Patients with neurologic alterations have increased needs because of hypermetabolism and catabolism after head injury. Poor food
intake is related to altered state of consciousness, dysphagia or other chewing or swallowing difficulties, or ileus resulting from
spinal cord injury or use of pentobarbital.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 105 | Box 7-6
17. The patient is receiving corticosteroid treatment for neurologic alterations. The patient should be routinely monitored for what
common complication of this type of therapy?
a. Hyponatremia
b. Hyperalbuminemia
c. Hyperkalemia
d. Hyperglycemia
ANS: D
Hyperglycemia is a common complication in patients receiving corticosteroids. Needs for protein and calories are increased by
infection and fever, as may occur in the patient with encephalitis or meningitis. Needs for protein, calories, zinc, and vitamin C are
increased during wound healing, as occurs in trauma patients and patients with pressure ulcers.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 105 | Box 7-6
18. Which nutritional interventions is a priority for the patient with renal disease who is receiving dialysis?
a. Increase fluids to replace losses.
b. Encourage potassium-rich foods to replace losses.
c. Ensure an adequate amount of protein to prevent catabolism.
d. Limit all nutrients to account for altered renal excretion.
ANS: C
Proteins and amino acids are removed during peritoneal dialysis, creating a greater nutritional requirement for protein. The renal
patient must receive an adequate amount of protein to prevent catabolism of body tissues to meet energy needs. Approximately 1.5
to 2.0 g protein/kg/day is required. Certain nutrients such as potassium and phosphorus are restricted because they are excreted by
the kidney. The patient has no specific requirement for the fat-soluble vitamins A, E, and K because they are not removed in
appreciable amounts by dialysis, and restriction generally prevents development of toxicity.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 106
TOP: Nutrition
19. The nursing management plan for a patient at risk for aspiration should include which intervention?
a. Administer intermittent feedings.
b. Add thickening agents to the tube feeding solution.
c. Suction the patient hourly.
d. Elevate the head of the bed 30 to 45 degrees.
ANS: D
To reduce the risk of pulmonary aspiration during enteral tube feeding, keep the patient’s head elevated at least 30 to 45 degrees
during feedings unless contraindicated.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 104 | Table 7-5
TOP: Nutrition
4
20. A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral
nutrition (TPN) is started. For which complication should the patient be evaluated immediately after insertion of the catheter?
a. Pneumothorax
b. Hypoglycemia
c. Central venous thrombosis
d. Pulmonary aspiration
ANS: A
Central vein total parenteral nutrition (TPN) carries an increased risk of sepsis as well as potential insertion-related complications
such as pneumothorax and hemothorax. Repeated traumatic catheterizations are most likely to result in thrombosis. To prevent
hypoglycemia, administer oral carbohydrates or an IV bolus of dextrose. Elevate the head of the bed 30 to 45 degrees to prevent
pulmonary aspiration after the infusion has begun.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 105 | Table 7-6
21. A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral
nutrition (TPN) is started. On the third day of infusion, the patient develops symptoms of fever and chills. What complication
should the nurse suspect?
a. Air embolism
b. Pneumothorax
c. Central venous thrombosis
d. Catheter-related sepsis
ANS: D
Because total parenteral nutrition (TPN) requires an indwelling catheter in a central vein, it carries an increased risk for sepsis and
potential insertion-related complications such as pneumothorax and hemothorax. Signs and symptoms of catheter-related sepsis
include fever, chills, glucose intolerance, and positive blood cultures. Air embolism is also more likely with central vein TPN.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
TOP: Nutrition
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 101 | Table 7-6
22. A patient is admitted with acute liver failure and encephalopathy. Which dietary restrictions should be maintained for the patient?
a. Fat and magnesium
b. Protein and sodium
c. Carbohydrate and potassium
d. Protein and calcium
ANS: B
Protein should be restricted because it contributes to the development of encephalopathy; sodium should be restricted because it
contributes to the development of edema. Release of lipids from their storage depots is accelerated, but the liver has decreased
ability to metabolize them for energy. Moreover, inadequate production of bile salts by the liver results in malabsorption of fat
from the diet.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 108
TOP: Nutrition
23. A patient is admitted with severe malnutrition. A central venous catheter is placed in the right subclavian vein and total parenteral
nutrition (TPN) is started. What medical interventions may be initiated with the onset of hyperglycemia?
a. Discontinuing the infusion
b. Adding insulin to the TPN
c. Weaning from the TPN over a 6-hour period
d. Starting an infusion of 0.9% normal saline
ANS: B
One method for controlling hyperglycemia in a patient receiving total parenteral nutrition (TPN) is to add insulin to the infusion.
Rapid cessation of TPN may not lead to hypoglycemia; however, tapering the infusion over 2 to 4 hours is recommended. Slow
advancement of the rate of TPN (25 mL/h) to the goal rate allows pancreatic adjustment to the dextrose load.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 105 | Table 7-6
TOP: Nutrition
5
24. A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube. To help ensure feeding tolerance, the
nurse checks residual volumes every 4 hours. During a residual check later in the shift, the nurse aspirates a total residual volume
of 350 mL. What action should the nurse take next?
a. Stop the tube feeding, wait 1 hour, and recheck the residual
b. Discontinue tube feeding and call the practitioner for parenteral nutrition orders
c. Continue the tube feeding if no other gastrointestinal symptoms exist and reassess
the patient with the next residual check
d. Continue the tube feeding and place the patient in the left lateral decubitus
position to facilitate gastric emptying
ANS: C
There is little evidence to support a correlation between gastric residual volumes and tolerance to feedings, gastric emptying, and
potential aspiration. Except in selected high-risk patients, there is little evidence to support holding tube feedings i n patients with
gastric residual volumes less than 400 mL.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 96 | p. 97
TOP: Nutrition
25. A tracheostomy patient is experiencing regurgitation of tube feeding formula. What should be the nurse’s first priority?
a. Checking to make sure the tracheostomy cuff is inflated during tube feedings
b. Placing the patient in the right lateral decubitus position to promote gastric
c.
d.
emptying
Discussing the use of metoclopramide to facilitate gastric motility with the
practitioner
Placing the patient in prone position to improve draining from mouth
ANS: A
When regurgitation of formula is an issue, the following interventions can be used as appropriate: keep the cuff of the endotracheal
or tracheostomy tube inflated during feedings to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless
contraindicated; if head cannot be raised, position the patient in the right lateral position or prone position to improve drainage of
vomitus from the mouth; and consider giving metoclopramide to improve gastric emptying.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
REF: p. 99
TOP: Nutrition
26. A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube. Which intervention should be included
the patient’s plan of care to prevent clogging of the feeding tube?
a. Flush the tube with gastric juice every 8 hours.
b. Obtain an order for a prokinetic agent to stimulate gastric emptying.
c. Irrigate the tube with water before and after administration of any medication.
d. Add crushed medications to the enteral feeding formula.
ANS: C
To prevent tube occlusion, irrigate tube with water before and after administering any medication and never add any medication to
the formula unless the two are known to be compatible. Gastric juice is never used to flush a tube as it can cause precipitation of
the formula. A prokinetic agent will help with gastric retention but not tube occlusion.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Safety and Infection Control
REF: p. 98 | Table 7-5
TOP: Nutrition
27. What nutritional alteration is most frequently encountered in hospitalized patients?
a. Respiratory quotient (RQ)
b. Protein-calorie malnutrition
c. Fat-calorie malnutrition
d. Gluconeogenesis
ANS: B
The nutritional alteration most frequently encountered in the hospitalized patient is protein-calorie malnutrition. The respiratory
quotient (RQ) is equal to the VCO2 divided by the VO2. Fat, protein, and carbohydrates each have a unique RQ; thus, RQ identifies
which substrate is being preferentially metabolized and may provide target goals for calorie replacement. This process of
manufacturing glucose from nonglucose precursors is called gluconeogenesis. Gluconeogenesis is carried out at all times, but it
becomes especially important in maintaining a source of glucose in times of increased physiologic need and limited supply. Fat is
used as a source of energy.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 88
OBJ: Nursing Process Step: Diagnosis
TOP: Nutritional Alterations and Management
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
28. A patient with heart failure is placed on a sodium and fluid restriction. What is the purpose of this order?
a. To enhance the metabolize of medications
b. To normalize the patient’s weight
c. To reduce cardiac workload
d. To decrease serum lipids
ANS: C
Myocardial infarction, nutrition interventions, and education are designed to reduce angina, cardiac workload, and the risk of
dysrhythmia. Sodium restriction applies in the treatment of patients with heart failure because water follows sodium. Fluids should
be restricted to 1500 to 2000 mL/day. Weight is an anthropometric measurement and is a long-term goal. Serum lipid is a
biochemical data and is a long-term goal. Medications are used to control fluid levels in the body and prevention of angina and
dysrhythmia.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
Nursing Process Step: Implementation
Nutritional Alterations and Management
NCLEX: Physiologic Integrity
REF: p. 102 | p. 103 | Box 7-4
MULTIPLE RESPONSE
1. Which signs would alert the nurse to possible nutritional alterations? (Select all that apply, one, some, or all.)
a. Impaired wound healing
b. Edema
c. Nail growth
d. Muscle atrophy
e. Diaphoresis
ANS: A, B, D
Impaired wound healing, edema, and muscle wasting atrophy are indicative of impaired nutrition. Nail growth would indicate
normal caloric intake. Diaphoresis refers to sweating and is indicated with exercising and infection.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 92 | Box 7-2
OBJ: Nursing Process Step: Assessment TOP: Nutritional Alterations and Management
MSC: NCLEX: Physiologic Integrity
2. A patient is admitted with end-stage renal disease (ESRD) and is on hemodialysis. Which nutritional elements should be restricted?
(Select all that apply, one, some, or all.)
a. Fluid
b. Protein
c. Carbohydrates
d. Fats
e. Phosphorus
ANS: A, B, E
The kidneys are responsible for the balance of fluids, protein, and other nutrients. When the kidneys are functioning suboptimally,
dietary intake of those substances must be restricted.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
Nursing Process Step: Implementation
Nutritional Alterations and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 106
7
Chapter 08: Pain and Pain Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which statement best describes the concept of pain?
a. Pain is an uncomfortable experience present only in the patient with an intact
b.
c.
d.
nervous system.
Pain is an unpleasant experience accompanied by crying and tachycardia.
Pain is activation of the sympathetic nervous system from an injury.
Pain is whatever the patient experiencing it says it is, occurring when that patient
says it does.
ANS: D
Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described
in terms of such damage. This definition emphasizes the subjective and multidimensional nature of pain. More specifically, the
subjective characteristic implies that pain is whatever the person experiencing it says it is and that it exists wheneve r he or she says
it does.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 114
2. What are the neural processes of encoding and processing noxious stimuli associated with pain called?
a. Perception
b. Nociception
c. Transduction
d. Transmission
ANS: B
Nociception represents the neural processes of encoding and processing noxious stimuli necessary, but not sufficient, for pain.
Transduction refers to mechanical (e.g., surgical incision), thermal (e.g., burn), or chemical (e.g., toxic substance) stimuli that
damage tissues. As a result of transduction, an action potential is produced and is transmitted by nociceptive nerve fibers in the
spinal cord that reach higher centers of the brain. This is called transmission, and it represents the second process of nociception.
Pain sensation transmitted by the nervous system (NS) pathway reaches the thalamus, and the pain sensation transmitted by the
parasympathetic nervous system (PS) pathway reaches brainstem, hypothalamus, and thalamus. These parts of the central nervous
system (CNS) contribute to the initial perception of pain.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 115
3. C fibers are small-diameter, unmyelinated fibers that transmit what type of pain?
a. Aching
b. Sharp
c. Prickling
d. Concentrated
ANS: A
C fibers are implicated in the transmission of pain described as dull, diffuse, prolonged, and delayed. Alpha fibers conduct the rapid
acute pain sensation described as prickling, sharp, and fast. These fibers are activated by mechanical and thermal stimuli and are
carried by the neospinothalamic tract.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 115
4. Which assessment findings might indicate respiratory depression after opioid administration?
a. Flushed, diaphoretic skin
b. Shallow respirations with a rate of 24 breaths/min
c. Tense, rigid posture
d. Snoring
ANS: D
Snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to
hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care
nurse to observe closely.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 128 | Table 8-9
1
5. The patient is admitted to the critical care unit with hemodynamic instability and an allergy to morphine. The nurse anticipates that
the practitioner will order which medication for severe pain?
a. Hydromorphone
b. Codeine
c. Fentanyl
d. Methadone
ANS: C
Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic instability or morphine allergy.
Hydromorphone is a semisynthetic opioid that has an onset of action and a duration similar to those of morphine. It is more potent
than morphine. Hydromorphone produces an inactive metabolite (i.e., hydromorphone-3-glucuronide), making it the opioid of
choice for use in patients with end-stage renal disease. Codeine has limited use in the management of severe pain. It is rarely used
in critical care units. It provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid. Methadone is a
synthetic opioid with morphine-like properties but less sedation. It is longer acting than morphine and has a long half-life. This
makes it difficult to titrate in the critical care patient.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 128
6. Which combinations of drugs have been found to be effective in managing the pain associated with musculoskeletal and soft tissue
inflammation?
a. Nonsteroidal antiinflammatory drugs (NSAIDs) and opioids
b. NSAIDs and antidepressants
c. Opioid agonists and opioid antagonists
d. Adjuvants and partial agonists
ANS: A
The use of nonsteroidal antiinflammatory drugs (NSAIDs) in combination with opioids is indicated in patients with acute
musculoskeletal and soft tissue inflammation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 129
7. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to respiratory
depression, the patient should be monitored for which complications?
a. Urinary retention, undue somnolence, itching, nausea, and vomiting
b. Urinary incontinence, photophobia, headache, and skin rash
c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus
d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain
ANS: A
Epidural analgesia is commonly used in critical care units after major abdominal surgery, nephrectomy, thoracotomy, and major
orthopedic procedures. Monitor for adverse reactions, including respiratory depression, urinary retention, undue somnolence,
itching, seizures, nausea, and vomiting.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 127 | Box 8-4
8. A patient underwent a thoracotomy 12 hours ago and has continuous epidural analgesia with morphine. In addition to closely
monitoring the patient for side effects and complications, which intervention might enhance the patient’s pain control?
a. Maintain her flat in bed during the infusion.
b. Position her on her right side to encourage flow of the medication across the dura.
c. Limit visitors and remove any distractions such as television and music.
d. Consider administration of adjunct medication such as a nonsteroidal
antiinflammatory agent.
ANS: D
Positioning will not affect medication administration, distractions such as visitors and soothing music can often enhance the effects
of pharmacologic pain control, adjuvant medications can help decrease anxiety, and nonopioid analgesics can provide greater pain
relief at the peripheral and central levels. Instruct and guide patient through nonpharmacologic measures (e.g., relaxation therapy,
guided imagery, and biofeedback) to enhance pharmacologic effectiveness. The epidural space is filled with fatty tissue and is
external to the dura mater. The fatty tissue interferes with uptake, and the dura acts as a barrier to diffusion, making diffusion rate
difficult to predict.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 129 | Box 8-4
2
9. Which statement accurately describes the duration of acute pain?
a. Acute pain is associated with the injury to the joints and lasts about 9 months.
b. Acute pain is associated with the healing process and should not exceed 6 months.
c. Acute pain is persistent pain of more than 6 months after the healing process.
d. Acute pain is associated with damage to the nervous system and is of infinite
duration.
ANS: B
Acute pain has a short duration, and it usually corresponds to the healing process (30 days) but should not exceed 6 months. It
implies tissue damage that is usually from an identifiable cause. If undertreated, acute pain may bring a prolonged stress response
and lead to permanent damage to the patient’s nervous system. In such instances, acute pain can become chronic.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 114
10. A patient complains of pain at his incision site. The nurse is aware that four processes are involved in nociception. In what order do
the processes occur?
a. Transmission, perception, modulation, and transduction
b. Perception, modulation, transduction, and transmission
c. Modulation, transduction, transmission, and perception
d. Transduction, transmission, perception, and modulation
ANS: D
Four processes are involved in nociception: transduction, transmission, perception, and modulation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 115 | Figure 8-2
11. Why use a specific pain intensity scale in the critical care unit?
a. It eliminates the subjective component from the assessment.
b. It focuses on the objective component of the assessment.
c. It provides consistency of assessment and management.
d. It provides a way to interpret physiologic indicators.
ANS: C
Many critical care units use a specific pain intensity scale because a single tool provides consistency of assessment, management,
and documentation. A pain intensity scale is useful in the critical care environment. Asking the patient to grade his or her pain on a
scale of 0 to 10 is a consistent method and aids the nurse in objectifying the subjective nature of the patient’s pain. However, the
patient’s tool preference should be considered.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 120 | Figure 8-5
12. The patient is sedated and breathing with the use of mechanical ventilation. The patient is unable to communicate any aspects of his
pain to the nurse. What tool should the nurse use to assess the patient’s pain?
a. FLACC
b. Wong-Baker FACES
c. BIS
d. BPS
ANS: D
The BPS and the CPOT are supported by experts in critical care and are suggested for use in medical, postoperative, and nonbrain
trauma critically ill adults unable to self-report in the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC
is a pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to associate a level of pain to a facial
representation. BIS is as an objective measure of sedation levels during neuromuscular blockade in the critical care unit.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 121 | Table 8-1
13. Which patient is MOST likely to be experiencing a life-threatening opioid side effect?
a. Patient with respiratory rate of 10 breaths/min who is breathing deeply
b. Patient with a respiratory rate of 8 breaths/min who is snoring
c. Patient with blood pressure of 150/75 mm Hg and heart rate of 102 beats/min
d. Patient with a temperature of 100.5° F who is asleep but easily roused
ANS: B
Although no universal definition of respiratory depression exists, it is usually described in terms of decreased respiratory rate
(fewer than 8 or 10 breaths/min), decreased SpO2 levels, or elevated ETCO2 levels. A change in the patient’s level of consciousness
or snoring is a warning sign. It can be a sign of respiratory depression associated with airway obstruction by the tongue, leading to
hypoxemia and possibly to cardiorespiratory arrest. A patient snoring after the administration of an opioid requires the critical care
nurse to observe closely.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pain
MSC: NCLEX: Safe and Effective Care Environment
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 128
3
14. The nurse is caring for a patient with liver dysfunction. What is the maximum dose of acetaminophen the patient should receive in
24 hours?
a. 1 g
b. 2 g
c. 4 g
d. 500 mg
ANS: B
Special care must be taken for patients with liver dysfunction, malnutrition, or a history of excess alcohol consumption, and their
acetaminophen total dose should not exceed 2 g/day.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Pharmacological Therapies
REF: p. 129
15. The nurse is caring for a patient with a patient-controlled analgesia (PCA). The patient’s spouse asks about the advantages of using
this type of pain management therapy. What should the nurse say to the spouse?
a. “The method allows the patient to act preemptively by administering a bolus of
medication when pain begins.”
b. “This method allows the patient to choose between an opioid and a nonopioid
medication to control pain.”
c. “This method decreases the risk of respiratory depression and other side effects.”
d. “This method allows for the rise and fall of the blood level of the opioid.”
ANS: A
The patient can self-administer a bolus of medication the moment the pain begins, acting preemptively. Allowing the patient to
self-administer opioid doses does not diminish the role of the critical care nurse in pain management. The nurse advises about
necessary changes to the prescription and continues to monitor the effects of the medication and doses. The patient is closely
monitored during the first 2 hours of therapy and after every change in the prescription. If the patient’s pain does not respond
within the first 2 hours of therapy, a total reassessment of the pain state is essential. If the patient is pressing the button to bolus
medication more often than the prescription, the dose may be insufficient to maintain pain control. Naloxone must be readily
available to reverse adverse opiate respiratory effects.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 130
16. Relaxation, distraction, guided imagery, and music therapy are all examples of what type of pain management?
a. Physical/emotional techniques
b. Cognitive-behavioral techniques
c. Nonopioid analgesia techniques
d. Nonpharmacological techniques
ANS: B
Using the cortical interpretation of pain as the foundation, several interventions can reduce the patient’s pain report. These
modalities include cognitive techniques such as relaxation, distraction, guided imagery, and music therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 133
17. The patient has received ketamine for its analgesic effects. The patient suddenly states, “I feel like I am floating and can see
everything you are doing. I am not in control.” What is this response called?
a. Hallucination state
b. Guided imagery
c. Dissociative state
d. Adverse event
ANS: C
Before administering ketamine, the dissociative state should be explained to the patient. Dissociative state refers to the feelings of
separateness from the environment, loss of control, hallucinations, and vivid dreams. The use of benzodiazepines (e.g., midazolam)
can reduce the incidence of this unpleasant effect.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 130
4
MULTIPLE RESPONSE
1. A nurse is administering naloxone to a patient experiencing respiratory depression. Which of the following interventions must be
observed when using naloxone? (Select all that apply, one, some, or all.)
a. Naloxone is normally given rapidly via IV.
b. Naloxone is discontinued as soon as a patient is responsive to physical stimulation
and able to take deep breaths.
c. Naloxone has a shorter duration than most opioids, so the nurse may need to
repeat naloxone as early as 30 minutes after the first dose.
d. The patient’s pain control is easily established after receiving naloxone.
e. Naloxone is not recommended after prolonged analgesia because it can induce
withdrawal and may cause nausea and dysrhythmias.
ANS: B, C, D
Naloxone is normally given intravenously very slowly (0.5 mL over 2 minutes) while the patient is carefully monitored for reversal
of the respiratory signs. Naloxone administration can be discontinued as soon as the patient is responsive to physical stimulation
and able to take deep breaths. However, the medication should be kept nearby. Because the duration of naloxone is shorter than
most opioids, another dose of naloxone may be needed as early as 30 minutes after the first dose. The benefits of reversing
respiratory depression with naloxone must be carefully weighed against the risk of a sudden onset of pain and the difficulty
achieving pain relief. To prevent this from occurring, it is important to provide a nonopioid medication for pain relief. Moreover,
the use of naloxone is not recommended after prolonged analgesia because it can induce withdrawal and may cause nausea and
cardiovascular complications (e.g., dysrhythmias).
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
REF: p. 129
2. Which statements are true regarding pain assessment and management? (Select all that apply, one, some, or all.)
a. The single most important assessment tool available to the nurse is the patient’s
b.
c.
d.
e.
self-report.
The only way to assess pain in patients unable to verbalize because of mechanical
ventilation is through observation of behavioral indicators.
The concept of equianalgesia uses morphine as a basis for dosage comparison for
other medications.
Transcutaneous electrical nerve stimulation and application of heat or cold
therapy stimulate the nonpain sensory fibers.
Meperidine, a synthetic form of morphine, is much stronger and is given at lower
doses at less frequent intervals.
ANS: A, C, D
Appropriate pain assessment is the foundation of effective pain treatment. Because pain is recognized as a subjective experience,
the patient’s self-report is considered the most valid measure for pain and should be obtained as often as possible. Unfortunately, in
critical care, many factors, such as the administration of sedative agents, the use of mechanical ventilation, and altered levels of
consciousness, may impact communication with patients. These obstacles make pain assessment more complex. Meperidine
(Demerol) is a less potent opioid with agonist effects similar to those of morphine. It is considered the weakest of the opioids, and it
must be administered in large doses to be equivalent in action to morphine. Because the duration of action is short, dosing is
frequent. Equianalgesic means approximately the same pain relief. Dosages in the equianalgesic chart for moderate to severe pain
are not necessarily starting doses. The doses suggest a ratio for comparing the analgesia of one medication with another.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Pain
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 114 | p. 131 | p. 132
5
Chapter 09: Sedation, Agitation, and Delirium Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. To achieve ventilator synchrony in a mechanically ventilated patient with acute respiratory distress syndrome (ARDS), which level
of sedation might be most effective?
a. Light
b. Moderate
c. Conscious
d. Deep
ANS: D
Deep sedation is used when the patient must be unresponsive to deliver necessary care safely.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Remembering
REF: p. 138 | Box 9-1
Nursing Process Step: Planning
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
2. A patient has been taking benzodiazepines and suddenly develops respiratory depression and hypotension. After careful
assessment, the nurse determines that the patient is experiencing benzodiazepine overdose. What is the nurse’s next action?
a. Decrease benzodiazepines to half the prescribed dose.
b. Increase IV fluids to 500 cc/h for 2 hours.
c. Administer flumazenil (Romazicon).
d. Discontinue benzodiazepine and start propofol.
ANS: C
The major unwanted side effects associated with benzodiazepines are dose-related respiratory depression and hypotension. If
needed, flumazenil (Romazicon) is the antidote used to reverse benzodiazepine overdose in symptomatic patients.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Application
REF: p. 138 | Box 9-1
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
3. A patient is admitted unit with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically
ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently
triggered. What action should be the nurse take first?
a. Administer midazolam 5 mg by intravenous push immediately.
b. Assess the patient to see if a physiologic reason exists for his agitation.
c. Obtain an arterial blood gas level to ensure the patient is not hypoxemic.
d. Apply soft wrist restraints to keep him from pulling out the endotracheal tube.
ANS: B
The first step in determining the need for sedation is to assess the patient quickly for any physiologic causes that can be quickly
reversed. In this case, endotracheal suctioning may solve the high-pressure alarm problem.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
REF: p. 141
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
4. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically
ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently
triggered. The patient continues to be very agitated, and the nurse can find nothing physiologic to account for the high-pressure
alarm. What action should the nurse take next?
a. Administer midazolam 5 mg by intravenous push immediately.
b. Eliminate noise and other stimuli in the room and speak softly and reassuringly to
the patient.
c. Obtain an arterial blood gas to ensure the patient is not becoming more
hypoxemic.
d. Call the respiratory care practitioner to replace the malfunctioning ventilator.
ANS: B
Optimizing the environment, speaking calmly, explaining things to the patient, and providing distractions are all nonpharmacologic
means to decrease anxiety.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 144
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically
ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has been frequently
triggered. Despite the nurse’s actions, the patient continues to be agitated, triggering the high-pressure alarm on the ventilator.
Which medication would be appropriate to sedate the patient this time?
a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until the
patient is no longer triggering the alarm
b. Haloperidol 5 mg IVP stat
c. Propofol 5 mcg/kg/min by IV infusion
d. Fentanyl 25 mcg IVP over a 15-minute period
ANS: A
Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can be used for short- and intermediate-term
sedation. Haloperidol is indicated for dementia. Fentanyl is a narcotic and is not appropriate for use as a sedative.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 144
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
6. A patient is admitted with acute respiratory distress syndrome (ARDS). The patient has been intubated and is mechanically
ventilated. The patient had become very agitated and required some sedation. After the patient’s agitation is controlled, which
medications would be most appropriate for long-term sedation?
a. Morphine 2 mg/h continuous IV drip
b. Haloperidol 15 mcg/kg/min continuous IV infusion
c. Propofol 5 mcg/kg/min by IV infusion
d. Lorazepam 0.01 to 0.1 mg/kg/h by IV infusion
ANS: D
Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1 to 3 days) and should be coupled with a
short-acting opioid analgesic. Morphine is an opioid analgesic and is not sedation. Lorazepam infusion (0.01 to 0.1 mg/kg/h) is
recommended for long-term sedation.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 144 | Table 9-2
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
7. When administering propofol over an extended period, what laboratory value should the nurse routinely monitor?
a. Serum triglyceride level
b. Sodium and potassium levels
c. Platelet count
d. Acid–base balance
ANS: A
Prolonged use of propofol may cause an elevated triglyceride level because of its high lipid content.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 144 | Table 9-2
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
8. What is a major side effect of benzodiazepines?
a. Hypertension
b. Respiratory depression
c. Renal failure
d. Phlebitis
ANS: B
The major side effects of benzodiazepines include hypotension and respiratory depression. These side effects are dose related.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141 | Table 9-2
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
9. What is the major advantage of using propofol as opposed to another sedative for short-term sedation?
a. Fewer side effects
b. Slower to cross the blood–brain barrier
c. Shorter half-life and rapid elimination rate
d. Better amnesiac properties
ANS: C
Propofol is an effective short-term anesthetic agent, useful for rapid “wake-up” of patients for assessment; if continuous infusion is
used for many days, emergence from sedation can take hours or days; sedative effect depends on the dose administered, depth of
sedation, and length of time sedated.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Remembering
REF: p. 144 | Box 9-2
Nursing Process Step: Evaluation
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. Which medication is used for sedation in patients experiencing withdrawal syndrome?
a. Dexmedetomidine
b. Hydromorphone
c. Diazepam
d. Clonidine
ANS: D
Clonidine (often prescribed as a Catapres patch) is a central α-agonist and is recommended for sedation during withdrawal
syndrome.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Remembering
REF: p. 140
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
11. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused,
seeing nonexistent animals in the room and pulling at the bedding. The nurse suspects the patient may be experiencing what issue?
a. Delirium
b. Hypoxemia
c. Hypocalcemia
d. Sedation withdrawal
ANS: A
Delirium is represented by a global impairment of cognitive processes, usually of sudden onset, coupled with disorientation,
impaired short-term memory, altered sensory perceptions (hallucinations), abnormal thought processes, and inappropriate behavior.
There is no evidence provided that would indicate the patient is hypoxemic, hypocalcemic, or going through sedation withdrawal.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141
Nursing Process Step: Diagnosis
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
12. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused,
seeing nonexistent animals in the room and pulling at the bedding. What is the medication of choice for treating this patient?
a. Diazepam
b. Haloperidol
c. Lorazepam
d. Propofol
ANS: B
Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with an increased incidence of delirium.
Propofol is indicated for sedation use. Diazepam is not an appropriate choice for this patient.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141
Nursing Process Step: Planning
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
13. A patient was admitted 5 days ago and has just been weaned from mechanical ventilation. The patient suddenly becomes confused,
seeing nonexistent animals in the room and pulling at the bedding. What parameter should be monitored while the patient is
haloperidol?
a. Sedation level
b. QTc-interval
c. Oxygen saturation level
d. Brain waves
ANS: B
Electrocardiogram (ECG) monitoring is recommended because haloperidol use can produce dose-dependent QTc-interval
prolongation, with an increased incidence of ventricular dysrhythmias. BIS monitoring is indicated for deep sedation use.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141
Nursing Process Step: Implementation
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Pharmacological Therapies | NCLEX: Safety and Infection Control
14. What is the most common contributing factor to the development of delirium in critically ill patients?
a. Sensory overload
b. Hypoxemia
c. Electrolyte disturbances
d. Sleep deprivation
ANS: D
Delirium is frequently associated with critical illness. Provision of adequate sleep and early mobilization are recommended to
reduce the incidence of delirium.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141
Nursing Process Step: Diagnosis
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. Which medication has a greater advantage for treatment of alcohol withdrawal syndrome (AWS) because of its longer half-life and
high lipid solubility?
a. Lorazepam
b. Midazolam
c. Propofol
d. Diazepam
ANS: D
Management of alcohol withdrawal involves close monitoring of AWS-related agitation and administration of IV benzodiazepines,
generally diazepam (Valium) or lorazepam (Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility.
Lipid-soluble medications quickly cross the blood–brain barrier and enter the central nervous system to rapidly produce a sedative
effect. Midazolam is the recommended drug for use in alleviating acute agitation but is known to cause seizures with AWS because
of rapid withdrawal. Propofol is indicated for sedation use.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 144 | Table 9-2
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
16. What are the risk factors for delirium?
a. Hypertension, alcohol abuse, and benzodiazepine administration
b. Coma, hypoxemia, and trauma
c. Dementia, hypertension, and pneumonia
d. Coma, alcohol abuse, hyperglycemia
ANS: A
Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity of illness, coma, and benzodiazepine
administration.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 141 | p. 145 | Figure 9-1
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
17. What are the two scales that are recommended for assessment of agitation and sedation in adult critically ill patients?
a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS)
b. Ramsay Scale and Motor Activity Assessment Scale (MAAS)
c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation
d.
Scale (RASS)
Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment
Scale (MAAS)
ANS: C
The two scales that are recommended for assessment of agitation and sedation in adult critically ill patients are the SAS and the
RASS.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 137
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
18. Which intervention is an effective nursing strategy to decrease the incidence of delirium?
a. Restriction of visitors
b. Early nutritional support
c. Clustering of nursing care activities
d. Bedrest
ANS: C
As lack of sleep is a major contributor to the development of delirium, interventions to promote sleep should help decrease the
incidence of delirium. Some critical care units have initiated sleep protocols to increase the opportunity for patients to sleep at
night, dimming lights at night, ensuring there are periods of time when tubes are not manipulated, and clustering nursing care
interventions to provide some uninterrupted rest periods. Early ambulation is also appropriate.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 144
Nursing Process Step: Intervention
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
MULTIPLE RESPONSE
1. What are the causes of delirium in critically ill patients? (Select all that apply, one, some, or all.)
a. Hyperglycemia
b. Meningitis
c. Cardiomegaly
d. Pulmonary embolism
e. Alcohol withdrawal syndrome
f. Hyperthyroidism
ANS: B, E, F
The causes of delirium in critically ill patients include metabolic causes (acid–base disturbance, electrolyte imbalance,
hypoglycemia), intracranial causes (epidural or subdural hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral
abscess, tumor), endocrine causes (hyperthyroidism or hypothyroidism, Addison disease, hyperparathyroidism, Cushing
syndrome), organ failure (liver encephalopathy, kidney encephalopathy, septic shock), respiratory causes (hypoxemia,
hypercarbia), and medication-related causes (alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Understanding
REF: p. 144 | p. 145 | Box 9-2
Nursing Process Step: Assessment
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
2. Which complications can result from prolonged deep sedation? (Select all that apply, one, some, or all.)
a. Pressure ulcers
b. Thromboembolism
c. Diarrhea
d. Nosocomial pneumonia
e. Delayed weaning from mechanical ventilation
f. Hypertension
ANS: A, B, D, E
Oversedation can result in a multitude of complications. Prolonged deep sedation is associated with significant complications of
immobility, including pressure ulcers, thromboembolism, gastric ileus, nosocomial pneumonia, and delayed weaning from
mechanical ventilation.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 138
Nursing Process Step: Diagnosis
Sedation, Agitation, and Delirium: Assessment and Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
Chapter 10: End-of-Life Care
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which statement about comfort care is accurate?
a. Withholding and withdrawing life-sustaining treatment are distinctly different in
b.
c.
d.
the eyes of the legal community.
Each procedure should be evaluated for its effect on the patient’s comfort before
being implemented.
Only the patient can determine what constitutes comfort care for him or her.
Withdrawing life-sustaining treatments is considered euthanasia in most states.
ANS: B
The goal of comfort care is to provide only treatments that do not cause pain or other discomfort to the patient.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 149
OBJ: Nursing Process Step: N/A
TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
2. What is a powerful influence when the decision-making process is dealing with recovery or a peaceful death?
a. Hope
b. Religion
c. Culture
d. Ethics
ANS: A
Hope is a powerful influence on decision-making, and a shift from hope for recovery to hope for a peaceful death should be guided
by clinicians with exemplary communication skills. Ethics, religion, and culture can influence the decision process regarding care
and end-of-life decisions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 147
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
3. Which nursing intervention is best when patients can no longer make end-of life decisions for themselves?
a. Obtain a verbal do-not-resuscitate (DNR) order from the practitioner.
b. Continue caring for the patient as originally ordered because she obviously
c.
d.
wanted this.
Consult the hospital attorney for recommendations on how to proceed.
Discuss with the family what the patient’s wishes would be if she could make
those decisions herself.
ANS: D
If the patient is not able to make end-of-life decisions for herself, her family members should be approached to discuss the next
steps because they may have insight into what her wishes would be.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 149
OBJ: Nursing Process Step: Intervention TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
4. What are the two basic ethical principles underlying the provision of health care?
a. Beneficence and nonmaleficence
b. Veracity and beneficence
c. Fidelity and nonmaleficence
d. Veracity and fidelity
ANS: A
The two basic ethical principles underlying the provision of health care are beneficence and nonmaleficence.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 149
OBJ: Nursing Process Step: N/A
TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass
grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no
meaningful brain activity. The patient does not have an advance directive. Which statement would be the best way to approach the
family regarding his ongoing care?
a. “I will refer this case to the hospital ethics committee, and they will contact you
when they have a decision.”
b. “What do you want to do about the patient’s care at this point?”
c. “Dr. Smith believes that there is no hope at this point and recommends
do-not-resuscitate status.”
d. “What would the patient want if he knew he were in this situation?”
ANS: D
Approaching the family and asking what they know about the patient’s wishes and preferences is the best way to begin this
discussion. Emotional support for the patient and the family is important as they discuss advance care planning in the critical care
setting.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 151
OBJ: Nursing Process Step: Intervention TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
6. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass
grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no
meaningful brain activity. After a family conference, the practitioner orders a do-not-resuscitate (DNR) order, and palliative care is
begun. How does this affect the patient’s treatment?
a. The patient will continue to receive the same aggressive treatment short of
resuscitation if he has another cardiac arrest.
b. All treatment will be stopped, and the patient will be allowed to die.
c. All attempts will be made to keep the patient comfortable without prolonging his
life.
d. The patient will be immediately transferred to hospice.
ANS: C
When palliative care is begun, the primary goal is to keep the patient comfortable by continuing assessments and managing
symptoms that might cause pain, anxiety, or distress.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 150
OBJ: Nursing Process Step: Intervention TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
7. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass
grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no
meaningful brain activity. The patient is placed on a morphine drip to alleviate suspected operative pain and assist in sedation. The
patient continues to grimace and fight the ventilator. What nursing intervention would be best?
a. Increase the morphine dosage until no signs of pain or discomfort are present.
b. Increase the morphine drip, but if the patient’s respiratory rate drops below 10
breaths/min, return to the original dosage.
c. Gradually decrease the morphine and switch to Versed to avoid respiratory
depression.
d. Ask the family to leave the room because their presence is causing undue stress to
the patient.
ANS: A
Even though opiates can cause respiratory depression, the goal in palliative care is to alleviate pain and suffering. A bolus dose of
morphine (2 to 10 mg IV) and a continuous morphine infusion at 50% of the bolus dose per hour is recommended. Because many
critical care patients are not conscious, assessment of pain and other symptoms becomes more difficult. Gélinas and colleagues
recommended using signs of body movements, neuromuscular signs, facial expressions, or responses to physical examination for
pain assessment in patients with altered consciousness.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 153 | p. 155
OBJ: Nursing Process Step: Intervention TOP: End-of-Life Issues
MSC: NCLEX: Psychological Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
8. A patient was admitted several weeks ago with an acute myocardial infarction and subsequently underwent coronary artery bypass
grafting surgery. Since a cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram shows no
meaningful brain activity. The decision is made to remove the patient from the ventilator. Which of the following statements is
most accurate?
a. “The cardiac monitor should be left on so everyone will know when the patient
has died.”
b. “Opioids, sedatives, and neuromuscular blocking agents should be discontinued
just before removing the ventilator.”
c. “The family and health care team should decide the best method for removing the
ventilator terminal wean versus immediate extubation.”
d. “If terminal weaning is selected, the family should be sent to the waiting room
until the ventilator has actually been removed.”
ANS: C
The choice of terminal wean as opposed to extubation is based on considerations of access for suctioning, appearance of the patient
for the family, how long the patient will survive off the ventilator, and whether the patient has the ability to communicate with
loved ones at the bedside.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 155
OBJ: Nursing Process Step: Intervention TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
9. A patient was admitted to the critical care unit after having a cerebrovascular accident (CVA) and myocardial infarction (MI). The
patient has poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The patient has been resuscitated
four times in the past 6 hours. The patient does not have advance directives. Family members are at the bedside. Who should the
practitioner approach to discuss decisions of care and possible do-not-resuscitate (DNR) status?
a. Patient
b. Family
c. Hospital legal system
d. Hospital ethics committee
ANS: A
Patients’ capacity for decision-making is limited by illness severity; they are too sick or are hampered by the therapies or
medications used to treat them. When decision-making is required, the patient is the first person to be approached.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 151
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
10. Which statement regarding organ donation is accurate?
a. Organ donation is a choice only the patient can make for him- or herself.
b. Hospitals must have written protocols for the identification of potential organ
c.
d.
donors.
Organ donation must be requested by the nurse caring for the dying patient.
Individual institutional policies govern how organ donation requests are made.
ANS: B
The Social Security Act Section 1138 requires that hospitals have written protocols for the identification of potential organ donors.
The Joint Commission has a standard on organ donation. The nurse must notify the organ procurement official to approach the
family with a donation request.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 156
OBJ: Nursing Process Step: N/A
TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
11. Hospice care is an option that should be considered, especially in end-stage illness. Hospice care can help families with which
issue(s)?
a. Organ and tissue donations
b. Symptom management and family support
c. Procurement of advance directives and living wills
d. Legal and voluntary euthanasia
ANS: B
Health professionals can assist patients and families by providing information about the hospice benefit, particularly regarding the
aggressive symptom management and family support. Organ donations must follow Social Security Act Section 1138 regarding
written protocols for identification of potential organ donors and notification of organ recovery agencies. Advance directives can be
taken care of at the hospital or legal firm. Euthanasia generally is not offered through hospice.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 152
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
12. Disagreement and distress among practitioners, nurse practitioners, and critical care nurses can lead to what issue?
a. Moral indignation
b. Ethical resentment
c. Moral distress
d. Interprofessional anguish
ANS: C
Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses consider withdrawal before
practitioners and patients do, and they then believe the care they are giving is unnecessary and possibly harmful. This issue is a
serious one for critical care nurses because moral distress can lead to burnout.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 156
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
13. Haloperidol are traditionally been used to managed which symptom?
a. Anxiety
b. Dyspnea
c. Delirium
d. Pain
ANS: C
Delirium is commonly observed in critically ill patients and in those approaching death. Haloperidol and benzodiazepines (such as
midazolam and lorazepam) have traditionally been used to manage delirium but have side effects that can be problematic. More
recently, atypical antipsychotics have proven equally effective without troubling side effects of other drug classes. Dyspnea is best
managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen,
positioning, and increased ambient air flow). Benzodiazepines, especially midazolam with its rapid onset and short half-life, are
frequently used to treat anxiety. Morphine is the most common drug used for pain management.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 154
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
14. A patient tells the nurse to call his family and tell them they need to come so they can say their goodbyes. The patient is sure he
will not be here tomorrow because his grandparent is waiting for him. What is the patient exhibiting?
a. Anxiety
b. Delirium
c. Metabolic derangement
d. Near-death awareness
ANS: D
The same behaviors may be seen in conscious critical care patients near death. Having an awareness of the phenomenon enables
more careful assessment of behaviors that may be interpreted as delirium, acid–base imbalance, or other metabolic derangements.
These behaviors include communicating with someone who is not alive, preparing for travel, describing a place the patient can see,
or even knowing when death will occur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 154
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
15. Recommendations for creating a supportive atmosphere during end-of-life discussions include which intervention?
a. Telling the family when and where the procedure will occur
b. Beginning the conversation by inquiring about the emotional state of the family
c. Ending the conversation by inquiring about the emotional state of the family
d. Recommendations that the family not be present when the procedure occurs
ANS: B
Recommendations for creating a supportive atmosphere during withdrawal discussions include taking a moment at the beginning of
the conversation to inquire about the family’s emotional state. During the family meeting in which a decision to withdraw life
support is made, a time to initiate withdrawal is usually established.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 154
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
16. What is the most common complaint heard from families of dying patients?
a. Poor nursing care
b. Inadequate communication
c. Lack of consistent plan of care
d. Confusion among health care team members
ANS: B
Communication seems to be the most common source of complaints in families across studies and should be at the center of efforts
to improve end-of-life care. Families have commonly complained about infrequent physician communication, unmet
communication needs in the shift from aggressive to end-of-life care, and lacking or inadequate communication.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 151
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
MULTIPLE RESPONSE
1. Which considerations are made with the decision to allow family at the bedside during resuscitation efforts? (Select all that apply,
one, some, or all.)
a. The patient’s wishes
b. Experience of the staff
c. The family’s need to participate in all aspects of the patient’s care
d. State regulatory issues
e. Seeing the resuscitation may confirm the impact of decisions made or delayed
ANS: A, B, C, E
The decision to allow family members at the bedside during resuscitative efforts should be made by the family and caregivers and
be based on needs and experiences. The family may become more aware of what is involved in decisions if they are present during
procedures or resuscitative attempts. Seeing the steps of resuscitation may make clearer the impact of decisions made or delayed.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 157
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
2. One study found that greater family satisfaction with withdrawal of life support was associated with which possible measures?
(Select all that apply, one, some, or all.)
a. The patient appearing comfortable
b. A chance to voice concerns
c. Discussions were held in the patient’s room
d. The process was well explained
e. Adequate privacy during withdrawal of life support
ANS: A, B, D, E
After the patient’s death, greater family satisfaction with withdrawal of life support was associated with the following measures:
the process of withdrawal of life support being well explained; withdrawal of life support proceeding as expected; patient appearing
comfortable; family and friends being prepared; appropriate person initiating discussion; adequate privacy during withdrawal of life
support; and a chance to voice concerns.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 151
OBJ: Nursing Process Step: Assessment TOP: End-of-Life Issues
MSC: NCLEX: Psychosocial Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
Chapter 11: Cardiovascular Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which structure is the primary or natural pacemaker of the heart?
a. Ventricular tissue
b. Atrioventricular node
c. Sinoatrial node
d. Purkinje fibers
ANS: C
With an intrinsic rate of 60 to 100 beats/min, the sinoatrial node is the primary pacemaker in a healthy heart. The atrioventricular
node beats 40 to 60 beats/min. Ventricular tissue must have an electrical impulse to contract. Purkinje fibers beat 15 to 40
beats/min.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 164
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. The atrioventricular (AV) node delays the conduction impulse from the atria (0.8 to 1.2 seconds) for what reasons?
a. To limit the amount of blood that fills the ventricle from the atria
b. To provide time for the ventricles to fill during diastole
c. To limit the number of signals the ventricles receive in some rhythms
d. To allow the atria to rest between signals
ANS: B
The atrioventricular (AV) node delays the conduction impulse from the atria (0.8 to 1.2 seconds) to provide time for the ventricles
to fill during diastole.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 164
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. Why do many patients with heart rates greater than 120 frequently have chest pain and shortness of breath?
a. Patients with heart disease frequently have an anxiety disorder as well.
b. The rapid pounding of the heart in the chest wall causes the physical pain.
c. The heart muscle gets tired from the increased work.
d. The decreased diastolic time decreases oxygen delivery to the myocardium.
ANS: D
The coronary arteries are perfused during diastole. When the heart rate increases, the diastolic time decreases as each contraction
has less time to be completed. This decreases the time the coronary arteries have to deliver oxygenated blood to the myocardium.
The symptoms described are caused by a lack of oxygen in the myocardium.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 179
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. A patient reports feeling dizzy after standing quickly. Which finding could provide a clue regarding the cause?
a. Hemoglobin level of 14.0 g/dL and hematocrit level of 42.3%
b. Poor skin turgor with extended tenting
c. Supine blood pressure of 146/93 mm Hg
d. Resting heart rate of 96 beats/min
ANS: B
Poor skin turgor could suggest dehydration. Dehydration can cause orthostatic hypotension because of low capacitance reserves
from hypovolemia. Supine blood pressure of 146/93 mm Hg would be considered hypertensive, and the patient would most likely
experience a headache rather than dizziness. A resting heart rate of 96 beats/min is still considered a normal value.
PTS: 1
DIF: Cognitive Level: Understanding
REF: n/a
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. A patient presents with atrial fibrillation, a heart rate of 156 beats/min, and a blood pressure of 124/76 mm Hg. The practitioner
orders diltiazem, a calcium channel blocker, to be given slowly by intravenous push. Why did the practitioner choose this
medication to treat this patient’s atrial tachyarrhythmia?
a. Diltiazem decreases the calcium influx into the atrioventricular (AV) nodal tissue
and decreases the speed of impulse conduction.
b. Diltiazem increases the calcium influx into the AV nodal tissue and decreases the
speed of impulse conduction.
c. Diltiazem decreases the calcium influx into the myocardial tissue and decreases
the strength of heart contraction.
d. Diltiazem increases the calcium influx into the myocardial tissue and decreases
the strength of heart contraction.
ANS: A
Calcium channel-blocking drugs, such as verapamil and diltiazem, inhibit the inward Ca++ current into pacemaker tissue,
especially the atrioventricular (AV) node. For this reason, they are used therapeutically to slow the rate of atrial tac hydysrhythmias
and protect the ventricle from excessive atrial impulses.
PTS: 1
DIF: Cognitive Level: Applying
REF: n/a
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. What is one hemodynamic effect of a pericardial effusion?
a. Increased ventricular ejection
b. Decreased ventricular filling
c. Myocardial ischemia
d. Increased afterload
ANS: B
If the fluid collection in the sac (pericardial effusion) impinges on ventricular filling, ventricular ejection, or coronary artery
perfusion, a clinical emergency may exist that necessitates removal of the excess pericardial fluid to restore normal cardiac
function. Myocardial ischemia is damage of the myocardium muscle as the result of a heart attack.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 161
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. What percentage of volume does atrial kick contribute to ventricular filling?
a. 10%
b. 20%
c. 5%
d. 45%
ANS: B
Atrial contraction, also known as “atrial kick,” contributes approximately 20% of blood flow to ventricular filling; the other 80%
occurs passively during diastole.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 163
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. What is the function of the atrioventricular (AV) valves?
a. Prevent backflow of blood into the atria during ventricular contraction
b. Prevent blood regurgitation back into the ventricles
c. Assist with blood flow to the lungs and aorta
d. Contribute to ventricular filling by atrial kick
ANS: A
The atrioventricular (AV) valves are open during ventricular diastole (filling) and prevent backflow of blood into the atria during
ventricular systole (contraction). Semilunar valves prevent the backflow of pulmonic and aortic blood back into the ventricles.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 163
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. Which step of impulse conduction is most conducive to atrial kick?
a. The firing of the sinoatrial node, which results in atrial depolarization
b. The conduction delay at the atrioventricular (AV) node, allowing time for filling
c. Conduction through the bundle of His, enhancing ventricular depolarization
d. Conduction to the Purkinje fibers, allowing for ventricular contraction
ANS: B
The conduction delay at the atrioventricular (AV) node allows adequate time for ventricular filling from atrial contraction.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 165
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. Which is an example of a physiologic shunt?
a. A ventricular septal defect
b. Blood returning from the inferior vena cava to the right atrium
c. A septal infarct
d. The thebesian vessels returning deoxygenated blood to the left ventricle
ANS: D
The thebesian vessels return blood to the left ventricle. The mixing of unoxygenated blood with freshly oxygenated blood is called
a physiologic shunt. A ventricular septal defect (VSD) allows mixing of blood from both ventricles. The clinical impact depends on
the size of the intracardiac shunt. A VSD is a congenital opening between the ventricles; a ventricular septal rupture can occur as a
complication of a large anterior wall myocardial infarction.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 167
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
11. What is the name of outermost layer of an artery?
a. Tunica
b. Intima
c. Adventitia
d. Media
ANS: C
The adventitia is the outermost layer of the artery that helps strengthen and shape the vessel. The media is the middle layer that is
made up of smooth muscle and elastic tissue. The intima is the innermost layer consists of a thin lining of endothelium and a small
amount of elastic tissue.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 169
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. Which of the following is most descriptive of the capillary?
a. Large diameter, low pressure
b. Small diameter, high pressure
c. Large diameter, high pressure
d. Small diameter, low pressure
ANS: D
The diameter of a capillary is less than that of an arteriole, but the pressure is relatively low as a result of the large cross-sectional
area of the branching capillary bed.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 170
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. Depolarization of one myocardial cell will likely result in what physiologic response?
a. Completion of the action potential in that cell before a new cell can accept an
b.
c.
d.
impulse
Quick depolarization and spread to all of the heart
Depolarization of only cells superior to the initial depolarization
Quick depolarization of only cells inferior to the initial depolarization
ANS: B
The cardiac muscle is a functional syncytium in which depolarization started in any cardiac cell is quickly spread to all of the heart.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 171
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. What is the normal resting membrane potential of a myocardial cell?
a. 10 to 20 mV
b. 30 to 40 mV
c. –20 to –30 mV
d. –80 to –90 mV
ANS: D
In a myocardial cell, the normal resting membrane potential is –80 to –90 mV.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 173
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. Which phase is the final repolarization phase of the action potential?
a. Phase 1
b. Phase 2
c. Phase 3
d. Phase 4
ANS: C
The final repolarization phase is phase 3 of the action potential. Phases 1 and 2 (partial repolarization) occur as the AP slope
returns toward zero. The plateau that follows is described as phase 2. In phase 4, the AP returns to an RMP of –80 to –90 mV.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 174
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. Which statement regarding the autonomic nervous system’s role in the regulation of heart rate is true?
a. Parasympathetic influences increase heart rate.
b. Sympathetic influences are predominantly present.
c. Parasympathetic influences are only compensatory.
d. Both sympathetic and parasympathetic influences are normally active.
ANS: D
The parasympathetic nervous system and the sympathetic nervous system operate to create a balance between relaxation and
fight-or-flight readiness. They affect cardiovascular function by slowing the heart rate during periods of calm and increasing it in
response to sympathetic stimulation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 179
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. A patient is admitted with a diagnosis of acute myocardial infarction. The monitor pattern reveals bradycardia. Occlusion of which
coronary artery most likely resulted in bradycardia from sinoatrial node ischemia?
a. Right
b. Left anterior descending
c. Circumflex
d. Dominant
ANS: A
The right coronary artery provides the blood supply to the sinoatrial and atrioventricular (AV) nodes in more than half the
population. The left coronary artery is a short but important artery that divides into two large arteries, the left anterior descending
and the circumflex arteries. These vessels serve the left atrium and most of the left ventricle. The term dominant coronary artery is
used to describe the artery that supplies the posterior part of the heart.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 166
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. An echocardiogram reveals an ejection fraction of 55%. On the basis of this information, how would the patient’s cardiac function
be described?
a. Adequate
b. Mildly decreased
c. Moderately decreased
d. Severely decreased
ANS: A
Ejection fraction is expressed as a percent, with normal being at least greater than 50%. An ejection fraction of less than 35%
indicates poor ventricular function (as in cardiomyopathy), poor ventricular filling, obstruction to outflow (as in some valve
stenosis conditions), or a combination of these.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 177
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. Which of the following values reflects a normal cardiac output at rest?
a. 2.5 L/min
b. 5.8 L/min
c. 7.3 L/min
d. 9.6 L/min
ANS: B
Cardiac output is normally expressed in liters per minute (L/min). The normal cardiac output in the human adult is approximately 4
to 8 L/min. It is approximately 4 to 6 L/min at rest and increases with exercise.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 178
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. A patient is admitted with right- and left-sided heart failure. The nurse’s assessment reveals that the patient has 3+ pitting edema on
the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath
and chest discomfort. On the basis of this information, how would the nurse evaluate the patient’s preload status?
a. The patient is hypovolemic and has too little preload.
b. The patient is experiencing congestive heart failure (CHF) and has too little
preload.
c. The patient is experiencing heart failure and has too much preload.
d. The patient is hypertensive and the preload is not a factor.
ANS: C
Whereas a patient with hypovolemia has too little preload, a patient with heart failure has too much preload.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 178 | p. 179
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. A patient is admitted with right- and left-sided heart failure. The nurse’s assessment reveals that the patient has 3+ pitting edema on
the sacrum, blood pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is experiencing shortness of breath
and chest discomfort. Increased afterload is probably present related to the patient’s blood pressure. Which therapeutic measure
will most likely decrease afterload in this patient?
a. Administration of vasodilators
b. Placement in high Fowler position
c. Elevation of extremities
d. Increasing intravenous fluids
ANS: A
Therapeutic management to decrease afterload is aimed at decreasing the work of the heart with the use of vasodilators. Placing the
patient in high Fowler position will cause an increase in the workload of the heart. Elevation of the extremities will ease the venous
return back to the heart. Increasing IV fluids will cause an increased workload on the heart.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 179
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. What are the two important proteins contained within the cardiac cells that contribute to contraction?
a. Z-disk and A-band
b. Actin and myosin
c. I-band and M-band
d. Renin and angiotensin
ANS: B
Actin and myosin form cross-bridges, allowing myocardial contraction to take place. Z-disk, A-band, I-band, and M-band are all
portions of the sarcomere functional unit to promote contraction in the heart. Renin converts the protein angiotensinogen to
angiotensin I. When angiotensin I passes through the pulmonary vascular bed, it is activated by angiotensin-converting enzyme to
become angiotensin II.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 172
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
23. What is the name of the valve that allows blood flow into pulmonary artery?
a. Aortic
b. Tricuspid
c. Mitral valve
d. Pulmonic valves
ANS: D
The pulmonic valve allows blood flow into the pulmonary artery, and the aortic valve allows blood flow into the aorta. The
tricuspid (right) and mitral valves (left) are located between the atria and the ventricles.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 164
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
24. Place the following components of the cardiac conduction pathway in the correct anatomic order.
1. Atrioventricular node
2. Bundle branches
3. Bundle of His
4. Internodal pathways
5. Purkinje fibers
6. Sinoatrial node
a. 6, 1, 4, 3, 2, 5
b. 6, 1, 3, 2, 4, 5
c. 6, 1, 4, 2, 3, 5
d. 4, 3, 2, 5, 6, 1
ANS: A
The three main areas of impulse propagation and conduction are (1) the sinoatrial node, (2) the atrioventricular node, and (3) the
conduction fibers within the ventricle, specifically the bundle of His, the bundle branches, and the Purkinje fibers. Interruption or
malfunction of any part of the conduction pathway can result in dysrhythmias specific to that structure.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 164 | p. 165
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. Which factors influence stroke volume? (Select all that apply, one, some, or all.)
a. Afterload
b. Cardiac output
c. Contractility
d. Heart rate
e. Preload
ANS: A, C, E
Stroke volume (SV) as a value is influenced by three primary factors: preload, afterload, and contractility. Cardiac output (CO) is
determined by SV × HR = CO. Preload is the volume of blood in the left ventricle at the end of diastole.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 178 | Figure 11-27
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 12: Cardiovascular Clinical Assessment
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which condition is usually associated with clubbing?
a. Central cyanosis
b. Peripheral cyanosis
c. Carbon monoxide poisoning
d. Acute hypoxemia
ANS: A
Clubbing in the nail bed is a sign associated with longstanding central cyanotic heart disease or pulmonary disease with hypoxemia.
Peripheral cyanosis, a bluish discoloration of the nail bed, is seen more commonly. Peripheral cyanosis results from a reduction in
the quantity of oxygen in the peripheral extremities from arterial disease or decreased cardiac output. Central cyanosis is a bluish
discoloration of the tongue and sublingual area. Multiracial studies indicate that the tongue is the most sensitive site for observation
of central cyanosis.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 184
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. The abdominojugular reflux test determines the presence of which disorder?
a. Right ventricular failure
b. Cirrhosis
c. Liver failure
d. Coronary artery disease
ANS: A
The abdominojugular reflux sign can assist with the diagnosis of right ventricular failure. A positive abdominojugular reflux sign is
an increase in the jugular venous pressure (CVP equivalent) of greater than 3 cm sustained for at least 15 seconds.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 187
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. Which statement best describes the purpose of the Allen test?
a. The Allen test assesses the adequacy of blood flow through the ulnar artery.
b. The Allen test evaluates oxygen saturation in the brachial artery.
c. The Allen test assesses the patency of an internal graft.
d. The Allen test determines the size of needle to be used for puncture.
ANS: A
The Allen test assesses the adequacy of blood flow to the hand through the ulnar artery.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 190 | Box 12-6
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. Evaluation of arterial circulation to an extremity is accomplished by assessing which of the following?
a. Homan’s sign
b. Skin turgor
c. Peripheral edema
d. Capillary refill
ANS: D
Capillary refill assessment is a maneuver that uses the patient’s nail beds to evaluate both arterial circulation to the extremity and
overall perfusion. The severity of arterial insufficiency is directly proportional to the amount of time necessary to reestablish flow
and color.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 190
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
5. When checking the patient’s back, the nurse pushes her thumb into the patient’s sacrum. An indentation remains. What assessment
finding should the nurse document?
a. Sacral compromise
b. Delayed skin turgor
c. Pitting edema
d. Dehydration
ANS: C
Pitting edema occurs when an impression is left in the tissue when the thumb is removed. The dependent tissues within the legs and
sacrum are particularly susceptible. Edema may be dependent, unilateral, or bilateral and pitting or nonpitting.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 190 | p. 191
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
6. An assessment finding of pulsus alternans may indicate evidence of what disorder?
a. Left-sided heart failure
b. Jugular venous distention
c. Pulmonary embolism
d. Myocardial ischemia
ANS: A
Pulsus alternans describes a regular pattern of pulse amplitude changes that alternate between stronger and weaker beats. This
finding is suggestive of end-stage left ventricular heart failure.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 192 | p. 193
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. The presence of a carotid or femoral bruit may be evidence of what anomaly?
a. Left-sided heart failure
b. Blood flow through a partially occluded vessel
c. Early onset of pulmonary embolism
d. Myocardial rupture
ANS: B
A bruit is an extracardiac vascular sound that results from blood flow through a tortuous or partially occluded vessel.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 193
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. A patient is admitted with a diagnosis of “rule out myocardial infarction.” The patient reports midchest pressure radiating into the
jaw and shortness of breath when walking up stairs. What factor influences the amount of history obtained during the admission
assessment?
a. Presence of cardiovascular risk factors
b. Prior medical history
c. Presenting symptoms
d. Current medications
ANS: C
For a patient in acute distress, the history taking is shortened to just a few questions about the patient’s chief complaint,
precipitating events, and current medications. For a patient who is not in obvious distress, the history focuses on the following four
areas: review of the patient’s present illness; overview of the patient’s general cardiovascular status; review of the patient’s general
health status, including family history of coronary artery disease (CAD), hypertension, diabetes, peripheral arterial disease, or
stroke; and survey of the patient’s lifestyle, including risk factors for CAD.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 184 | p. 185 | Box 12-1
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. A patient is admitted with a diagnosis of “rule out myocardial infarction.” The patient reports midchest pressure radiating into the
jaw and shortness of breath when walking up stairs. When inspecting the patient, the nurse notes that the patient needs to sit in a
high Fowler position to breathe. The nurse suspects the patient may be experiencing what problem?
a. Pericarditis
b. Anxiety
c. Heart failure
d. Angina
ANS: C
Sitting upright to breathe may be necessary for the patient with acute heart failure, and leaning forward may be the least painful
position for a patient with pericarditis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 185
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
10. A patient is admitted with left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an
S3 and a 3/6 systolic murmur. Which statement about an S3 is accurate?
a. It is normal for a person this age.
b. It is synonymous with a ventricular gallop.
c. It is only heard during systole.
d. It is best heard best with the diaphragm of the stethoscope.
ANS: B
The abnormal heart sounds are labeled the third heart sound (S3) and the fourth heart sound (S4) and are referred to as gallops
when auscultated during an episode of tachycardia. Not unexpectedly, the development of an S3 heart sound is strongly associated
with elevated levels of brain natriuretic peptide.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 195 | Box 12-11
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
11. A patient is admitted with left-sided heart failure related to mitral stenosis. Physical assessment findings reveal tachycardia with an
S3 and a 3/6 systolic murmur. The grading of a murmur as a 3/6 refers to which characteristics of the murmur?
a. Intensity
b. Quality
c. Timing
d. Pitch
ANS: A
Intensity, or the “loudness,” is graded on a scale of 1 to 6; the higher the number, the louder the murmur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 196 | Box 12-13
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. An 82-year-old patient is admitted into the critical care unit with a diagnosis of left-sided heart failure related to mitral stenosis.
Physical assessment findings reveal tachycardia with an S3 and a 3/6 systolic murmur. Which of the following descriptions best
describes the murmur heard with mitral stenosis?
a. High-pitched systolic sound
b. Medium-pitched systolic sound
c. High-pitched diastolic sound
d. Low-pitched diastolic sound
ANS: D
Mitral stenosis describes a narrowing of the mitral valve orifice. This produces a low-pitched murmur, which varies in intensity and
harshness depending on the degree of valvular stenosis. It occurs during diastole, is auscultated at the mitral area (fifth ICS,
midclavicular line), and does not radiate.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 194
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. What sounds are created by the turbulence of blood flow through a vessel caused by constriction of the blood pressure cuff?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: A
Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood pressure
cuff. Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as gallops
when auscultated during an episode of tachycardia. Murmurs are produced by turbulent blood flow through the chambers of the
heart, from forward flow through narrowed or irregular valve openings, or backward regurgitate flow through an incompetent
valve.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 191
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment
MSC: NCLEX: Physiologic Integrity
14. Abnormal heart sounds are labeled S3 and S4 and are referred to as what when auscultated during a tachycardic episode?
a. Korotkoff sounds
b. Grating murmurs
c. Blowing murmurs
d. Gallops
ANS: D
Abnormal heart sounds are known as the third heart sound (S3) and the fourth heart sound (S4); they are referred to as gallops
when auscultated during an episode of tachycardia. Murmurs are produced by turbulent flood flow through the chambers of the
heart, from forward flow through narrowed or irregular valve openings, or backward regurgitate flow through an incompetent
valve. Korotkoff sounds are the sounds created by turbulence of blood flow within a vessel caused by constriction of the blood
pressure cuff. Pulse pressure describes the difference between systolic and diastolic values. A normal pulse pressure is 40 mm Hg.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 194
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment
MSC: NCLEX: Physiologic Integrity
15. A heart murmur is described as blowing, grating, or harsh. This description would fall under which criteria?
a. Intensity
b. Quality
c. Timing
d. Pitch
ANS: B
Quality is whether the murmur is blowing, grating, or harsh. Intensity is the loudness graded on a scale of 1 through 6; the higher
the number, the louder is the murmur. Timing is the place in the cardiac cycle (systole/diastole). Pitch is whether the tone is high or
low.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 195
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
16. The nurse assesses the dorsalis pedis and posterior tibial pulses as weak and thready. What should the nurse document for the pulse
volume?
a. 0
b. 1+
c. 2+
d. 3+
ANS: B
Pulse volumes are 0, not palpable; 1+, faintly palpable (weak and thready); 2+, palpable (normal pulse); and 3+, bounding
(hyperdynamic pulse).
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 190 | Box 12-5
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. A nurse palpates the descending aorta and feels a strong, bounding pulse. The nurse reports the findings to the physician because
this result is suggestive of what disorder?
a. Decreased cardiac output
b. Increased cardiac output
c. An aneurysm
d. Aortic insufficiency
ANS: C
When the patient is in the supine position, the abdominal aortic pulsation is located in the epigastric area and can be felt as a
forward movement when firm fingertip pressure is applied above the umbilicus. An abnormally strong or bounding pulse suggests
the presence of an aneurysm or an occlusion distal to the examination site. If it is prominent or diffuse, the pulsation may indicate
an abdominal aneurysm. A diminished or absent pulse may indicate low cardiac output (CO), arterial stenosis, or occlusion
proximal to the site of the examination.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 190
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. A nurse admits a patient with a diagnosis of syncope of unknown etiology. Orthostatic vital signs are lying: 110/80 mm Hg; sitting:
100/74 mm Hg; standing: 92/40 mm Hg. Based on this information, what should the nurse monitor?
a. Respirations
b. Fluid intake
c. Peripheral pulses
d. Activity
ANS: D
Postural (orthostatic) hypotension occurs when the systolic blood pressure drops by 10 to 20 mm Hg or the diastolic blood pressure
drops by 5 mm Hg after a change from the supine posture to the upright posture. This is usually accompanied by dizziness,
lightheadedness, or syncope. If a patient experiences these symptoms, it is important to complete a full set of postural vital signs
before increasing the patient’s activity level.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 191
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. A patient’s blood pressure is 90/72 mm Hg. What is the patient’s pulse pressure?
a. 40 mm Hg
b. 25 mm Hg
c. 18 mm Hg
d. 12 mm Hg
ANS: C
Pulse pressure describes the difference between systolic and diastolic values. The normal pulse pressure is 40 mm Hg (i.e., the
difference between an SBP of 120 mm Hg and a DBP of 80 mm Hg). A patient with a blood pressure of 90/72 mm Hg has a pulse
pressure of 18 mm Hg.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 192
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. A sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output, caused by the ventricle contracting
during systole, are all characteristics of what condition?
a. Acute mitral regurgitation
b. Aortic insufficiency
c. Chronic mitral regurgitation
d. Pericardial friction rub
ANS: A
Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood is sent in a retrograde manner to the
left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low cardiac output (CO) and leading to
cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs during systole. It is high pitched and
blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As mitral regurgitation progresses, the
murmur radiates more widely. Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the
sound of blood flowing back into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur. A
pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from
pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic
and diastolic, corresponding to cardiac motion within the pericardial sac.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 195
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. A patient was admitted 3 days ago with a myocardial infarction. The patient is complaining of increased chest pain when coughing,
swallowing, and changing positions. The nurse hears a systolic scratching sound upon auscultation of the apical pulse. Based on the
symptoms, the nurse suspects the patient may have developed what condition?
a. Acute mitral regurgitation
b. Aortic insufficiency
c. Chronic mitral regurgitation
d. Pericarditis
ANS: D
A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from
pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic
and diastolic, corresponding to cardiac motion within the pericardial sac. Acute mitral regurgitation occurs when the ventricle
contracts during systole and a jet of blood is sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial
pressure, acute pulmonary edema, and low cardiac output (CO) and leading to cardiogenic shock. Chronic mitral regurgitation is
auscultated in the mitral area and occurs during systole. It is high pitched and blowing, although the pitch and intensity vary,
depending on the degree of regurgitation. As mitral regurgitation progresses, the murmur radiates more widely. Aortic insufficiency
is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back into the left ventricle
during diastole is heard as a decrescendo, high-pitched, blowing murmur.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 196
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. During a history examination, a patient tells the nurse, “The cardiologist says I have a leaking valve.” The nurse documents that the
patient has a history of what condition?
a. Acute mitral regurgitation
b. Aortic insufficiency
c. Chronic mitral regurgitation
d. Pericarditis
ANS: B
Aortic insufficiency is an incompetent aortic valve. If the valve cusps do not maintain this seal, the sound of blood flowing back
into the left ventricle during diastole is heard as a decrescendo, high-pitched, blowing murmur. A pericardial friction rub is a sound
that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis).
Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, correspond ing to cardiac
motion within the pericardial sac. Acute mitral regurgitation occurs when the ventricle contracts during systole and a jet of blood is
sent in a retrograde manner to the left atrium, causing a sudden increase in left atrial pressure, acute pulmonary edema, and low
cardiac output (CO) and leading to cardiogenic shock. Chronic mitral regurgitation is auscultated in the mitral area and occurs
during systole. It is high pitched and blowing, although the pitch and intensity vary, depending on the degree of regurgitation. As
mitral regurgitation progresses, the murmur radiates more widely.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 196
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
23. A patient was admitted with of acute myocardial infarction. Upon auscultation, the nurse hears a harsh, holosystolic murmur along
the left sternal border. The nurse notifies the physician immediately because the symptoms indicate the patient has developed what
complication?
a. Papillary muscle rupture
b. Tricuspid stenosis
c. Ventricular septal rupture
d. Pericarditis
ANS: C
Ventricular septal rupture is a new opening in the septum between the two ventricles. It creates a harsh, holosystolic murmur that is
loudest (by auscultation) along the left sternal border. Papillary muscle rupture is auscultation of a new, high-pitched, holosystolic,
blowing murmur at the cardiac apex. Tricuspid stenosis is a quiet murmur that becomes louder with inspiration and is located in the
epigastrium area. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction
rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is
both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 196
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. Which statements describe S1, the first heart sound? (Select all that apply, one, some, or all.)
a. It is associated with closure of the mitral and tricuspid valves.
b. It is a high-pitched sound.
c. It can be heard most clearly with the diaphragm of the stethoscope.
d. The best listening point is in the aortic area.
e. The “split” sound can best be detected in the tricuspid area.
ANS: A, B, C, E
S1 is the sound associated with mitral and tricuspid valve closure and is heard most clearly in the mitral and tricuspid areas. S1
sounds are high pitched and heard best with the diaphragm of the stethoscope.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 193 | Box 12-10
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment
MSC: NCLEX: Physiologic Integrity
2. Heart murmurs are characterized by which criteria? (Select all that apply, one, some, or all.)
a. Intensity
b. Location
c. Quality
d. Pitch
e. Pathologic cause
ANS: A, B, C, D
Murmurs are characterized by specific criteria. Timing is the place in the cardiac cycle (systole/diastole). Location is where it is
auscultated on the chest wall (mitral or aortic area). Radiation is how far the sound spreads across chest wall. Quality is whether the
murmur is blowing, grating, or harsh. Pitch is whether the tone is high or low. Intensity is the loudness is graded on a scale of 1
through 6; the higher the number, the louder the murmur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 194 | p. 195 | Box 12-12
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Clinical Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 13: Cardiovascular Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient with a serum potassium level of 6.8 mEq/L may exhibit what type of electrocardiographic changes?
a. A prominent U wave
b. Tall, peaked T waves
c. A narrowed QRS
d. Sudden ventricular dysrhythmias
ANS: B
Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually, although not uniquely, associated
with early hyperkalemia and are followed by prolongation of the PR interval, loss of the P wave, widening of the QRS complex,
heart block, and asystole. Severely elevated serum potassium (greater than 8 mEq/L) causes a wide QRS tachycardia.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 269
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. What places a patient with heart failure at risk for hypomagnesemia?
a. Pump failure
b. Diuretic use
c. Fluid overload
d. Inotropic drugs
ANS: B
Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes to low serum magnesium levels.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 270
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. Which diagnostic test is most effective for measuring overall heart size?
a. 12-lead electrocardiography
b. Echocardiography
c. Chest radiography
d. Vectorcardiography
ANS: C
Chest radiography is the oldest noninvasive method for visualizing images of the heart, and it remains a frequently used and
valuable diagnostic tool. Information about cardiac anatomy and physiology can be obtained with ease and safety at a relatively
low cost. Radiographs of the chest are used to estimate the cardiothoracic ratio and measure overall heart size.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 277 | Figure 13-88
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. What is the most accurate method for monitoring the existence of true ischemic changes?
a. Biomarkers
b. Echocardiogram
c. 5-lead ECG
d. 12-lead ECG
ANS: D
Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial elevation of cTnI, cTnT, and CK-MB
occurs 3 to 6 hours after the acute myocardial damage. This means that if an individual comes to the emergency department as soon
as chest pain is experienced, the biomarkers will not have risen. For this reason, it is clinical practice to diagnose an acute
myocardial infarction by 12-lead electrocardiography and clinical symptoms without waiting for elevation of cardiac biomarkers.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 244
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
5. Which criteria are representative of the patient in normal sinus rhythm?
a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04
b.
c.
d.
second
Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06
second
Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08
second
Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04
second
ANS: B
The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR interval, 0.12 to 0.20 second; and
QRS, 0.06 to 0.10 second.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 250 | p. 251
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
6. What cardiac influence ability to response to causes the patient to have symptoms with atrial flutter?
a. Atrial response rate
b. Ventricular response rate
c. PR interval
d. QRS duration
ANS: B
The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is 300 and the atrioventricular
(AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min and should be well tolerated. If, on the other hand, the
atrial rate is 300 beats/min but the AV conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause
angina, acute heart failure, or other signs of cardiac decompensation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 255
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. What characteristic is associated with junctional escape rhythms?
a. Irregular rhythm
b. Rate greater than 100 beats/min
c. P wave may inverted or absent
d. QRS greater than 0.10 seconds
ANS: C
Characteristics of a junctional escape rhythm include a rate of 40 to 60 beats/min, regular rhythm, present or absent P waves, PR
less than 0.12 seconds, and QRS between 0.06 and 0.10 seconds.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 259 | Table 13-12
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal by what characteristic?
a. In various shapes in the same lead
b. With increasing frequency
c. Wider than a normal QRS
d. On the T wave
ANS: A
If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal. Multifocal ventricular ectopic beats are
more serious than unifocal ventricular ectopic beats because they indicate a greater area of irritable myocardial tissue and are more
likely to deteriorate into ventricular tachycardia or fibrillation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 260 | Figure 13-67B
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. What major clinical finding is present with ventricular fibrillation (VF)?
a. Hypertension
b. Bradycardia
c. Diaphoresis
d. Pulselessness
ANS: D
In ventricular fibrillation (VF), the patient does not have a pulse, no blood is being pumped forward, and defibrillation is the only
definitive therapy. No forward flow of blood or palpable pulse is present in VF.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
10. Which portion of the electrocardiogram (ECG) is most valuable in diagnosing atrioventricular (AV) conduction disturbances?
a. P wave
b. PR interval
c. QRS complex
d. QT interval
ANS: B
The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial depolarization. The QRS complex
represents ventricular depolarization, corresponding to phase 0 of the ventricular action potential. The QT interval is measured
from the beginning of the QRS complex to the end of the T wave and indicates the total time interval from the onset of
depolarization to the completion of repolarization.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 267
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
11. Which findings would be reasons to abort an exercise stress test?
a. Ventricular axis of +90 degrees
b. Increase in blood pressure
c. Inverted U wave
d. ST segment depression or elevation
ANS: D
Signs that can alert the nurse to stop the test include ST segment elevation equal to or greater than 1.0 mm (one small box) or ST
depression equal to or greater than 2.0 mm (2 small boxes). Blood pressure is expected to rise during exercise, but a systolic blood
pressure greater than 250 mm Hg or a diastolic blood pressure greater than 115 mm Hg is considered high enough to stop the test.
Parameters for ventricular axis in degrees are –30 to +90. Left-axis deviation is present if the axis falls between –30 and –90
degrees.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 280
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. What is the rationale for giving the patient additional fluids after a cardiac catheterization?
a. Fluids help keep the femoral vein from clotting at the puncture site.
b. The patient had a nothing-by-mouth order before the procedure.
c. The radiopaque contrast acts as an osmotic diuretic.
d. Fluids increase cardiac output and prevent rehydration.
ANS: C
Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic. Fluid is also used to prevent
contrast-induced nephropathy or damage to the kidney from the contrast dye used to visualize the heart structures.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 276
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. How can pulsus paradoxus finding be assessed on the bedside monitor?
a. A decrease of more than 10 mm Hg in the arterial waveform during inhalation
b. A single, nonperfused beat on the electrocardiogram (ECG) waveform
c. Tall, tented T waves on the ECG waveform
d. An increase in pulse pressure greater than 20 mm Hg on exhalation
ANS: A
Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs during inhalation. It is caused by a fall
in cardiac output (CO) as a result of increased negative intrathoracic pressure during inhalation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 205
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. When assessing the pulmonary arterial waveform, the nurse notices dampening. After tightening the stopcocks and flushing the
line, the nurse decides to calibrate the transducer. What are two essential components included in calibration?
a. Obtaining a baseline blood pressure and closing the transducer to air
b. Leveling the transducer to the phlebostatic axis and opening the it to air
c. Having the patient lay flat and closing the transducer to air
d. Obtaining blood return on-line and closing all stopcocks
ANS: B
Ensuring accuracy of waveform calibration of the system includes opening the transducer to air and leveling the air–fluid interface
of the transducer to the phlebostatic axis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 199
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
15. What is the formula for calculating mean arterial pressure (MAP)?
a. Averaging three of the patient’s blood pressure readings over a 6-hour period
b. Dividing the systolic pressure by the diastolic pressure
c. Adding the systolic pressure and two diastolic pressures and then dividing by 3
d. Dividing the diastolic pressure by the pulse pressure
ANS: C
The mean arterial pressure is one-third systole and two-thirds diastole.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 202
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
16. What is the physiologic effect of left ventricular afterload reduction?
a. Decreased left atrial tension
b. Decreased systemic vascular resistance
c. Increased filling pressures
d. Decreased cardiac output
ANS: B
Afterload is defined as the pressure the ventricle generates to overcome the resistance to ejection created by the arteries and
arterioles. After a decrease in afterload, wall tension is lowered. The technical name for afterload is systemic vascular resistance
(SVR). Resistance to ejection from the right side of the heart is estimated by calculating the pulmonary vascular resistance (PVR).
The PVR value is normally one-sixth of the SVR.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 215
OBJ: Nursing Process Step: Evaluation
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. What parameter is used to assess the contractility of the left side of the heart?
a. Pulmonary artery occlusion pressure
b. Left atrial pressure
c. Systemic vascular resistance
d. Left ventricular stroke work index
ANS: D
Contractility of the left side of the heart is measured by the left ventricular stroke work index.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 217
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. Which intervention should be strictly followed to ensure accurate cardiac output readings?
a. Inject 5 mL of iced injectate at the beginning of exhalation over 30 seconds.
b. Inject 10 mL of warmed injectate into the pulmonary artery port three times.
c. Ensure at least 5° C difference between injectate and the patient temperature.
d. Administer the injectate within 4 seconds during inspiration.
ANS: D
To ensure accurate readings, the difference between injectate temperature and body temperature must be at least 10° C, and the
injectate must be delivered within 4 seconds, with minimal handling of the syringe to prevent warming of the solution. This is
particularly important when iced injectate is used.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 222
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. Why is mixed venous oxygen saturation (SVO2) monitoring helpful in the management of the critically ill patient?
a. It facilitates oxygen saturation monitoring at the capillary level.
b. It can detect an imbalance between oxygen supply and metabolic tissue demand.
c. It assesses the diffusion of gases at the alveolar capillary membrane.
d. It estimates myocardial workload during heart failure and acute pulmonary
edema.
ANS: B
Continuous venous oxygen monitoring permits a calculation of the balance achieved between arterial oxygen supply (SaO 2) and
oxygen demand at the tissue level by sampling desaturated venous blood from the PA catheter distal tip.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 222 | Figure 14-22
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
20. A patient reports that he has been having “indigestion” for the last few hours. Upon further review the nurse suspects the patient is
having of chest pain. Cardiac biomarkers and a 12-lead electrocardiogram (ECG) are done. What finding is most significant in
diagnosing an acute coronary syndrome (ACS) within the first 3 hours?
a. Inverted T waves
b. Elevated troponin I
c. Elevated B-type natriuretic peptide (BNP)
d. Indigestion and chest pain
ANS: B
The troponins are biomarkers for myocardial damage. The elevation of Troponin I and troponin T occurs 3 to 6 hours after acute
myocardial damage. Because troponin I is found only in cardiac muscle, it is a highly specific biomarker for myocardial damage.
B-type natriuretic peptide (BNP) is usually drawn when heart failure is suspected, not acute coronary syndrome (ACS). Usually
within 4 to 24 hours from the onset of the infarction, abnormal Q waves begin to develop in the affected leads, and T waves begin
to invert.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 271
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
21. Which serum lipid value is a significant predictor of future acute myocardial infarction (MI) in persons with established coronary
artery atherosclerosis?
a. High-density lipoprotein (HDL)
b. Low-density lipoprotein (LDL)
c. Triglycerides
d. Very-low-density lipoprotein
ANS: B
Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary artery disease, and high levels of
each are significant predictors of future acute myocardial infarction in persons with established coronary artery atherosclerosis.
LDL-C is the major atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 274
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Which of the electrocardiogram (ECG) findings would be positive for an inferior wall myocardial infarction (MI)?
a. ST segment depression in leads I, aVL, and V2 to V4
b. Q waves in leads V1 to V2
c. Q waves in leads II, III, and aVF
d. T-wave inversion in leads V4 to V6, I, and aVL
ANS: C
Abnormal Q waves develop in leads overlying the affected area. An inferior wall infarction is seen with changes in leads II, III, and
aVF. Leads I and aVF are selected to detect a sudden change in ventricular axis. If ST segment monitoring is required, the lead is
selected according to the area of ischemia. If the ischemic area is not known, leads V3 and III are recommended to detect ST
segment ischemia.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 246
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. A patient’s bedside electrocardiogram (ECG) strips show the following changes: increased PR interval; increased QRS width; and
tall, peaked T waves. Vital signs are temperature 98.2° F; heart rate 118 beats/min; blood pressure 146/90 mm Hg; and respiratory
rate 18 breaths/min. The patient is receiving the following medications: digoxin 0.125 mg PO every day; D 51/2 normal saline with
40 mEq potassium chloride at 125 mL/h; Cardizem at 30 mg PO q8h; and aldosterone at 300 mg PO q12h. The practitioner is
notified of the ECG changes. What orders should the nurse expect to receive?
a. Change IV fluid to D51/2 normal saline and draw blood chemistry.
b. Give normal saline with 40 mEq of potassium chloride over a 6-hour period.
c. Hold digoxin and draw serum digoxin level.
d. Hold Cardizem and give 500 mL normal saline fluid challenge over a 2-hour
period.
ANS: A
The electrocardiographic (ECG) changes are most consistent with hyperkalemia. Removing the potassium from the intravenous line
and drawing laboratory values to check the potassium level is the best choice with the least chance of further harm. Digoxin
toxicity can be suspected related to the prolonged PR interval, but hyperkalemia explains all the ECG changes. The patient is not
hypotensive or bradycardic, so holding the Cardizem is not indicated.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 269
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
24. A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period. A repeat potassium level is obtained, and the
current potassium level is 3.2 mEq/L. In addition to administering additional potassium supplements, what intervention should now
be considered?
a. Discontinue spironolactone
b. Drawing a serum magnesium level
c. Rechecking the potassium level
d. Monitoring the patient’s urinary output
ANS: B
The patient should have serum magnesium level drawn. Hypomagnesemia is commonly associated with other electrolyte
imbalances, most notably alterations in potassium, calcium, and phosphorus. Low serum magnesium levels can result from many
causes.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 270 | p. 271
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
25. Which cardiac biomarker is elevated in decompensated heart failure?
a. Triglycerides
b. Troponin I
c. Troponin T
d. B-type natriuretic peptide (BNP)
ANS: D
In decompensated heart failure, ventricular distension from volume overload or pressure overload causes myocytes in the ventricle
to release B-type natriuretic peptide (BNP). With greater ventricular wall stress, more natriuretic peptide is released from the
myocardium, reflected as an elevated BNP level. The BNP value is combined with the physical examination, the 12-lead ECG, and
a chest radiograph to increase the accuracy of heart failure diagnosis. Troponins are elevated with acute coronary syndrome.
Triglycerides are not a biomarker and are reflective of lipids in the bloodstream.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 272
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. The physician is going to place a central venous catheter. Which anatomic site is associated with a lower risk of infection?
a. Subclavian vein
b. External jugular vein
c. Internal jugular vein
d. Femoral vein
ANS: A
The subclavian site should be used for insertion rather than jugular or femoral insertion sites to minimize infection risk.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 209
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
27. Most chest radiographs of critically ill patients are obtained using a portable chest radiograph machine. What is the difference
between a chest radiograph taken in the radiology department and one taken in the critical care unit?
a. Portable chest radiographs are usually clearer.
b. Only posterior views can be obtained in the critical care unit.
c. The sharpness of the structures is decreased with a portable chest radiograph.
d. Chest radiographs taken in radiology enlarge some thoracic structures.
ANS: C
In the supine radiograph with the patient lying flat on the bed, the x-ray tube can be only approximately 36 inches from the
patient’s chest because of ceiling height and x-ray equipment construction. This results in a lower quality film from a diagnostic
standpoint because the images of the heart and great vessels are magnified and are not as sharply defined.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 277
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
28. A patient asks why it is necessary to take a deep breath when the radiology technician preformed the chest radiograph. Which
statement is the best response?
a. “Deep breaths get the chest wall closer to the machine.”
b. “When the lungs are filled with air, the picture is clearer.”
c. “Taking a deep breath decreases the error caused by motion.”
d. “Holding the breath makes the heart appear larger.”
ANS: B
A radiograph is taken when the patient has taken a deep breath (inspiration). During exhalation, the lungs are less full of air, which
can make the lung tissue appear “cloudy” as if there is additional lung water. The heart also appears larger during exhalation. This
could lead to an erroneous diagnosis of heart failure.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 277
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29. What is the most common complication of a central venous catheter (CVC)?
a. Air embolus
b. Infection
c. Thrombus formation
d. Pneumothorax
ANS: B
Infection related to the use of central venous catheters (CVCs) is a major problem. The incidence of infection strongly correlates
with the length of time the CVC has been inserted, with longer insertion times leading to a higher infection rate. The risk of air
embolus, although uncommon, is always present for a patient with a central venous line in place. Air can enter during insertion
through a disconnected or broken catheter by means of an open stopcock, or air can enter along the path of a removed CVC.
Unfortunately, clot formation (thrombus) at the CVC site is common. Thrombus formation is not uniform; it may involve
development of a fibrin sleeve around the catheter, or the thrombus may be attached directly to the vessel wall. Pneumothorax has a
higher occurrence during placement of a CVC than during removal.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 210
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
30. A physician orders removal of the central venous catheter (CVC) line. The patient has a diagnosis of heart failure with chronic
obstructive pulmonary disease. What position would the nurse place the patient in for this procedure?
a. Supine in bed
b. Supine in a chair
c. Flat in bed
d. Reverse Trendelenburg position
ANS: A
Recommended techniques to avoid air embolus during central venous catheter (CVC) removal include removing the catheter when
the patient is supine in bed (not in a chair) and placing the patient flat or in the reverse Trendelenburg position if the patient’s
clinical condition permits this maneuver. Patients with heart failure, pulmonary disease, and neurologic conditions with raised
intracranial pressure should not be placed flat.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 211
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
31. Mechanical contraction of the heart occurs during which phase of the cardiac cycle?
a. Phase 0
b. Phase 2
c. Phase 3
d. Phase 4
ANS: B
During phases 1 and 2, an electrical plateau is created, and during this plateau, mechanical contraction occurs. Because there is no
significant electrical change, no waveform appears on the electrocardiogram (ECG). During phase 0 (depolarization), the electrical
potential changes rapidly from a baseline of –90 mV to +20 mV and stabilizes at about 0 mV. Because this is a significant electrical
change, it appears as a wave on the ECG as the QRS. During phase 3 (repolarization), the electrical potential again changes, this
time a little more slowly, from 0 mV back to –90 mV. This is another major electrical event and is reflected on the ECG as a T
wave. During phase 4 (resting period), the chemical balance is restored by the sodium pump, but because positively charged ions
are exchanged on a one-for-one basis, no electrical activity is generated, and no visible change occurs on the ECG tracing.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 235
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
32. What does the P wave component of the electrocardiographic waveform represent?
a. Atrial contraction
b. Atrial depolarization
c. Sinus node discharge
d. Ventricular contraction
ANS: B
The P wave is an electrical event and represents atrial depolarization. Atrial contraction should accompany the P wave but does not
always. The sinus node discharge is too faint to be recorded on the surface electrocardiogram. Ventricular contraction usually
accompanies the QRS complex.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 239
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
33. Why is the measurement of the QT interval important?
a. It facilitates rhythm identification and is best assessed in Lead II.
b. It helps differentiate myocardial ischemia from infarction.
c. An increasing QT interval increases the risk of torsades de pointes.
d. A decreasing QT interval increases the risk of torsades de pointes.
ANS: C
A prolonged QT interval is significant because it can predispose the patient to the development of polymorphic ventricular
tachycardia, also known as torsades de pointes. A long QT interval can be congenital, as a result of genetic inheritance, or it can be
acquired from an electrolyte imbalance or medications.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 240
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
34. Which lead is best to monitor a patient?
a. Depends on condition and history
b. Lead aVF A/V cardiac blocks
c. Lead V1 for atrial dysrhythmias
d. Lead II for ventricular dysrhythmias
ANS: A
The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The
monitoring lead should be chosen with consideration of the patient’s clinical condition and recent clinical history. Lead II is
recommended for monitoring of atrial dysrhythmias. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I
and aVF are selected to detect a sudden change in ventricular axis.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 242
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
35. When performing a 12-lead electrocardiogram (ECG), how many wires are connected to the patient?
a. 3
b. 5
c. 10
d. 12
ANS: C
The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart using 10 different electrode positions to
create 12 unique views of electrical activity occurring within the heart. Four wires are applied to the extremities to produce leads I,
II, III, aVR, aVL, and aVF. Six wires are attached to the V1 to V6 chest lead positions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 236 | p. 237
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
36. A patient returns from the cardiac catheterization laboratory after angioplasty and stent placement (ECG changes had indicated an
inferior wall myocardial infarction in progress). Which lead would best monitor this patient?
a. Varies based on the patient’s clinical condition and recent clinical history
b. Lead V3
c. Lead V1
d. Lead II
ANS: D
The selection of an electrocardiographic monitoring lead is not a decision to be made casually or according to habit. The
monitoring lead should be chosen with consideration of the patient’s clinical condition and recent clinical history. Lead II is
recommended for monitoring of atrial dysrhythmias and would be appropriate in this case as due to inferior wall injuries. Lead V1
is recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a sudden change in ventricular
axis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 243
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
37. The patient’s admitting 12-lead ECG shows tall, peaked P waves. What diagnosis could be responsible for this finding?
a. Mitral stenosis
b. Pulmonary edema
c. Ischemia
d. Pericarditis
ANS: B
Tall, peaked P waves occur in right atrial hypertrophy and are referred to as P pulmonale because this condition is often the result
of chronic pulmonary disease. Ischemia occurs when the delivery of oxygen to the tissues is insufficient to meet metabolic demand.
Cardiac ischemia in an unstable form occurs because of a sudden decrease in supply, such as when the artery is blocked by a
thrombus or when coronary artery spasm occurs. If the pulmonary edema is caused by heart failure, sometimes described as
hydrostatic pulmonary edema, the fluid may be in a “bat-wing” distribution, with the white areas concentrated in the hilar region
(origin of the major pulmonary vessels). However, as the heart failure progresses, the quantity of fluid in the alveolar spaces
increases, and the white, fluffy appearance is seen throughout the lung. Pericarditis is inflammation of the sac around the heart.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 245
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
38. A nurse is obtaining the history of a patient who reveals that he had a myocardial infarction (MI) 5 years ago. When the admission
12-lead electrocardiogram (ECG) is reviewed, Q waves are noted in leads V3 and V4 only. Which conclusion is most consistent
with this situation?
a. The patient may have had a posterior wall MI.
b. The patient must have had a right ventricular MI.
c. The admission 12-lead ECG was done incorrectly.
d. The patient may have had an anterior MI.
ANS: D
Not every acute myocardial infarction (MI) results in a pathologic Q wave on the 12-lead electrocardiogram (ECG). When the
typical ECG changes are not present, the diagnosis depends on symptomatic clinical presentation, specific cardiac biomarkers (e.g.,
cTnI, cTnT, CK-MB), and non-ECG diagnostic tests such as cardiac catheterization. Anterior and posterior wall MIs have ST
changes, not Q wave changes.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 246 | Table 13-8
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
8
39. A new-onset myocardial infarction (MI) can be recognized by what electrocardiogram (ECG) change?
a. Q waves
b. Smaller R waves
c. Widened QRS
d. ST segment elevation
ANS: D
Any change from baseline is expressed in millimeters and may indicate myocardial ischemia (one small box equals 1 mm). ST
segment elevation of 1 to 2 mm is associated with acute myocardial injury, preinfarction, and pericarditis. ST segment depression
(decrease from baseline more of 1 to 2 mm) is associated with myocardial ischemia. Widened QRS complexes are indicative of
ventricular depolarization abnormalities such as bundle branch blocks and ventricular dysrhythmias. Q waves and smaller R waves
are indications usually present 24 hours to 1 week after the myocardial infarction is completely evolved; they represent necrosis.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 246
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
40. To accurately measure the heart rate of a patient in normal sinus rhythm, which technique would be the most accurate?
a. The number of R waves in a 6-second strip
b. The number of large boxes in a 6-second strip
c. The number of small boxes between QRS complexes divided into 1500
d. The number of large boxes between consecutive R waves divided into 300
ANS: C
Calculation of heart rate if the rhythm is regular may be done using the following methods. Method 1: number of RR intervals in 6
seconds multiplied by 10 (e.g., 8 × 10 = 80/min). Method 2: number of large boxes between QRS complexes divided into 300 (e.g.,
300 ÷ 4 = 75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (e.g., 1500 ÷ 18 = 84/min).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 249
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
41. What is the initial intervention in a patient with sinus tachycardia with the following vital signs: heart rate, 136 beats/min; blood
pressure, 102/60 mm Hg; respiratory rate, 24 breaths/min; temperature, 99.2° F; SpO2, 94% on oxygen 2 L/min by nasal cannula?
a. Administer adenosine IV push.
b. Identify the cause.
c. Administer nitroglycerine 0.4 mg sublingual.
d. Administer lidocaine 75 mg IV push.
ANS: B
Sinus tachycardia can be caused by a wide variety of factors, such as exercise, emotion, pain, fever, hemorrhage, shock, heart
failure, and thyrotoxicosis. Many medications used in critical care can also cause sinus tachycardia; common culprits are
aminophylline, dopamine, hydralazine, atropine, and catecholamines such as epinephrine. This patient has a stable heart rate and
SpO2; therefore, there is time to identify the cause of the sinus tachycardia. Lidocaine is indicated for ventricular dysrhythmias.
Nitroglycerine is not indicated because the patient is not having chest pain at this time. Adenosine is usually not indicated unless
the heart rate is greater than 150 beats/min.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 251
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
42. A patient presents with atrial flutter with an atrial rate of 280 beats/min and a ventricular rate of 70 beats/min. Which statement best
explains this discrepancy in rates?
a. The ventricles are too tired to respond to all the atrial signals.
b. The atrioventricular (AV) node does not conduct all the atrial signals to the
ventricles.
c. Some of the atrial beats are blocked before reaching the AV node.
d. The ventricles are responding to a ventricular ectopic pacemaker.
ANS: B
The atrioventricular (AV) node does not allow conduction of all these impulses to the ventricles. In this case, the rhythm would be
described as atrial flutter with a 4:1 AV block, indicating that only one of every four atrial signals is conducted to the ventricles.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 254
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
43. Why is a new onset of atrial fibrillation serious?
a. It increases the patient’s risk for a stroke.
b. It increases the patient’s risk for a deep venous thrombosis.
c. It may increase cardiac output to dangerous levels.
d. It indicates the patient is about to have a myocardial infarction.
ANS: A
In atrial fibrillation the atria do not contract normally; they quiver. This increases the chance of the blood clotting in the atria
because of a lack of complete emptying of the atria. These clots can break free and cause embolic strokes and pulmonary emboli.
Atrial fibrillation does not indicate impending myocardial infarction or an increased risk of deep venous thrombosis. Atrial
fibrillation decreases cardiac output from the loss of atrial kick.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 257
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
9
44. Which electrocardiographic (ECG) abnormality is most often found in ventricular dysrhythmias?
a. Retrograde P waves
b. Wide QRS complexes
c. No P waves
d. An inverted T wave
ANS: B
Ventricular dysrhythmias result from an ectopic focus in any portion of the ventricular myocardium. The usual conduction pathway
through the ventricles is not used, and the wave of depolarization must spread from cell to cell. As a result, the QRS complex is
prolonged and is always greater than 0.12 second. It is the width of the QRS, not the height that is important in the diagnosis of
ventricular ectopy.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 252
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
45. The patient has a heart rate (HR) of 84 beats/min and a stroke volume (SV) of 65 mL. Calculate the cardiac output (CO).
a. 149 mL
b. 500 mL
c. 4650 mL
d. 5460 mL
ANS: D
Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is the volume of blood ejected by the
heart during each beat (reported in milliliters). 84 × 65 = 5460 mL.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 213
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
46. After a myocardial infarction, a patient presents with an increasing frequency of premature ventricular contractions (PVCs). The
patient's heart rate is 110 beats/min, and electrocardiogram (ECG) indicates a sinus rhythm with up to five unifocal PVCs per
minute. The patient is alert and responsive and denies any chest pain or dyspnea. What action should the nurse take next?
a. Administer lidocaine 100 mg bolus IV push stat.
b. Administer Cardizem 20 mg IV push stat.
c. Notify the physician and monitor the patient closely.
d. Nothing; PVCs are expected in this patient.
ANS: C
Although premature ventricular contractions (PVCs) are frequently present after myocardial infarction, they are not always benign.
In individuals with underlying heart disease, PVCs or episodes of self-terminating ventricular tachycardia (VT) are potentially
malignant. Nonsustained VT is defined as three or more consecutive premature ventricular beats at a rate faster than 110 beats/min
lasting less than 30 seconds. The patient does not appear symptomatic from the PVCs at this time; therefore, lidocaine is not
indicated. Cardizem is not prescribed for ventricular ectopy.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 243 | p. 259 | p. 260
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
47. A patient becomes unresponsive. The patient’s heart rate is 32 beats/min in an idioventricular rhythm; blood pressure is 60/32 mm
Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which intervention would the nurse do first?
a. Notify the physician and hang normal saline wide open.
b. Notify the physician and obtain the defibrillator.
c. Notify the physician and obtain a temporary pacemaker.
d. Notify the physician and obtain a 12-lead ECG.
ANS: C
If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their own intrinsic rate of 20 to 40 times
per minute. This is called an idioventricular rhythm and is naturally protective mechanism. Rather than trying to abolish the
ventricular beats, the aim of treatment is to increase the effective heart rate (HR) and reestablish dominance of a higher pacing site
such as the sinus node or the AV junction. Usually, a temporary pacemaker is used to increase the HR until the underlying
problems that caused failure of the other pacing sites can be resolved.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 262
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
48. What effect does ventricular tachycardia have on cardiac output?
a. Increases cardiac output due to an increase in ventricular filling time
b. Decreases cardiac output due to a decrease in stroke volume
c. Increases cardiac output due to an increase in preload
d. Decreases cardiac output due to a decrease in afterload
ANS: B
Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time for ventricular filling, decreases
stroke volume, and compromises cardiac output. Tachycardia increases heart work and myocardial oxygen demand while
decreasing oxygen supply by decreasing coronary artery filling time.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
10
49. The patient is admitted with a diagnosis of cardiogenic shock. The patient’s heart rate (HR) is 135 beats/min with weak peripheral
pulses. The patient has bilaterally crackles in the bases of the lungs. O 2 saturation is 90% on 4L/NC. The practitioner orders
diuretics and vasodilators. What response should the nurse expect after starting the medications?
a. Decreased preload and afterload
b. Increased preload and afterload
c. Decreased preload and increased afterload
d. Increased preload and decreased afterload
ANS: A
Vasodilators are used to decrease afterload, and diuretics are used to decrease preload.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 215 | p. 217
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
50. Which diagnostic tool can be used to detect structural heart abnormalities?
a. Echocardiogram
b. Electrocardiogram (ECG)
c. Exercise stress test
d. 24-hour Holter monitor
ANS: A
Echocardiography is used to detect structural heart abnormalities such as mitral valve stenosis and regurgitation, prolapse of mitral
valve leaflets, aortic stenosis and insufficiency, hypertrophic cardiomyopathy, atrial septal defect, thoracic aortic dissection, cardiac
tamponade, and pericardial effusion.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 281
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
51. What is the target range for an international normalized ratio (INR)?
a. 1.0 to 2.0
b. 1.5 to 3.0
c. 1.5 to 2.5
d. 2.0 to 3.0
ANS: D
A target international normalized ratio of 2.5 (range, 2.0 to 3.0) is desirable.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 258
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
52. What type of atrioventricular (AV) block can be described as a gradually lengthening PR interval until ultimately the final P wave
in the group fails to conduct?
a. First-degree AV block
b. Second-degree AV block, type I
c. Second-degree AV block, type II
d. Third-degree AV block
ANS: B
In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen until a P wave is not conducted. This
typically occurs in a pattern of grouped beats and is observed on the electrocardiogram (ECG) by a gradually lengthening PR
interval until ultimately the final P wave in the group fails to conduct. When all atrial impulses are conducted to the ventricles but
the PR interval is greater than 0.20 second, a condition known as first-degree AV block exists. Mobitz type II block is always
anatomically located below the AV node in the bundle of His in the bundle branches or even in the Purkinje fibers. This results in
an all-or-nothing situation with respect to AV conduction. Sinus P waves are or are not conducted. When conduction does occur, all
PR intervals are the same. Because of the anatomic location of the block, on the surface, ECG the PR interval is constant and the
QRS complexes are wide. Third-degree, or complete, AV block is a condition in which no atrial impulses can conduct from the
atria to the ventricles. This is also described by the term complete heart block.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 267
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
53. Which blood test standardizes prothrombin time (PT) results among worldwide clinical laboratories?
a. aPTT
b. ACT
c. HDL
d. INR
ANS: D
The international normalized ratio (INR) was developed by the World Health Organization in 1982 to standardize prothrombin time
results among clinical laboratories worldwide. High-density lipoproteins (HDLs) are particles of the total serum cholesterol.
Activated coagulation time (ACT) is also known as the activated clotting time. The ACT is a point of care test that is performed
outside of the laboratory setting in areas such as the cardiac catheterization laboratory, the operating room, or critical care units.
The activated partial thromboplastin time (aPTT) is used to measure the effectiveness of intravenous or subcutaneous
ultrafractionated heparin therapy.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 274
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
11
54. On returning from the cardiac catheterization laboratory, the patient asks if he can get up in the chair. What should the nurse tell the
patient?
a. “You cannot get up because you may pass out.”
b. “You cannot get up because you may start bleeding.”
c. “You cannot get up because you may fall.”
d. “You cannot get up until you urinate.”
ANS: B
After catheterization, the patient remains flat for up to 6 hours (varies by institutional protocol and catheter size) to allow the
femoral arterial puncture site to form a stable clot. Most bleeding occurs within the first 2 to 3 hours after the procedure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 275
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
55. Which statement made by a patient would indicate the need for further education before an electrophysiology procedure?
a. “I need to take all my heart medications the morning of the procedure.”
b. “The doctor is going to make my heart beat wrong on purpose.”
c. “I will be awake but relaxed during the procedure.”
d. “I will be x-rayed during the procedure.”
ANS: A
All antidysrhythmic medications are discontinued several days before the study so that any ventricular dysrhythmias may be readily
induced during the electrophysiology procedure (EPS). Anticoagulants, especially warfarin, are also stopped before EPS.
Premedication is administered before the study to induce a relaxed state, and during the procedure, the patient is conscious but
receives sedative agents (midazolam) at regular intervals.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 276
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
56. A positive signal-averaged electrocardiogram (ECG) indicates that a patient is at risk for what problem?
a. Myocardial infarction
b. Sudden cardiac death
c. Coronary artery disease
d. Stroke
ANS: B
A positive signal-averaged electrocardiogram (ECG)—in combination with other specific indicators—is a predictor of increased
risk for sudden cardiac death. Many patients with a positive signal-averaged ECG (abnormal) display a normal signal-averaged
ECG when placed on antidysrhythmic medications. The signal-averaged ECG is not analyzed in isolation. It is used in conjunction
with other cardiac diagnostic tests, including the electrophysiology study (EPS). It is a helpful adjunct to the EPS but does not
replace it.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 281
OBJ: Nursing Process Step: Evaluation
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
57. Zeroing the pressure transducer on hemodynamic monitoring equipment occurs when the displays reads which number?
a. 0
b. 250
c. 600
d. 760
ANS: A
The monitor is adjusted so that “0” is displayed, which equals atmospheric pressure. Atmospheric pressure is not zero; it is 760 mm
Hg at sea level. Using zero to represent current atmospheric pressure provides a convenient baseline for hemodynamic
measurement purposes.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 199
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
58. Which statement expresses the correct order when working with an invasive pressure monitor?
a. Level the transducer, locate the phlebostatic axis, zero the transducer, and take the
b.
c.
d.
reading.
Locate the phlebostatic axis, level the transducer, zero the transducer, and take the
reading.
Take the reading, level the transducer, locate the phlebostatic axis, and zero the
transducer.
Locate the phlebostatic axis, zero the transducer, level the transducer, and take the
reading.
ANS: B
The correct order is locate the phlebostatic axis, level the transducer, zero the transducer, and take the reading. The transducer
cannot be zeroed before it is leveled. Readings cannot be taken before the transducer is zeroed, and leveling the transducer cannot
occur until the phlebostatic axis has been identified.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 199
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
12
59. A patient’s central venous pressure (CVP) reading suddenly increased from 10 to 48 mm Hg. His lungs are clear except for fine
rales at the bases. What should the nurse do next?
a. Nothing as this reading is still within normal limits.
b. Place a STAT call into the physician.
c. Administer ordered prn Lasix.
d. Check the level of the transducer.
ANS: D
If the transducer falls below the correct level, the reading would be falsely elevated. This rise is consistent with a transducer having
fallen from the correct level on the bed to the floor. Lasix is not indicated. Central venous pressure (CVP) of 45 mm Hg, if true, is
severely elevated. Not enough information has been provided to call the physician. If the CVP value is true and the patient’s
condition is poor, a call to the physician would be appropriate after assessment.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 200
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
60. Why is the Allen test performed before placement of a radial arterial line placement?
a. To evaluate collateral circulation to the hand
b. To estimate patency of the radial artery
c. To appraise the neurologic function of the hand
d. To assess the sensitivity of the insertion point
ANS: A
The Allen test involves occluding the radial or ulnar artery after blanching the hand. If the hand turns pink, then the nonoccluded
artery provides enough circulation to the hand. If the hand remains blanched, then no collateral circulation exists, and that wrist
should not be used for arterial line placement.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 202
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
61. Which statement regarding the use of cuff blood pressures is true?
a. Cuff pressures may be unreliable when a patient is in shock.
b. Cuff pressures are more accurate than arterial line pressures.
c. Cuff pressures and arterial line pressures should be nearly identical.
d. Cuff pressures should not be compared to arterial line pressures.
ANS: A
If the arterial line becomes unreliable or dislodged, a cuff pressure can be used as a reserve system. In the normotensive,
normovolemic patient, little difference exists between the arm cuff blood pressure and the intravascular catheter pressure, and
differences of 5 to 10 mm Hg do not generally alter clinical management. The situation is different if the patient has a low cardiac
output (CO) or is in shock. The concern is that the cuff pressure may be unreliable because of peripheral vasoconstriction, and an
arterial line is generally required. It is usual practice to compare a cuff pressure after the arterial line is inserted .
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 202
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
62. A patient’s arterial line waveform has become damped. What action should the nurse take to correct the situation?
a. Check for kinks, blood, and air bubbles in the pressure tubing.
b. Prepare for a normal saline fluid challenge for hypotension.
c. Discontinue the arterial line as it has become nonfunctional.
d. Check the patient’s lung sounds for a change in patient condition.
ANS: A
A damped waveform occurs when communication from the artery to the transducer is interrupted and produces false values on the
monitor and oscilloscope. Damping is caused by a fibrin “sleeve” that partially occludes the tip of the catheter, by kinks in the
catheter or tubing, or by air bubbles in the system.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 206 | Table 13-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
63. Patient education for a patient with a Holter monitor should include which instruction?
a. Keep a diary of activities, symptoms, and any medications that are taken.
b. Do not drink coffee while the recorder is on.
c. Do not take a bath but a shower is alright.
d. Carry the monitor in a purse or backpack.
ANS: A
The patient should be instructed to keep a diary of activities, symptoms, and any medications that are taken and to carry the
monitor by a shoulder strap or clipped to a belt or pocket. The only activities that are restricted while wearing a Holter monitor are
those that would get the chest electrodes or monitor wet, eliminating swimming and taking a shower or tub bath. The patient can
drink coffee during the test.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 279
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
13
64. A 55-year-old patient is scheduled for a stress test. What is the estimation of the patient’s maximal predicted heart rate?
a. 65 beats/min
b. 155 beats/min
c. 165 beats/min
d. 265 beats/min
ANS: C
The maximal predicted heart rate is estimated using the formula: 220 – Patient’s age: 220 – 55 = 165.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 280
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
65. Which of the following is most indicative of decreased left ventricular preload?
a. Increased pulmonary artery occlusion pressure (PAOP)
b. Decreased pulmonary artery occlusion pressure (PAOP)
c. Increased central venous pressure (CVP)
d. Decreased central venous pressure (CVP)
ANS: B
Pulmonary artery occlusion pressure (PAOP) normally reflects the pressure in the left ventricle at the end of diastole. Left
ventricular end-diastolic pressure is preload, and so an increase in preload will first increase the PAOP measurements and vice
versa. Central venous pressure changes are reflective of right ventricular preload.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 213 | Table 13-1
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
66. What is the effect of preload on cardiac output?
a. As preload increases, cardiac output increases.
b. As preload increases, cardiac output decreases.
c. As preload increases, cardiac output increases until it overstretches the ventricle
d.
and cardiac output decreases.
Increased preload has no effect on cardiac output.
ANS: C
According to the Frank-Starling law of the heart, if preload increases stroke volume, then cardiac output may increase. If, however,
preload causes excessive left ventricular stretch, it can actually decrease cardiac output and may result in congestive heart failure.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 214
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
67. Which condition can cause an artificial increase in the pulmonary artery occlusion pressure (PAOP)?
a. Aortic regurgitation
b. Aortic stenosis
c. Mitral stenosis
d. Mitral regurgitation
ANS: D
If mitral regurgitation is present, the mean pulmonary artery occlusion pressure reading is artificially elevated because of abnormal
backflow of blood from the left ventricle to the left atrium during systole.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 215
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
68. The patient’s admitting 12-lead ECG shows wide, M-shaped P waves. What diagnosis could be responsible for this finding?
a. Mitral stenosis
b. Chronic pulmonary disease
c. Hypotension
d. Pericarditis
ANS: A
Wide, M-shaped P waves are seen in left atrial hypertrophy and are called P mitrale because left atrial hypertrophy is often caused
by mitral stenosis.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 245
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
14
69. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: B
The electrocardiographic tracing in atrial fibrillation is notable for an uneven atrial baseline that lacks clearly defined P waves and
instead shows rapid oscillations or fibrillatory wavelets that vary in size, shape, and frequency. Junctional escape rhythm has a rate
of 40 to 60 beats/min and regular rhythm but P waves maybe present or absent, inverted in lead II, PR interval less than 0.12
second, and QRS complex is 0.06 to 0.10 seconds. With premature ventricular contractions, the QRS can manifest in an unlimited
number of shapes or patterns. If all of the ventricular ectopic beats look the same in a particular lead, they are called unifocal,
which means that they probably all result from the same irritable focus. Ventricular tachycardia is caused by a ventricular pacing
site firing at a rate of 100 times or more per minute, usually maintained by a re-entry mechanism within the ventricular tissue. The
complexes are wide, and the rhythm may be slightly irregular, often accelerating as the tachycardia continues.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 256
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
70. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: A
Under normal conditions, the junction never has a chance to escape and depolarize the heart because it is overridden by the sinus
node. However, if the sinus node fails, the junctional impulses can depolarize completely and pace the heart. In this strip, the
ventricular rate is 38. P waves are absent, and the QRS has a normal width.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 260
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
15
71. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: C
When all of the ventricular ectopic beats look the same in a particular lead, they are called unifocal, which is what is shown in this
strip. This means that they probably all result from the same irritable focus.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 260
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
72. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: D
Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or more per minute, usually maintained by
a re-entry mechanism within the ventricular tissue. The complexes are wide, and the rhythm may be slightly irregular, often
accelerating as the tachycardia continues. In most cases, the sinus node is not affected, and it continues to depolarize the atria on
schedule. P waves can sometimes be seen on the electrocardiographic tracing. They are not related to the QRS and may even
appear to conduct a normal impulse to the ventricles if their timing is just right.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
16
73. Identify the rhythm.
a.
b.
c.
d.
Ventricular tachycardia
Ventricular fibrillation
Supraventricular tachycardia
Torsades de pointes
ANS: B
On an electrocardiogram, ventricular fibrillation appears as a continuous, undulating pattern without clear P, QRS, or T waves.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 264
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
74. Which noninvasive imaging technique is useful in diagnosing complications of a myocardial infarction (MI)?
a. 12-lead ECG
b. CT
c. MRI
d. Echocardiography
ANS: C
Magnetic resonance imaging is useful in diagnosing complications of myocardial infarction, such as pericarditis or pericardial
effusion, valvular dysfunction, ventricular septal rupture, aneurysm, and intracardiac thrombus. Computed tomography is used to
calculate the coronary artery calcium score. Echocardiography uses ultrasound reflected best at interfaces between tissues that have
different densities. In the heart, these are the blood, cardiac valves, myocardium, and pericardium. Because all these structures
differ in density, their borders can be seen on the echocardiogram. The standard 12-lead electrocardiogram provides a picture of
electrical activity in the heart using 10 different electrode positions to create 12 unique views of electrical activity occurring within
the heart.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 284
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
17
Chapter 14: Cardiovascular Disorders
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which statement about coronary artery disease (CAD) is accurate?
a. There is a low correlation between modifiable risk factors and CAD.
b. The onset of CAD occurs in middle age women sooner than men of the same age.
c. There is an association between development of specific risk factors and CAD.
d. The lower the C-reactive protein level, the higher the risk for a coronary event.
ANS: C
Research and epidemiologic data collected during the past 50 years have demonstrated a strong association between specific risk
factors and the development of coronary artery disease (CAD). In general, CAD symptoms are seen in persons aged 45 years and
older. Primary cardiovascular risk factors are different in men and women, with women having higher rates of diabetes and
hypertension compared with men. C-reactive protein (CRP) is associated with an increased risk for development of other
cardiovascular risk factors including diabetes, hypertension, and weight gain. The higher the value, the greater the risk of a
coronary event, especially if all other potential causes of systemic inflammation such as infection can be ruled out.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 290
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. Which value, when elevated, places the patient at lowest risk for coronary artery disease (CAD)?
a. Very-low-density lipoproteins (VLDLs)
b. Triglycerides
c. Low-density lipoproteins (LDLs)
d. High-density lipoproteins (HDLs)
ANS: D
All of the reasons are not completely understood, but one recognized physiologic effect is the ability of high-density lipoprotein
(HDL) to promote the efflux of cholesterol from cells. This process may minimize the accumulation of foam cells in the artery wall
and thus decrease the risk of developing atherosclerosis. High HDL levels confer both antiinflammatory and antioxidant benefits on
the arterial wall. In contrast, a low HDL level is an independent risk factor for the development of CAD and other atherosclerotic
conditions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 290 | p. 291 | Table 14-1
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108, respiratory rate 24, temperature 103° F,
and oxygen saturation of 94% on oxygen 2L nasal cannula. The patient is responsive and denies chest pain. The physician has
ordered a work-up for coronary artery disease (CAD). These findings are suggestive of which diagnosis?
a. Silent ischemia
b. Prehypertension
c. Stage 1 hypertension
d. Stage 2 hypertension
ANS: D
Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and a diastolic blood pressure of 100 mm Hg
or above.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 348 | Table 14-2
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. Which statement regarding the difference between stable and unstable angina is accurate?
a. Stable angina responds predictably well to nitrates.
b. Stable angina is not precipitated by activity.
c. Stable angina has a low correlation to coronary artery disease (CAD).
d. Stable angina is a result of coronary artery spasm.
ANS: A
Stable angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Pain control is
usually achieved by rest and by sublingual nitroglycerin within 5 minutes. Stable angina is the result of fixed lesions (blockages) of
more than 75% of the coronary artery lumen and thus has a high correlation to coronary artery disease (CAD), not coronary spasm.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. The nursing management plan for a patient with angina would include which intervention?
a. Immediate administration of antiplatelet therapy
b. Teaching the patient how to perform the Valsalva maneuver
c. Assessment and documentation of chest pain episodes
d. Administration of prophylactic lidocaine for ventricular ectopy
ANS: C
Nursing interventions focus on early identification of myocardial ischemia, control of chest pain, recognition of complications,
maintenance of a calm environment, and patient and family education. It is important to document the characteristics of the pain
and the patient’s heart rate and rhythm, blood pressure, respirations, temperature, skin color, peripheral pulses, urine output,
mentation, and overall tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced
expiration against a closed glottis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. Why do women have higher mortality rates from acute myocardial infarction (MI) than men?
a. Women wait longer to seek medical care.
b. Women have more risk factors for coronary artery disease than men.
c. Women have a higher risk of coronary spasm than men.
d. Women have smaller hearts than men.
ANS: A
Many reasons contribute to higher mortality rates from acute myocardial infarction (MI) in women, and these include waiting
longer to seek medical care, having smaller coronary arteries, being older when symptoms occur, and experiencing very different
symptoms from those of men of the same age. Women do not have a higher risk of coronary spasm than men.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 293
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. What dysrhythmia is most frequently associated with sudden cardiac death?
a. Premature ventricular contractions
b. Ventricular tachycardia
c. Third degree heart block
d. Asystole
ANS: B
When the onset of symptoms is rapid, the most likely mechanism of death is ventricular tachycardia, which degenerates into
ventricular fibrillation.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 306 | p. 315
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. Assessment of a patient with pericarditis may reveal which signs and symptoms?
a. Ventricular gallop and substernal chest pain
b. Narrowed pulse pressure and shortness of breath
c. Pericardial friction rub and pain
d. Pericardial tamponade and widened pulse pressure
ANS: C
Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common initial sign. A friction rub is
best auscultated with a stethoscope at the sternal border and is described as a grating, scraping, or leathery scratchin g. Pericarditis
frequently produces a pericardial effusion.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 311
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. What are the clinical manifestations of right-sided heart failure?
a. Elevated central venous pressure and sacral edema
b. Pulmonary congestion and jugular venous distention
c. Hypertension and chest pain
d. Liver tenderness and pulmonary edema
ANS: A
The common manifestations of right ventricular failure are the following: jugular venous distention, elevated central venous
pressure, weakness, peripheral or sacral edema, hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal
symptoms include poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 320
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. Which intervention is an essential aspect of the patient teaching plan for the patient with chronic heart failure?
a. Instructing the patient to call the practitioner prior to dental surgery
b. Stressing the importance of compliance with diuretic therapy
c. Instructing the patient to take nitroglycerin if chest pain occurs
d. Teaching the patient how to take an apical pulse
ANS: B
Primary topics of education include (1) the importance of a daily weight, (2) fluid restrictions, and (3) written information about the
multiple medications used to control the symptoms of heart failure. Reduction or cessation of diuretics usually results in sodium
and water retention, which may precipitate heart failure.
PTS: 1
DIF: Cognitive Level: Creating
REF: p. 326
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
11. In the acute phase after ST segment elevation myocardial infarction (STEMI), fibrinolytic therapy is used in combination with
heparin to recanalize the coronary artery. What dosage is the initial heparin bolus?
a. 60 units/kg maximum 5000 units
b. 30 units/kg maximum 3000 units
c. 25 units/kg maximum of 2500 units
d. 12 units/kg maximum of 1000 units
ANS: A
In the acute phase after ST segment elevation myocardial infarction, heparin is administered in combination with fibrinolytic
therapy to recanalize (open) the coronary artery. For patients who will receive fibrinolytic therapy, an initial heparin bolus of 60
units/kg (maximum, 5000 units) is given intravenously followed by a continuous heparin drip at 12 units/kg/h (maximum 1000
units/h) to maintain an activated partial thromboplastin time between 50 and 70 seconds (1.5 to 2.0 times control).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 313
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. The nurse is caring for a patient with left-sided heart failure. The nurse suspects the patient is developing pulmonary edema. Which
finding would confirm the nurse’s suspicions?
a. Pulmonary crackles
b. Peripheral edema
c. Pink, frothy sputum
d. Elevated central venous pressure
ANS: C
Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and have a sensation of suffocation.
They expectorate pink, frothy sputum and feel as if they are drowning. They may sit bolt upright, gasp for breath, or thrash about.
The respiratory rate is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck muscles.
Respirations are characterized by loud inspiratory and expiratory gurgling sounds.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 324
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. A patient is admitted with hypertrophic cardiomyopathy. The nurse would expect the medical management of this patient to include
which intervention?
a. Administration of beta-blockers
b. Administration of positive inotropes
c. Plans for intensive exercise regimen
d. Plans for an aortic valve replacement
ANS: A
Pharmacologic management includes beta-blockers to decrease left ventricular workload, medications to control and prevent atrial
and ventricular dysrhythmias, anticoagulation if atrial fibrillation or left ventricular thrombi are present, and, finally, drugs to
manage heart failure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 327
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. The nurse is developing a patient education plan for a patient with valvular heart disease. Which instruction would be included as
part of that plan?
a. Increase fluid intake to increase cardiac output.
b. Take sodium replacement tablets to replace sodium lost with diuretics.
c. Increase daily activity until shortness of breath occurs.
d. Take prophylactic antibiotics before undergoing any invasive procedure.
ANS: D
Education for the patient with acute or chronic heart failure secondary to valvular dysfunction includes (1) information related to
diet, (2) fluid restrictions, (3) the actions and side effects of heart failure medications, (4) the need for prophylactic antibiotics
before undergoing any invasive procedures such as dental work, and (5) when to call the health care provider to report a negative
change in cardiac symptoms.
PTS: 1
DIF: Cognitive Level: Creating
REF: p. 342
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. A patient has been admitted in hypertensive crisis. Which medication would the nurse expect the practitioner to order for this
patient?
a. Digitalis
b. Vasopressin
c. Verapamil
d. Sodium nitroprusside
ANS: D
Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive emergency. Sodium nitroprusside is
useful because of its half-life of seconds. It is not suitable for long-term use because of development of a metabolite that causes
cyanide-like toxicity. Short-acting beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective
if aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 352 | p. 353
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. Which description best describes the pain associated with aortic dissection?
a. Substernal pressure
b. Tearing in the chest, abdomen, or back
c. Numbness and tingling in the left arm
d. Stabbing in the epigastric area
ANS: B
The classic clinical presentation is the sudden onset of intense, severe, tearing pain, which may be localized initially in the chest,
abdomen, or back. As the aortic tear (dissection) extends, pain radiates to the back or distally toward the lower extremities. Many
patients have hypertension upon initial presentation, and the focus is on control of blood pressure and early operation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 343
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. Which clinical manifestation is usually the first symptom of peripheral arterial disease (PAD)?
a. Cramping when walking
b. Thrombophlebitis
c. Pulmonary embolism
d. Cordlike veins
ANS: A
Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces ischemic muscle pain known as
intermittent claudication. This cramping, aching pain while walking is often the first symptom of peripheral arterial occlusive
disease. The pain is relieved by rest and may remain stable in occurrence and intensity for many years.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 346
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. The nurse is developing a patient education plan for the patient with endocarditis. What information would be included in the plan?
a. Endocarditis is a viral infection that is easily treated with antibiotics.
b. The risk of this diagnosis is occlusion of the coronary arteries.
c. A long course of antibiotics is needed to treat this disorder.
d. Complications are rare after antibiotics have been started.
ANS: C
Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the specific infective endocarditis
microbe and patient circumstances. Antibiotic treatment is prolonged, administered in high doses intravenously, and may involve
combination therapy. Best outcomes are achieved if therapy is initiated before hemodynamic compromise.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 355
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
19. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the
area of infarction. Which finding on the ECG is most conclusive for infarction?
a. Inverted T waves
b. Tall, peaked T waves
c. ST segment depression
d. Pathologic Q waves
ANS: D
The changes in repolarization are seen by the presence of new Q waves. These new, pathologic Q waves are deeper and wider than
tiny Q waves found on the normal 12-lead ECG.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 301
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram (ECG) is done to validate the
area of infarction. Which leads on the ECG would correlate with an inferior wall MI?
a. II, III, aVF
b. V5 to V6, I, aVL
c. V2 to V4
d. V1 to V2
ANS: A
Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF. Lateral wall infarctions are
manifested by ECG changes in leads V5 to V6, I, and aVL. Anterior wall infarctions are manifested by ECG changes in leads V2 to
V4. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 307
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. A patient is admitted with an acute myocardial infarction (MI). What common complication should the nurse anticipate in this
patient?
a. Pulmonary edema
b. Cardiogenic shock
c. Dysrhythmias
d. Deep vein thrombosis
ANS: C
Many patients experience complications occurring either early or late in the postinfarction course. These complications may result
from electrical dysfunction or from a cardiac contractility problem. Cardiac monitoring for early detection of ventricular
dysrhythmias is ongoing. Pumping complications can cause heart failure, pulmonary edema, and cardiogenic shock. The presence
of a new murmur in a patient with an acute myocardial infarction warrants special attention because it may indicate rupture of the
papillary muscle. The murmur can be indicative of severe damage and impending complications such as heart failure and
pulmonary edema.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 304
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Which classification of dysrhythmia is most common with an inferior wall infarction in the first hour after ST segment elevation
myocardial infarction (STEMI)?
a. Sinus tachycardia
b. Multifocal PVCs
c. Atrial fibrillation
d. Sinus bradycardia
ANS: D
Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain an acute myocardial infarction
(MI). It is more prevalent with an inferior wall infarction in the first hour after ST segment elevation MI. Sinus tachycardia (heart
rate more than 100 beats/min) most often occurs with an anterior wall MI. Premature atrial contractions (PACs) occur frequently in
patients who sustain an acute MI. Atrial fibrillation is also common and may occur spontaneously or may be preceded by PACs.
Premature ventricular contractions (PVCs) are seen in almost all patients within the first few hours after an MI.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 304
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. Which laboratory value indicates a heightened risk for the development of coronary artery disease (CAD)?
a. Total cholesterol level of 170 mg/dL
b. HDL cholesterol level of 30 mg/dL
c. Triglyceride level of 120 mg/dL
d. LDL cholesterol level >190 mg/dL
ANS: D
Low-density lipoprotein (LDL) cholesterol is usually described as the “bad cholesterol” because high levels are associated with an
increased risk of acute coronary syndrome (ACS), stroke, and peripheral arterial disease (PAD). High LDL levels initiate the
atherosclerotic process by infiltrating the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol
levels below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at low risk of coronary
artery disease. Triglyceride levels below 150 are considered normal.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 291
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
24. A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly awakened with severe chest pain.
Three nitroglycerin sublingual tablets are administered 5 minutes apart without relief. A 12-lead electrocardiograph (ECG) reveals
nonspecific ST segment elevation. The nurse suspects the patient may have which disorder?
a. Silent ischemia
b. Stable angina
c. Unstable angina
d. Prinzmetal angina
ANS: C
Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or may necessitate more than
nitrates for pain relief. A change in the level or frequency of symptoms requires immediate medical evaluation. Severe angina that
persists for more than 5 minutes worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical emergency. Stable
angina is predictable and caused by similar precipitating factors each time; typically, it is exercise induced. Patients become used
to the pattern of this type of angina and may describe it as “my usual chest pain.” Pain control should be achieved within 5 minutes
of rest and by taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of ischemia is
observed on an electrocardiographic monitor but the person does not complain of anginal symptoms. Variant unstable angina, or
Prinzmetal angina, is caused by a dynamic obstruction from intense vasoconstriction of a coronary artery. Spasm can occur with or
without atherosclerotic lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic, occurring at
the same time every day.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
25. A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot about his diagnosis already because his
father had the same diagnosis 15 years ago. The nurse asks him to state what he already knows about angina. Which response
indicates the need for additional education?
a. He should stop smoking.
b. He can no longer drink colas or coffee.
c. He can no longer get a strong back massage.
d. He should take stool softeners to prevent straining.
ANS: C
Longer term education of the patient and the family can begin. Points to cover include (1) risk factor modification, (2) signs and
symptoms of angina, (3) when to call the physician, (4) medications, and (5) dealing with emotions and stress. It is essential to
teach avoidance of the Valsalva maneuver, which is defined as forced expiration against a closed glottis. This can be explained to
the patient as “bearing down” during defecation or breath holding when repositioning in bed. Relaxation therapy and techniques
including back rubs are encouraged when appropriate.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 301
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. A patient presents with severe substernal chest pain. The patient exclaims, “This is the most severe pain I have ever felt!” The
patient reports that the pain came on suddenly about 2 hours ago and that three sublingual nitroglycerin tablets have not relieved
the pain. The 12-lead electrocardiogram (ECG) reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and
V5; pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4. Which statement is accurate
about this patient?
a. This patient has an old lateral wall infarction.
b. This patient is having an inferior wall infarction.
c. This patient is having an acute anterior wall infarction.
d. This patient is having a posterior wall infarction.
ANS: C
Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to V4. Inferior infarctions are
manifested by ECG changes in leads II, III, and aVF. Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I,
and aVL. Posterior wall infarctions are manifested by ECG changes in leads V1 to V2.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 303
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
27. A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains of fatigue, not sleeping the past
two nights, and change in appetite. Based on these findings the nurse suspects the patient may be experiencing which problem?
a. Angina
b. Anxiety
c. Depression
d. Endocarditis
ANS: C
Depression is a phenomenon that occurs across a wide spectrum of human experience. Key symptoms of depression mentioned
frequently by cardiac patients are fatigue, change in appetite, and sleep disturbance.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 314
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
28. Patient is admitted with heart failure. The patient has developed dyspnea with wheezing, a nonproductive cough, and pulmonary
crackles that progress to the gurgling sounds of pulmonary edema. The nurse suspects the patient may be developing with problem?
a. Dyspnea
b. Orthopnea
c. Paroxysmal nocturnal dyspnea
d. Cardiac asthma
ANS: D
Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary edema
are symptoms of cardiac asthma. With dyspnea, the patient feels shortness of breath from pulmonary vascular congestion and
decreased lung compliance. In orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous
return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of orthopnea in which the patient awakens
from sleep gasping for air.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 324
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29. A patient is admitted for palliative care for end-stage heart failure. What is the nurse’s primary goal when caring for this patient?
a. To reverse heart failure with the use of diuretics
b. To increase activity tolerance
c. To manage symptoms and relieve pain
d. To increase cardiac output related to alteration of contractility
ANS: C
The primary aim of palliative care is symptom management and the relief of suffering. Fundamental to all symptom management
strategies for heart failure is the optimization of medications, according to current guidelines.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 325
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
30. A patient is admitted with a fever of unknown origin. The patient is complaining of fatigue, malaise, joint pain, and shivering. The
patient’s vital signs include temperature, 103° F; heart rate, 90 beats/min; respiratory rate, 22 breaths/min; blood pressure, 132/78;
and oxygen saturation, 94% on 2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient
has developed which problem?
a. Coronary artery disease
b. Heart failure
c. Endocarditis
d. Pulmonary embolus
ANS: C
Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise, with up to 50% of patients
complaining of myalgias and joint pain. Blood cultures are drawn during periods of elevated temperature.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 336
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
31. At what size is an aortic aneurysm evaluated for surgical repair or stent placement?
a. 2 cm
b. 4 cm
c. 5 cm
d. >5 cm
ANS: D
An aneurysm smaller than 4 cm in diameter can be managed on an outpatient basis with frequent blood pressure monitoring and
ultrasound testing to document any changes in the size of the aneurysm. Management includes weight loss, smoking cessation, and
control of hypertension as appropriate. An aortic aneurysm larger than 5 cm in diameter requires evaluation for surgical repair or
placement of an aortic stent to eliminate the risk of rupture.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 343
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
MULTIPLE RESPONSE
1. Which physiologic effects can be associated with physical exercise? (Select all that apply, one, some, or all.)
a. Decreased LDL cholesterol
b. Increased HDL cholesterol
c. Decreased triglycerides
d. Increased insulin resistance
e. Decreased incidence of depression
ANS: A, B, C, E
Many research trials have demonstrated the positive effects of physical activity on the other major cardiac risk factors. Exercise
alters the lipid profile by decreasing low-density lipoprotein (LDL) cholesterol and triglyceride levels and increasing high-density
lipoprotein (HDL) cholesterol levels. Exercise reduces insulin resistance at the cellular level, lowering the risk for d eveloping type
2 diabetes, especially if combined with a weight loss program.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 292
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders
MSC: NCLEX: Physiologic Integrity
2. Which clinical manifestations are indicative of left ventricular failure? (Select all that apply, one, some, or all.)
a. Cool, pale extremities
b. Jugular venous distention
c. Liver tenderness
d. Weak peripheral pulses
e. Rales
ANS: A, D, E
Patients presenting with left ventricular failure have one of the following: (1) decreased exercise tolerance, (2) fluid retention, or
(3) discovery during examination of noncardiac problems. Clinical manifestations of left ventricular failure include decreased
peripheral perfusion with weak or diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 318 | p. 319
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders
MSC: NCLEX: Physiologic Integrity
3. Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply, one, some, or all.)
a. Coronary artery thrombosis
b. Plaque rupture
c. Coronary artery spasm near the ruptured plaque
d. Preinfarction angina
e. Hyperlipidemia
ANS: A, B, C
The three mechanisms that block the coronary artery and are responsible for the acute reduction in oxygen delivery to the
myocardium are (1) plaque rupture, (2) new coronary artery thrombosis, and (3) coronary artery spasm close to the ruptured plaque.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 301
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
8
Chapter 15: Cardiovascular Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The possibility of microshock when handling a temporary pacemaker can be minimized by which intervention?
a. Decreasing the milliamperes
b. Wearing gloves
c. Positioning the patient on the left side
d. Wearing rubber-soled shoes
ANS: B
The possibility of “microshock” can be minimized by wearing gloves when handling the pacing wires and by proper insulation of
terminal pins of pacing wires when they are not in use. The latter can be accomplished either by using caps provided by the
manufacturer or by improvising with a plastic syringe or section of disposable rubber glove. The wires are to be taped securely to
the patient’s chest to prevent accidental electrode displacement.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 366 | Box 15-6
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Safe and Effective Care Environment
2. Which hemodynamic alteration is the most common cause of a decrease in cardiac output in the postoperative cardiovascular
patient?
a. Reduced preload
b. Increased afterload
c. Increased contractility
d. Bradycardia
ANS: A
In most patients, reduced preload is the cause of low postoperative cardiac output. To enhance preload, volume may be
administered in the form of crystalloid, colloid, or packed red blood cells.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 386
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. A patient has an implantable cardioverter defibrillator (ICD) for chronic ventricular tachydysrhythmias. What action should the
nurse take when the patient’s rhythm deteriorates to ventricular fibrillation?
a. Apply an external defibrillator to the patient.
b. Call a code and start cardiopulmonary resuscitation (CPR) on the patient.
c. Wait for the ICD to defibrillate the patient.
d. Turn the ICD off and administer epinephrine.
ANS: C
If the dysrhythmia deteriorates into ventricular fibrillation, the implantable cardioverter defibrillator is programmed to defibrillate
at a higher energy. If the dysrhythmia terminates spontaneously, the device will not discharge.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 368
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. How does a percutaneous transluminal coronary angioplasty (PTCA) improve blood flow?
a. The balloon stretches the vessel wall, fractures the plaque, and enlarges the vessel
b.
c.
d.
lumen.
Medication is delivered through the catheter that dissolves the plague and
enhances vessel patency.
The balloon removes blood clots from the vessel improving patency of the vessel.
The balloon compresses the plaque against the vessel wall enlarging the vessel
lumen.
ANS: A
Percutaneous transluminal coronary angioplasty involves the use of a balloon-tipped catheter that, when advanced through an
atherosclerotic lesion (atheroma), can be inflated intermittently for the purpose of dilating the stenotic area and improving blood
flow through it. The high balloon-inflation pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 374 | p. 375
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. What is the rationale for administrating a fibrinolytic agent to a patient experiencing acute ST-elevation myocardial infarction
(STEMI)?
a. Dilation of the blocked coronary artery
b. Anticoagulation to prevent formation of new emboli
c. Dissolution of atherosclerotic plaque at the site of blockage
d. Restoration of blood flow via lysis of the thrombus
ANS: D
The administration of a fibrinolytic agent results in the lysis of the acute thrombus, thus recanalizing, or opening, the obstructed
coronary artery and restoring blood flow to the affected tissue. After perfusion is restored, adjunctive measures are taken to prevent
further clot formation and reocclusion.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 370
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. A nurse is providing care to a patient on fibrinolytic therapy. Which statements from the patient warrants further assessment and
intervention by the nurse?
a. “My back is killing me!”
b. “There is blood on my toothbrush!”
c. “Look at the bruises on my arms!”
d. “My arm is bleeding where my IV is!”
ANS: A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture
sites are common and not causes for concern. However, severe lower back pain and ecchymoses are suggestive of retroperitoneal
bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors,
or both are administered.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 373 | Box 15-12
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. Which finding is a reliable indicator of reperfusion after fibrinolytic therapy?
a. Dysrhythmias
b. Q waves
c. Elevated ST segments
d. Immediate rapid decrease in cardiac biomarkers
ANS: A
Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored. Another reliable indicator of
reperfusion is the appearance of various “reperfusion” dysrhythmias. Premature ventricular contractions, bradycardias, heart block,
ventricular tachycardia, and (rarely) ventricular fibrillation may occur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 373
OBJ: Nursing Process Step: Evaluation
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. What is the most common complication of fibrinolytic therapy?
a. Reperfusion chest pain
b. Lethargy
c. Bleeding
d. Heart blocks
ANS: C
The most common complication related to thrombolysis is bleeding.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 373
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. Which mechanism is responsible for the augmentation of coronary arterial blood flow and increased myocardial oxygen supply
seen with the intraaortic balloon pump?
a. The vacuum created in the aorta as a result of balloon deflation
b. Diastolic inflation with retrograde perfusion
c. Forward flow to the peripheral circulation
d. Inflation during systole to augment blood pressure
ANS: B
The blood volume in the aorta below the level of the balloon is propelled forward toward the peripheral vascular system, which
may enhance renal perfusion. Subsequently, the deflation of the balloon just before the opening of the aortic valve creates a
potential space or vacuum in the aorta, toward which blood flows unimpeded during ventricular ejection. This decreased resistance
to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and reduces myocardial oxygen demands.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 391
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. What parameter must be assessed frequently in the patient with an intraaortic balloon in place?
a. Skin turgor in the affected extremity
b. Peripheral pulses distal to the insertion site
c. Blood pressures in both arms and legs
d. Oxygen saturation
ANS: B
One complication of intraaortic balloon support is lower extremity ischemia resulting from occlusion of the femoral artery by the
catheter itself or by emboli caused by thrombus formation on the balloon. Although ischemic complications have decreased with
sheathless insertion techniques and the introduction of smaller balloon catheters, evaluation of peripheral circulation remains an
important nursing assessment. The presence and quality of peripheral pulses distal to the catheter insertion site are assessed
frequently along with color, temperature, and capillary refill of the involved extremity. Signs of diminished perfusion must be
reported immediately.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 392
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
11. Which statement regarding beta-blockers is correct?
a. They increase heart rate and are contraindicated in tachydysrhythmias.
b. They result in bronchospasm and should not be used in patients with chronic
c.
d.
obstructive pulmonary disease (COPD).
They increase cardiac output and help with left ventricular failure.
They are helpful in increasing atrioventricular node conduction and are used in
heart blocks.
ANS: B
Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the therapeutic responses brought
about by beta-blockade but also the potential adverse effects of these agents. For example, bronchospasm can be precipitated by
noncardioselective beta-blockers in a patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2
receptors in the lungs.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 399
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. Adenosine is an antidysrhythmic agent that is given primarily what reason?
a. To convert supraventricular tachycardias
b. To suppress premature ventricular contractions (PVCs)
c. To treat second and third degree AV blocks
d. To coarsen ventricular fibrillation so that defibrillation is effective
ANS: A
Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses,
adenosine slows conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert
supraventricular tachycardias and to facilitate the differential diagnosis of rapid dysrhythmias.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 400 | Table 15-16
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. Which dosage of dopamine results in stimulation of beta1 receptors and increased myocardial contractility?
a. 1 mcg/kg/min
b. 5 mcg/kg/min
c. 15 mcg/kg/min
d. 20 mcg/kg/min
ANS: B
At low dosages of 1 to 2 mcg/kg/min, dopamine stimulates dopaminergic receptors, causing renal and mesenteric vasodilation.
Moderate dosages result in stimulation of beta1 receptors to increase myocardial contractility and improve cardiac output. At
dosages greater than 10 mg/kg/min, dopamine predominantly stimulates alpha receptors, resulting in vasoconstriction that often
negates both the beta-adrenergic and dopaminergic effects.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 402 | Table 15-18
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. A patient is admitted with left-sided heart failure and a blood pressure of 220/118 mm Hg. Which drug will be most effective in
decreasing the blood pressure and reducing afterload?
a. Dopamine
b. Verapamil
c. Propranolol
d. Sodium nitroprusside
ANS: D
Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly suitable for rapid reduction
of blood pressure in hypertensive emergencies and perioperatively. It also is effective for afterload reduction in the setting of severe
heart failure. The drug is administered by continuous intravenous infusion, with the dosage titrated to maintain the desired blood
pressure and systemic vascular resistance.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 403 | Table 15-19
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. Through what mechanism does enalapril decrease blood pressure?
a. Direct arterial vasodilation
b. Block the conversion of angiotensin I to angiotensin II
c. Increase fluid excretion at the loop of Henle
d. Peripheral vasoconstriction and central vasodilation
ANS: B
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that produces vasodilation by blocking the conversion of
angiotensin I to angiotensin II. Because angiotensin is a potent vasoconstrictor, limiting its production decreases peripheral
vascular resistance. In contrast to the direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce
sodium and water retention.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 404
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. Noninvasive emergency pacing is best achieved via the use of which type of temporary pacing?
a. Transvenous (endocardial)
b. Epicardial
c. Transthoracic
d. Transcutaneous
ANS: D
Transcutaneous cardiac pacing involves the use of two large skin electrodes, one placed anteriorly and the other posteriorly on the
chest, connected to an external pulse generator. It is a rapid, noninvasive procedure that nurses can perform in the emergency
setting and is recommended for the treatment of symptomatic bradycardia.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 361 | Box 15-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. A transvenous pacemaker is inserted through the right subclavian vein and threaded into the right ventricle. The pacemaker is
placed on demand at a rate of 70. What is the three letter code for this pacing mode?
a. VVI
b. AOO
c. DDD
d. VAT
ANS: A
The original code is based on three categories, each represented by a letter. The first letter refers to the cardiac chamber that is
paced. The second letter designates which chamber is sensed, and the third letter indicates the pacemaker’s response to the sensed
event. A VVI pacemaker paces the ventricle when the pacemaker fails to sense an intrinsic ventricular depolarization.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 362 | Table 15-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. A patient is connected to an external temporary pulse generator. What does the sensitivity control regulate?
a. The time interval between the atrial and ventricular pacing stimuli
b. The amount of electrical current and is measured in milliamperes
c. The ability of the pacemaker to detect the heart's intrinsic electrical activity
d. The number of impulses that can be delivered to the heart per minute
ANS: C
The sensitivity control regulates the ability of the pacemaker to detect the heart’s intrinsic electrical activity. Sensitivity is
measured in millivolts (mV) and determines the size of the intracardiac signal that the generator will recognize.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 363
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. When analyzing the electrocardiogram (ECG) strip of the patient with a pacemaker, the nurse notices there is a spike before each
QRS complex. What is this phenomenon indicative of?
a. 60-cycle electrical interference; check equipment
b. Pacing artifact; the pacemaker is sensing and capturing
c. Electrical artifact; the pacemaker is not sensing
d. Patient movement; check electrodes
ANS: B
The pacing artifact is the spike that is seen on the electrocardiographic tracing as the pacing stimulus is delivered to the heart. A P
wave is visible after the pacing artifact if the atrium is being paced. Similarly, a QRS complex follows a ventricular pacing artifact.
With dual-chamber pacing, a pacing artifact precedes both the P wave and the QRS complex.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 363 | Figure 15-4B
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. A patient is undergoing ventricular pacing via a transvenous pacing lead. The nurse notes a pacing artifact, but it is not followed by
a QRS on the electrocardiogram (ECG) monitoring. Which nursing intervention may correct this situation?
a. Position the patient on the left side
b. Decrease the milliamperes as ordered
c. Increase the rate as ordered
d. Monitor the patient in a different lead
ANS: A
The patient is experiencing “loss of capture,” which most often can be attributed either to displacement of the pacing electrode or to
an increase in threshold as a result of drugs, metabolic disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the
site of electrode placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For transvenous leads,
repositioning the patient to the left side may improve lead contact and restore capture.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 365
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. A patient suddenly develops a wide QRS complex tachycardia. The patient’s heart rate is 220 beats/min and regular; blood pressure
is 96/40 mm Hg; and respiratory rate is 22 breaths/min, and the patient is awake without complaint except for palpitations. Which
of the following interventions would be best to try first?
a. Adenosine 6 mg rapid IV push
b. Lidocaine 1 mg/kg IV push
c. Verapamil 5 mg IV push
d. Digoxin 0.5 mg IV push
ANS: A
Adenosine (Adenocard) is an antidysrhythmic agent that remains unclassified under the current system. Adenosine occurs
endogenously in the body as a building block of adenosine triphosphate (ATP). Given in intravenous boluses, adenosine slows
conduction through the atrioventricular (AV) node, causing transient AV block. It is used clinically to convert supraventricular
tachycardias and to facilitate differential diagnosis of rapid dysrhythmias.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 400 | Table 15-16
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Why are vasopressors used cautiously in the treatment of critical care patients?
a. They cause vasoconstriction of the smooth muscles.
b. They cause vasodilation of the smooth muscles.
c. They increase afterload.
d. They decrease preload.
ANS: C
Vasopressors are not widely used in the treatment of critically ill cardiac patients because the dramatic increase in afterload is
taxing to a damaged heart. Vasopressin, also known as antidiuretic hormone, has become popular in the critical care setting for its
vasoconstrictive effects. At higher doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in
vasoconstriction of capillaries and small arterioles.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 405
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. Which calcium channel blocker is beneficial in the treatment of patients with coronary artery disease or ischemic stroke?
a. Nifedipine
b. Nicardipine
c. Clevidipine
d. Diltiazem
ANS: B
Nicardipine was the first available intravenous calcium channel blocker and as such could be more easily titrated to control blood
pressure. Because this medication has vasodilatory effects on coronary and cerebral vessels, it has proven beneficial in treating
hypertension in patients with coronary artery disease or ischemic stroke. Nifedipine is available only in an oral form, but in the past
it was prescribed sublingually during hypertensive emergencies. Clevidipine is a new, short-acting calcium channel blocker that
allows for even more precise titration of blood pressure in the management of acute hypertension. Diltiazem (Cardizem) is from the
benzothiazine group of calcium channel blockers. These medications dilate coronary arteries but have little effect on the peripheral
vasculature. They are used in the treatment of angina, especially that which has a vasospastic component, and as antidysrhythmics
in the treatment of supraventricular tachycardias.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 404
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
24. A patient is admitted after a femorotibial bypass graft. What nursing action is critical in the immediate postoperative period?
a. Frequent assessment of the skin
b. Hourly assessment of intake and output
c. Monitoring for ST segment changes
d. Frequent pulse checks to the affected limb
ANS: D
The primary focus of nursing care in the immediate postprocedural period is assessment of the adequacy of perfusion to the
affected limb and identification of complications. Pulse checks are performed frequently, and the physician is notified of any
decrease in the strength of the Doppler signal. Because distal perfusion is compromised in this patient population, nursing measures
to prevent skin breakdown are implemented. If the repair was performed above the renal arteries, kidney function may be impaired
as a result of interruption of renal blood flow during the procedure. Urine output is therefore assessed hourly and supported with
fluids and diuretics as needed. Because patients with peripheral vascular disease are at high risk for cardiac events, ST segment
monitoring is performed to detect episodes of myocardial ischemia throughout the perioperative period.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 398
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
25. When is a patient a candidate for a surgical repair of an abdominal aortic aneurysm (AAA)?
a. Size is 1 cm
b. Patient experiencing symptoms
c. Aneurysm size unchanged over several years
d. Size less than 4 cm
ANS: B
An abdominal aortic aneurysm (AAA) is usually repaired when the aneurysm is 5 cm or larger, creating symptoms, or rapidly
expanding. This is done to prevent the high mortality rate associated with abdominal rupture.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 396
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient’s vital signs include temperature 103°
F, heart rate 112, respiratory rate 22, blood pressure 134/78 mm Hg, and O2 saturation 94% on 3L nasal cannula. The nurse
suspects that the patient has developed what problem?
a. Infection and notifies the physician immediately
b. Infection, which is common postoperatively, and monitors the patient’s condition
c. Cardiac tamponade and notifies the physician immediately
d. Delirium caused by the elevated temperature
ANS: A
Postoperative fever is fairly common after cardiopulmonary bypass. However, persistent temperature elevation to greater than 101°
F (38.3° C) must be investigated. Sternal wound infections and infective endocarditis are the most devastating infectious
complications, but leg wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal complication,
cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart’s ability to pump.
Signs of tamponade include elevated and equalized filling pressures (e.g., central venous pressure, pulmonary artery diastolic
pressure, pulmonary artery occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention,
pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened cardiac silhouette on radiographs.
The risk of delirium is increased in cardiac surgery patients, especially elderly patients, and is associated with increased mortality
rates and reduced quality of life and cognitive function. Nursing staff can play a critical role in the prevention and recognition of
delirium.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 388
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
27. Identify complications with the above rhythm strip.
a.
b.
c.
d.
Undersensing from a pacemaker
Oversensing from a pacemaker
ICD firing caused by VF
Atrial pacing failure to capture
ANS: A
Undersensing is the inability of the pacemaker to sense spontaneous myocardial depolarizations. Undersensing results in
competition between paced complexes and the heart’s intrinsic rhythm. This malfunction is manifested on the electrocardiogram by
pacing artifacts that occur after or are unrelated to spontaneous complexes. Oversensing occurs as a result of inappropriate sensing
of extraneous electrical signals that leads to unnecessary triggering or inhibition of stimulus output, depending on the pacer mode.
The source of these electrical signals can range from tall peaked T waves to external electromagnetic interference in the critical
care environment. The implantable cardioverter defibrillator system consists of leads and a generator and is similar to a pacemaker
but with some key differences. The leads contain not only electrodes for sensing and pacing but also integrated defibrillator coils
capable of delivering a shock. If the pacing stimulus fires but fails to initiate a myocardial depolarization, a pacing artifact will be
present but will not be followed by the expected P wave.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 365
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
28. What is the preferred initial treatment of an acute myocardial infarction?
a. Fibrinolytic therapy
b. Percutaneous coronary intervention (PCI)
c. Coronary artery bypass surgery (CABG)
d. Implanted Cardioverter defibrillator (ICD)
ANS: B
Percutaneous coronary intervention (PCI) is now preferred as the initial method of treatment for acute myocardial infarction (MI;
primary PCI). PCI includes balloon angioplasty, atherectomy, and stent implantation, as well as a number of adjunctive devices
used to facilitate successful revascularization in coronary vessels.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 374
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29. What two medications are commonly prescribed at discharge for patients who have had a coronary artery stent placed?
a. Aspirin and prasugrel
b. Aspirin and abciximab
c. Clopidogrel and eptifibatide
d. Tirofiban and ticagrelor
ANS: A
Because platelet activation is a complex process involving multiple pathways, combination therapy with two or more agents has
proven most effective. The current standard of care for percutaneous coronary intervention typically includes dual antiplatelet
therapy with aspirin and a thienopyridine. These oral agents are administered before the procedure and continued at discharge.
Abciximab, eptifibatide, and tirofiban are all intravenous antiplatelet agents.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 376 | Table 15-5
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
30. Which anticoagulant enhances the activity of antithrombin III and does not require activated partial thromboplastin time (aPTT) or
activated clotting time (ACT) monitoring?
a. Heparin
b. Enoxaparin
c. Bivalirudin
d. Argatroban
ANS: B
Enoxaparin (Lovenox) enhances activity of antithrombin III, a more predictable response than heparin, because enoxaparin is not
largely bound to protein. There is no need for activated partial thromboplastin time (aPTT) or activated clotting time (ACT)
monitoring, and there is a lower risk of heparin-induced thrombocytopenia (HIT) than with unfractionated heparin (UFH). Heparin
sodium enhances activity of antithrombin III, a natural anticoagulant, to prevent clot formation. The effectiveness of treatment may
be monitored by aPTT or ACT. Response is variable because of binding with plasma proteins effects may be reversed with
protamine sulfate. Bivalirudin (Angiomax) directly inhibits thrombin. It may be administered alone or in combination with
glycoprotein IIb/IIIa inhibitors and produces a dose-dependent increase in aPTT and ACT. It may be used instead of UFH for
patients with HIT. Argatroban (Argatroban) directly inhibits thrombin. It may be used instead of UFH for patients with HIT.
Whereas ACT is monitored during percutaneous coronary intervention, aPTT is used during prolonged infusion.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 378 | Table 15-8
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
31. A patient is admitted after a positive exercise treadmill test with a diagnosis of coronary artery disease (CAD) and stable angina.
Radiographic tests show that the patient has blockage in the left main coronary artery and four other vessels. The nurse anticipates
that the patient’s treatment plan will include what treatment or procedure?
a. Medical therapy
b. PCI
c. TAVR
d. CABG
ANS: D
Early studies demonstrated coronary artery bypass graft (CABG) surgery was more effective than medical therapy for improving
survival in patients with left main or three-vessel coronary artery disease and at relieving anginal symptoms. Medical therapy is
recommended if the ischemia is prevented by antianginal medications that are well tolerated by the patient. Surgical
revascularization has been shown to be more efficacious than percutaneous coronary intervention (PCI) in patients with
multivessel or left main coronary disease. Transcatheter aortic valve replacement (TAVR) is a transformational therapy for patients
who have severe aortic stenosis but who are extremely high-risk surgical candidates or who are inoperable by virtue of associated
comorbidities.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 382 | p. 383
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. A patient is diagnosed with third-degree heart failure. The nurse reviews the patient’s medication list. Which classifications of
drugs should be avoided with this patient? (Select all that apply, one, some, or all.)
a. Nonsteroidal antiinflammatory drugs (NSAIDs)
b. Antidysrhythmics
c. Angiotensin-converting enzyme (ACE) inhibitors
d. Calcium channel blockers
e. Beta-blockers
ANS: A, B, D
Types of medications that have been found to worsen heart failure should be avoided, including most antidysrhythmics, calcium
channel blockers, and nonsteroidal antiinflammatory medications. Angiotensin-converting enzyme inhibitors and beta-blockers are
used to treat heart failure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 405 | Table 15-21
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. Which patients would be a candidate for fibrinolytic therapy? (Select all that apply, one, some, or all.)
a. The patient’s chest pain started 8 hours ago. She has a diagnosis of
b.
c.
d.
e.
non-ST-elevation myocardial infarction (NSTEMI).
The patient’s chest pain started 3 hours ago, and her electrocardiogram (ECG)
shows a new left bundle branch block.
The patient presents to the emergency department with chest pain of 30 minutes’
duration. She has a history of cerebrovascular accident 1 month ago.
The patient has a history of unstable angina. He has been experiencing chest pain
with sudden onset.
The patient’s chest pain started 1 hour ago, and his ECG shows ST elevation.
ANS: B, E
Eligibility criteria for administering fibrinolytics include chest pain of less than 12 hours’ duration and persistent ST elevation.
Exclusion criteria include recent surgery, cerebrovascular accident, and trauma.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 370 | p. 371
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic Integrity
3. Which signs and symptoms would indicate successful reperfusion after administration of a fibrinolytic agent? (Select all that apply,
one, some, or all.)
a. Gradual decrease in chest pain
b. Intermittent, multifocal premature ventricular contractions
c. Rapid resolution of ST elevation
d. Rapid rise in creatine kinase MB fraction
ANS: B, C, D
A reliable indicator of reperfusion is the appearance of various “reperfusion” dysrhythmias such as premature ventricular
contractions, bradycardia, heart block, and ventricular tachycardia. Rapid resolution of the previously elevated ST segment should
occur. The serum concentration of creatine kinase rises rapidly and markedly, a phenomenon termed washout.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 373
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
8
4. Nursing interventions after angioplasty would include which of the following? (Select all that apply, one, some, or all.)
a. Elevating the head of the bed to 45 degrees
b. Hydration as a renal protection measure
c. Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours
d.
e.
after the procedure
Monitoring the vascular hemostatic device for signs of bleeding
Educating the patient on the necessity of staying supine for 1 to 2 hours after the
procedure
ANS: B, C, D
The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to keep the affected leg
straight. Bed rest is 6 to 8 hours in duration unless a vascular hemostatic device is used. The nurse observes the patient for bleeding
or swelling at the puncture site and frequently assesses adequacy of circulation to the involved extremity.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 380
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
9
Chapter 16: Pulmonary Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. At what anatomic site does the trachea divide into the right and left mainstem bronchi?
a. Posterior larynx
b. Cricoid cartilage
c. Epiglottis
d. Major carina
ANS: D
The trachea is a hollow tube approximately 11 cm in length and 2.5 cm in diameter. It begins at the cricoid cartilage and ends at the
bifurcation (the major carina) from which the two mainstem bronchi arise.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 415 | p. 416 | Figure 16-5
2. Which physiologic mechanism is a passive event in a spontaneously breathing patient?
a. Coughing
b. Inhalation
c. Exhalation
d. Yawning
ANS: C
Inhalation involves the contraction of the diaphragm, an active event, as do yawning and coughing. Exhalation in the healthy lung
is a passive event requiring very little energy.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 414
3. What substance do alveolar type II cells secrete?
a. Trypsin
b. Chyme
c. Amylase
d. Surfactant
ANS: D
The most important function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant. Trypsin and
amylase are proteins used for digestion. Chyme is a semifluid mass of partly digested food that is expelled by the stomach into the
duodenum.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 418
4. Which pulmonary condition is related to a lack of surfactant?
a. Pulmonary embolus
b. Pulmonary hypertension
c. Pulmonary atelectasis
d. Pulmonary edema
ANS: C
Surfactant is responsible for preventing the alveoli from completely collapsing on exhalation. Lack of this lipoprotein allows the
alveoli to collapse, producing atelectasis. Lack of surfactant is not responsible for the other conditions.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 418
5. What is the main function of the conducting airways?
a. Gas exchange
b. Cool the inhaled air
c. Remove moisture from inhaled air
d. Prevent the entry of foreign material
ANS: D
The conducting airways consist of the upper airways, the trachea, and the bronchial tree. Their major functions are to warm and
humidify the inhaled air, prevent the entrance of foreign matter into the gas exchange areas, and serve as a passageway for air
entering and leaving the gas exchange regions of the lungs.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 414 | p. 415
1
6. A patient has sustained a stroke and is no longer able to control his epiglottis. Why should the nurse be concerned about the
patient?
a. The patient is at increased risk of aspiration.
b. The patient will need surgery to close his epiglottis.
c. The patient will need a tracheostomy to breathe.
d. The patient is at risk for a pneumothorax.
ANS: A
The epiglottis is responsible for closing over the trachea and preventing entry of swallowed material into the lungs. An inability to
control the epiglottis increases the risk of aspiration and may warrant placement of a feeding tube. The patient will still be able to
breathe. Closure of the epiglottis over the trachea will occlude the airway.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 415
7. Patients who have aspiration pneumonitis often present with right lower lobe involvement more than left lower lobe involvement.
Why does this occur?
a. The left mainstem bronchus angles down more than the right.
b. More people are right-side dominant.
c. The right mainstem bronchus angles down more than the left.
d. The right mainstem bronchus is narrower than the left.
ANS: C
The right bronchus is wider than the left and angles at 20 to 30 degrees from the midline. Because of this angulation and the forces
of gravity, the most common site of aspiration of foreign objects is through the right mainstem bronchus into the lower lobe of the
right lung.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 415 | p. 416
8. Which artery(s) have the lowest oxygen saturation?
a. Aorta
b. Subclavian
c. Carotid
d. Pulmonary
ANS: D
The pulmonary artery delivers blood from the right ventricle to the lungs, where they receive oxygen from the alveoli. The aorta,
subclavian artery, and carotid artery are all supplied from the left ventricle, where the oxygen concentration is highest.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
9. Which range would be considered normal for pulmonary artery systolic pressures?
a. 15 to 30 mm Hg
b. 4 to 12 mm Hg
c. 25 to 35 mm Hg
d. 1 to 11 mm Hg
ANS: A
Pulmonary artery systolic pressure ranges from 15 to 30 mm Hg, pulmonary artery diastolic pressure ranges from 4 to 12 mm Hg,
and pulmonary artery mean pressure ranges from 9 to 18 mm Hg. Pulmonary hypertensions is defined as pulmonary artery systolic
pressure of greater than 35 mm Hg.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
10. The oxygen saturation of a healthy individual rarely reaches 100% on room air. This can best be explained by what concept?
a. Physiologic shunting
b. Alveolar capillary diffusion
c. Collateral air passages
d. Anatomic dead space
ANS: A
The mixing of venous blood from the bronchial circulation with the oxygenated blood in the left atrium decreases the saturation of
left atrial blood to a range between 96% and 99%. This is referred to as physiologic shunting. For this reason, while a person is
breathing room air, the oxygen saturation of arterial blood is less than 100%.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 420
2
11. Which pulmonary alteration increases the work of breathing in the patient with emphysema?
a. Decreased lung recoil
b. Decreased chest wall compliance
c. Increased lung compliance
d. Increased airway resistance
ANS: A
Emphysema results in destruction and enlargement of the alveoli, leading to decreased lung recoil and increased work of breathing.
Emphysema results in decreased lung compliance not increased compliance. Emphysema does not affect chest wall compliance or
airway resistance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 420-422 | Box 16-2
12. What anatomic regions are considered physiologic dead space?
a. Respiratory bronchiole and unperfused alveoli
b. Trachea and perfused alveoli
c. Trachea and unperfused alveoli
d. Trachea and mainstem bronchi
ANS: C
Respiratory bronchioles participate in gas exchange. The areas in the lungs that are ventilated but in which no gas exchange occurs
are known as dead space regions (trachea and mainstem bronchi). These unperfused alveoli are known as alveolar dead space.
Anatomic dead space plus alveolar dead space is called physiologic dead space.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
13. If a patient sustained an injury to the apneustic center in the lower pons area, in which area should the nurse most expect the patient
to exhibit problems?
a. Respiratory rate
b. Triggering exhalation
c. Respiratory rhythm
d. Depth of respiration
ANS: D
The apneustic center in the lower pons is thought to work with the pneumotaxic center to regulate the depth of inspiration. The
pneumotaxic center in the pons is responsible for limiting inhalation and triggering exhalation. This response also facilitates control
of the rate and pattern of respiration. The ventral respiratory group, located in the medulla, is responsible for inspiration and
expiration during periods of increased ventilation.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 423 | p. 424 | Figure 16-18
14. Normally, which central chemoreceptor is responsible for triggering ventilation changes?
a. Increased PaCO2
b. Increased HCO3¯
c. Decreased PaO2
d. Increased PaO2
ANS: A
Ventilation increases when the hydrogen ion concentration increases and decreases when the hydrogen ion concentration decreases.
An increase in the partial pressure of carbon dioxide (PaCO 2) causes the movement of carbon dioxide across the blood–brain
barrier into the cerebrospinal fluid, stimulating the movement of hydrogen ions into the brain’s extracellular fluid. Peripheral
chemoreceptors respond to changes in PaO2 levels.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 424
15. Which V/Q ratio would most suggest intrapulmonary shunting?
a. 0.8
b. 2.2
c. 0.4
d. 0.9
ANS: C
A V/Q ratio of 4:5 or 0.8 is considered normal. A V/Q less than 0.8 is considered shunt producing, and a V/Q greater than 0.8 is
considered dead space producing.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 426 | p. 427
3
16. A shift to the left of the oxyhemoglobin dissociation curve would cause which physiologic alteration?
a. Better tissue perfusion
b. Lower SpO2
c. Decreased hemoglobin affinity for O2
d. Impaired tissue oxygen delivery
ANS: D
When the curve is shifted to the left, there is a higher arterial saturation for any given PaO 2 because hemoglobin has an increased
affinity for oxygen. Although the saturation is higher, oxygen delivery to the tissues is impaired because hemoglobin does not
unload as easily.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 428 | p. 429 | Figure 16-23
17. A patient in diabetic ketoacidosis would exhibit what alteration to the pulmonary system?
a. Breathe faster to increase pH
b. Breathe slower to increase pH
c. Breathe faster to decrease pH
d. Breathe slower to decrease pH
ANS: C
Breathing faster increases the expiration of CO2, which results in less acid in the bloodstream and a decreased pH.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 428 | Figure 16-23
18. What are the primary functions of the pulmonary system?
a. Gas exchange and the movement of air in and out of the lungs
b. Gas exchange and the transfer of oxygen to the tissues
c. The movement of blood in and out of the lungs
d. Gas exchange and the prevention of infections
ANS: A
The primary functions of the pulmonary system are ventilation and respiration. Ventilation is the movement of air in and out of the
lungs. Respiration is the process of gas exchange, that is, the movement of oxygen from the atmosphere into the bloodstream and
the movement of carbon dioxide from the bloodstream into the atmosphere.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 411
19. Which part of the pulmonary anatomy does most of the work of breathing?
a. Pleura
b. Intercostal muscles
c. Diaphragm
d. Sternocleidomastoid
ANS: C
The main muscle of inhalation is the diaphragm. It is connected to the sternum, ribs, and vertebrae. During normal, quiet breathing,
the diaphragm does approximately 80% of the work of breathing. The most important of these are the external intercostal muscles,
which elevate the ribs and expand the chest cage outward. The scalene, anterior serratus, and sternocleidomastoid muscles also
participate to elevate the first two ribs and sternum.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 413
20. Which statement best describes the left bronchus?
a. The left bronchus has a slight angle of 20 to 30 degrees from the midline.
b. The two mainstem bronchi are structurally and functionally similar.
c. The left bronchus is slightly narrower.
d. The bronchi are the end units of the bronchial tree.
ANS: C
The two mainstem bronchi are structurally different. The right bronchus is wider and angles at 20 to 30 degrees from the midline.
The right mainstem bronchus is the most common site of aspiration of foreign objects. The left bronchus is slightly narrower than
the right, and because of its position above the heart, the left bronchus angles directly toward the left lung at approximately 45 to 55
degrees from the midline.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 415 | p. 416 | Figure 16-5
4
21. What is the most important function of type I alveolar epithelial cells?
a. They comprise 90% of total alveolar surface in the lungs for gas exchange.
b. The ability to produce, store, and secrete pulmonary surfactant.
c. The ability to trap foreign particles for auto digestion.
d. The maintenance, repair, and restoration of the mucociliary escalator.
ANS: A
Type I alveolar epithelial cells comprise approximately 90% of the total alveolar surface within the lungs. The most important
function of the type II cells is their ability to produce, store, and secrete pulmonary surfactant.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 417
22. Which statement describes the relationship between the pulmonary circulation and the pulmonary vascular bed?
a. The pulmonary circulation is a high-pressure system with normal pressures
b.
c.
d.
averaging 100/60 to 120/70 mm Hg.
Because of the low pulmonary arterial pressures, the right ventricular wall
thickness needs to be only one-third that of the left ventricle.
Pulmonary hypertension is defined as increased pulmonary artery systolic
pressure above 20 mm Hg.
The most common cause of pulmonary hypertension is right-sided heart failure.
ANS: B
Because of low pulmonary artery pressures, right ventricular wall thickness needs to be only approximately one-third of left
ventricular wall thickness. Pulmonary hypertension is defined as increased pressure (pulmonary artery systolic greater than 35 mm
Hg and pulmonary artery mean less than 25 mm Hg at rest or less than 30 mm Hg with exertion) within the pulmonary arterial
system. Pulmonary hypertension increases the afterload of the right ventricle and, when chronic, can result in right ventricular
hypertrophy (cor pulmonale) and failure.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
23. Oxygen saturation of left atrial blood is normally between 96% and 99%. What is the explanation for less than 100% saturation?
a. As blood passes to the alveolar–capillary membrane, a predicted percentage of
b.
c.
d.
hemoglobin will not bind with oxygen.
During normal respiration, the majority of alveoli are not expanded.
Venous blood from the bronchial circulation is returned to the left atrium.
A small amount of blood leaks from the right atrium to the left atrium with each
ventricular contraction.
ANS: C
Venous blood from the bronchial circulation returns directly into the left atrium. The mixing of venous blood decreases the
saturation of left atrial blood to a range between 96% and 99%.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
24. What is the movement of air into and out of the lungs termed?
a. Ventilation
b. Respiration
c. Diffusion
d. Perfusion
ANS: A
Ventilation is the movement of air into and out of the lungs and is distinct from respiration, which refers to gas exchange, not
movement by air. Respiration is the process of gas exchange by means of movement of oxygen from the atmosphere into the
bloodstream and movement of carbon dioxide from the bloodstream into the atmosphere. Diffusion moves molecules from an area
of high concentration to an area of low concentration. The distribution of perfusion through the lungs is related to gravity and
intra-alveolar pressures.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
25. How much of the basal oxygen consumption is required by the pulmonary system during normal quiet breathing?
a. 10% to 20%
b. 5% to 10%
c. 3% to 5%
d. 1% to 2%
ANS: D
During normal quiet ventilation, only 1% to 2% of basal oxygen consumption is required by the pulmonary system.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 420
5
26. What is the portion of total ventilation that participates in gas exchange termed?
a. Alveolar dead space
b. Anatomic dead space
c. Physiologic dead space
d. Alveolar ventilation
ANS: D
The portion of total ventilation that participates in gas exchange is known as alveolar ventilation. The areas in the lungs that are
ventilated but in which no gas exchange occurs are known as dead space regions. The conducting airways are referred to as
anatomic dead space because they are ventilated but not perfused and therefore not able to participate in gas exchange. These
unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called physiologic dead
space.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
27. Which physiologic alteration will stimulate the central chemoreceptors?
a. Decreased PaO2
b. Increased PaO2
c. Decreased SaO2
d. Increased PaCO2
ANS: D
The central chemoreceptors respond to changes in the hydrogen ion concentration of that fluid. Ventilation is increased when the
hydrogen ion concentration increases, as evidenced by a rise in the plasma arterial PaCO 2.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 424
28. Which factor will increase diffusion of gases across the alveolar capillary membrane?
a. A decrease in the surface area of the membrane
b. An increase in the thickness of the membrane
c. An increase in the driving pressure of the gas
d. A decrease in the solubility coefficient of the gas
ANS: C
Several factors affect the rate of diffusion, including increasing the driving pressure of the gas. A decrease in surface area of the
membrane, an increase in the thickness of the membrane, and a decrease in the solubility coefficient of the gas decrease diffusion
of gases across the membrane.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 425
29. Atelectasis can cause a shunt-producing ventilation-perfusion mismatch. Which pathophysiologic mechanism explains how this
occurs?
a. An alveolus that is receiving perfusion exceeding ventilation
b. An alveolus that is receiving ventilation exceeding perfusion
c. An alveolus that is receiving ventilation but not perfusion
d. An alveolus that is not receiving perfusion or ventilation
ANS: A
A shunt-producing ventilation-perfusion mismatch is one in which perfusion exceeds ventilation. Whereas situations in which
ventilation exceeds perfusion V/Q greater than 0.8 are considered to be dead space producing, situations in which perfusion
exceeds ventilation V/Q less than 0.8 are considered to be shunt producing.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 426 | p. 427 | Figure 16-21
30. Which factor will result in a shift of the oxyhemoglobin dissociation curve to the left?
a. Increased PaCO2
b. Increased pH
c. Increased temperature
d. Increased 2,3-DPG
ANS: B
Factors shifting the curve to the left are increased pH, decreased PaCO 2, decreased temperature, and decreased 2,3-DPG.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 428 | p. 429 | Figure 16-23
6
31. Which statement about methemoglobin is true?
a. Methemoglobin does not carry oxygen.
b. Methemoglobin occurs when carbon monoxide combines with hemoglobin.
c. Carbon dioxide is carried on methemoglobin.
d. Hemoglobin S is responsible for methemoglobin.
ANS: A
Methemoglobin occurs when the iron atoms within the hemoglobin molecule are oxidized from the ferrous state to the ferric state.
Methemoglobin does not carry oxygen. The most common abnormality involving hemoglobin is a decrease in amount. This can be
an acute or a chronic situation (anemia). Abnormal hemoglobin structure also can pose problems, such as hemoglobin S, which is
responsible for sickle cell anemia. Hemoglobin carries approximately 97% of the total amount of oxygen held within the
bloodstream.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 429
32. A patient is admitted with community-associated pneumonia. Respirations are 32 breaths/min. Temperature is 102° F (38.6° C).
Based on the readings the nurse would expect the oxyhemoglobin dissociation curve to shift. What other factors would cause the
curve to shift in the same direction?
a. Decreased 2,3-DPG
b. Increased pH
c. Increased CO2
d. Increased O2
ANS: C
The oxyhemoglobin dissociation curve will shift to the right as a result of the patient’s temperature. Other factors that cause the
curve to shift to the right are decreased pH, increased CO 2, and increased 2,3-DPG. Increased O2 will not shift the curve either right
or left.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 428 | p. 429 | Figure 16-23
33. A patient is admitted with an acute exacerbation of asthma. Respirations are 28 breaths/min. Blood gases reveal an uncompensated
respiratory acidosis. The patient’s work effort for breathing is increased due to which pathophysiologic mechanism?
a. Increased lung compliance
b. Decreased lung recoil
c. Increased chest wall compliance
d. Increased airway resistance
ANS: D
Pulmonary diseases that decrease lung compliance (e.g., atelectasis, pulmonary edema), decrease chest wall compliance (e.g.,
kyphoscoliosis), increase airway resistance (e.g., bronchitis, asthma), or decrease lung recoil (e.g., emphysema) can increase the
work of breathing so much that one-third or more of the total body energy is used for ventilation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
34. Based on the oxyhemoglobin dissociation curve, respiratory acidosis will have which effect?
a. A shifting of the curve to the left
b. Increased oxygen saturation
c. Enhanced oxygen delivery at the tissue level
d. Hypothermia
ANS: C
When the curve is shifted to the right, as occurs in acidosis, although the saturation is lower than expected, a right shift enhances
oxygen delivery at the tissue level because hemoglobin unloads more readily.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 428 | p. 429 | Figure 16-23
35. The lobes are divided into 18 segments. How many are on the right lung?
a. 3
b. 8
c. 10
d. 15
ANS: C
The lobes are divided into 18 segments, each of which has its own bronchus branching immediately off a lobar bronchus. Ten
segments are located in the right lung and eight in the left lung.
PTS: 1
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OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 411
7
36. Which pleura adheres to the lungs?
a. Parietal
b. Visceral
c. Intrapleural
d. Surfactant
ANS: B
The visceral pleura adheres to the lungs, extending onto the hilar bronchi and into the major fissures. The parietal pleura lines the
inner surface of the chest wall and mediastinum. The pleural space has a pressure within it called the intrapleural pressure.
Surfactant is responsible for preventing the alveoli from completely collapsing on exhalation.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 411
37. Which nerve stimulates movement of the diaphragm?
a. Musculocutaneous nerve
b. Phrenic nerve
c. Median nerve
d. Axillary nerve
ANS: B
The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and
fifth cervical nerves. The other nerves control use and feeling of the arms.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 413 | p. 414
38. Trauma to which vertebrae will cause ventilation dysfunction?
a. C3 to C5
b. C5 to T3
c. T4 to T6
d. T7 to T10
ANS: A
The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and
fifth cervical nerves. For this reason and because the diaphragm does most of the work of inhalation, trauma involving levels C3 to
C5 causes ventilation dysfunction.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 414
MULTIPLE RESPONSE
1. Muscles of exhalation include which of the following? (Select all that apply, one, some, or all.)
a. Abdominal
b. Diaphragm
c. External intercostals
d. Internal intercostals
e. Scalene
ANS: A, D
Exhalation occurs when the diaphragm relaxes and moves back up toward the lungs. The intrinsic elastic recoil of the lungs assists
with exhalation. Because exhalation is a passive act, there are no true muscles of exhalation other than the internal intercostal
muscles, which assist the inward movement of the ribs.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 414
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
2. The lymphatic system plays which of the following important roles? (Select all that apply, one, some, or all.)
a. Ridding lung tissue of excess CO2
b. Connecting the thebesian veins
c. Removing fluid from the lungs
d. Producing immune responses
e. Removing cell debris from the lungs
ANS: C, D, E
The lymphatic system in the lungs serves two purposes. As part of the immune system, it is responsible for removing foreign
particles and cell debris from the lungs and for producing both antibody and cell-mediated immune responses. It also is responsible
for removing fluid from the lungs and for keeping the alveoli clear.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 420
OBJ: Nursing Process Step: N/A
TOP: Pulmonary Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
8
Chapter 17: Pulmonary Clinical Assessment
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to check for evidence of what
condition?
a. Hypoxia
b. Dyspnea
c. Dehydration
d. Malnutrition
ANS: A
Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and
nutritional status can both be partially assessed by oral cavity inspection, this information is not as vital as determining hypoxia.
Dyspnea means difficulty breathing.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
2. Which lung sounds would be most likely heard in a patient experiencing an asthma attack?
a. Coarse rales
b. Pleural friction rub
c. Fine crackles
d. Expiratory wheezes
ANS: D
Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed small airways. They are heard
mainly on expiration but may also be heard throughout the ventilatory cycle. Depending on their severity, wheezes can be further
classified as mild, moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli or by the
snapping open of collapsed airways during inspiration. A pleural friction rub is a dry, coarse sound produced by irritated pleural
surfaces rubbing together and is caused by inflammation of the pleura.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 436 | pp. 439-443 | Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
3. Which statement describes the major difference between tachypnea and hyperventilation?
a. Tachypnea has increased rate; hyperventilation has decreased rate.
b. Tachypnea has decreased rate; hyperventilation has increased rate.
c. Tachypnea has increased depth; hyperventilation has decreased depth.
d. Tachypnea has decreased depth; hyperventilation has increased depth.
ANS: D
Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an
increase in both the rate and depth of ventilation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433
4. A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is
complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient’s tongue is
blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find?
a. Kussmaul breathing pattern
b. Absent breath sounds in the right lower lung fields
c. Absent breath sounds in the left lung fields
d. Diminished breath sounds in the right upper lung fields
ANS: C
The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away
from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent
breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 438 | Table 17-2
1
5. While palpating a patient’s lungs the nurse notes fremitus over the patient’s trachea but not the lung periphery. What do these
findings indicate?
a. Bilateral pleural effusion
b. Bronchial obstruction
c. A normal finding
d. Apical pneumothorax
ANS: C
Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt over the trachea but are
barely palpable over the periphery. With decreased fremitus, there is interference with the transmission of vibrations. Examples of
disorders that decrease fremitus include pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 434
6. Which chest wall deformity is characterized by an increase in anteroposterior (AP) diameter with displacement of the sternum
forward and the ribs outward?
a. Funnel chest
b. Pigeon breast
c. Barrel chest
d. Harrison’s groove
ANS: C
Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is characterized by displacement
of the sternum forward and the ribs outward and is suggestive of chronic obstructive pulmonary disease. Funnel chest, pectus
excavatum, creates a pit-shaped depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both
are related to restrictive pulmonary disease. Harrison’s groove, a rib deformity, is a result of rickets.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
7. A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining a history is very important.
What is the appropriate intervention at this time for obtaining this data?
a. Collect an overview of past medical history, present history, and current health
status.
b. Do not obtain any history at this time.
c. Curtail the history to just a few questions about the patient’s chief complaint and
precipitating events.
d. Complete the history and then provide measures to assist the patient to breathe
easier.
ANS: C
The initial presentation of the patient determines the rapidity and direction for the interview. For a patient in acute distress, the
history should be curtailed to just a few questions about the patient’s chief complaint and the precipitating events.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
8. While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the
patient’s breathing is rapid and shallow. What is this type of breathing pattern called?
a. Hyperventilation
b. Tachypnea
c. Obstructive breathing
d. Bradypnea
ANS: B
Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an
increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until
the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an
adult.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433
9. Which condition is an example of a disorder with increased tactile fremitus?
a. Emphysema
b. Pleural effusion
c. Pneumothorax
d. Pneumonia
ANS: D
Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis. Emphysema, pleural
effusion, and pneumothorax are disorders that decrease fremitus.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 434
2
10. What is the sequence for auscultation of the anterior chest?
a. Right side, top to bottom, then left side, top to bottom
b. Left side, top to bottom, then right side, top to bottom
c. Side to side, bottom to top
d. Side to side, top to bottom
ANS: D
Auscultation should be done in a systematic sequence: side to side, top to bottom, posteriorly, laterally, and anteriorly.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436 | Figure 17-8
11. A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric
chest movement. These findings are indicative of which disorder?
a. Tension pneumothorax
b. Pneumonia
c. Pulmonary fibrosis
d. Atelectasis
ANS: A
Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are
indicative of tension pneumothorax.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433 | p. 439 | Table 17-3
12. When auscultating a patient’s lungs, the nurse notes breath sounds that sound like popping in the small airways. What should the
nurse document in the patient’s record?
a. Sonorous wheezes
b. Crackles
c. Sibilant wheezes
d. Pleural friction rub
ANS: B
Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436 | Figure 17-8
13. In what condition are bronchophony, egophony, and whispering pectoriloquy increased?
a. Pneumonia with consolidation
b. Pneumothorax
c. Asthma
d. Bronchiectasis
ANS: A
Voice sounds are increased in pneumonia with consolidation because there is increased vibration through material. Bronchophony
and whispering pectoriloquy are heard as clear transmission of sounds on auscultation; egophony is heard as an “a” sound when the
patient is saying “e.”
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 436 | pp. 439-443 | Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
14. A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease (COPD). Upon inspection of the
patient, the nurse observes that the patient’s fingers appear discolored. What does this finding indicate the presence of?
a. Clubbing
b. Central cyanosis
c. Peripheral cyanosis
d. Chronic tuberculosis
ANS: C
Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the unsaturated hemoglobin of
arterial blood exceeds 5 g/dL and is considered a life-threatening situation. Clubbing refers to an abnormality of the fingers caused
by chronically low blood levels of oxygen often related to a heart or lung disease.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 431
3
15. A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung fields will predictably exhibit which
tone?
a. Resonance
b. Hyperresonance
c. Tympany
d. Dullness
ANS: B
The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung. Resonance can be found in
normal lungs or with the diagnosis of bronchitis. Tympany occurs with the diagnosis of large pneumothorax and emphysematous
blebs. Dullness occurs with the diagnosis of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436 | Table 17-1
16. A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery,
coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what
condition?
a. Emphysema
b. Atelectasis
c. Pulmonary fibrosis
d. Pleural effusion
ANS: D
A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse
sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or
pulmonary fibrosis.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 438 | Table 17-2
17. A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The nurse notes that the patient has
difficulty getting breath out. Which phrase best describes the patient’s breathing pattern?
a. Deep sighing breaths without pauses
b. Rapid, shallow breaths
c. Normal breathing pattern interspersed with forced expirations
d. Irregular breathing pattern with both deep and shallow breaths
ANS: C
Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal breathing pattern interspersed with
forced expirations. As the patient breathes, air becomes trapped in the lungs, and ventilations become progressively shallower until
the patient actively and forcefully exhales.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433
18. A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent
breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea
reveals what finding?
a. A shift to the right
b. A shift to the left
c. No deviation
d. Subcutaneous emphysema
ANS: A
With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as
the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the
trachea but to air trapped in the mediastinum and general neck area.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433 | p. 434
19. The nurse is caring for a patient with respiratory failure. The nurse notes the patient’s diaphragmatic excursing is 8 cm. What
coexisting conditions could account for this finding?
a. Asthma and emphysema
b. Hepatomegaly and ascites
c. Atelectasis and pleural effusion
d. Pneumonia and pneumothorax
ANS: C
Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical examination. Diaphragmatic
excursion is increased in pleural effusion, and disorders that elevate the diaphragm, such as atelectasis or paralysis. Diaphragmatic
excursion is decreased in disorders such as ascites, pregnancy, hepatomegaly, and emphysema.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 435
4
20. When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what
technique?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
ANS: B
Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying
structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the
surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening
with a stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
21. When assessing a patient, the use of observation is referred to as what technique?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
ANS: A
Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape,
texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the
surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening
with a stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
22. What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
ANS: C
Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying
areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or
underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated
listening with a stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
23. What assessment technique involves having the patient breathe in and out slowly with an open mouth?
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
ANS: D
Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying
areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or
underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated
listening with a stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
24. The nurse is observing a new graduate listen to a patient’s lungs. Which action by the new graduate indicates a need to review
auscultation skills?
a. The nurse starts at the apices and moves to the bases.
b. The nurse compares breath sounds from side to side.
c. The nurse listens during inspiration.
d. The nurse listens posteriorly, laterally, and anteriorly.
ANS: C
Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a systematic sequence: side-to-side,
top-to-bottom, posteriorly, laterally, and anteriorly.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 436 | p. 437 | Figure 17-8
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
25. The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis. Which finding is unexpected?
a. Diminished thoracic expansion
b. Tracheal deviation to the most affected side
c. Hyperresonant percussion tones
d. Decreased breath sounds
ANS: C
Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion, tracheal deviation to the most
affected side, decreased or absent breath sounds, and resonance or dullness on percussion. Hyperresonance is not an expected
finding in pulmonary fibrosis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443 | Table 17-3
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
26. The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding is unexpected?
a. Rasping productive cough
b. Decreased tactile fremitus
c. Resonant percussion tones
d. Crackles and wheezes
ANS: B
Assessment findings associated with acute bronchitis include rasping productive cough, resonance on percussion, crackles and
wheezes, and normal to increased tactile fremitus. Decreased tactile fremitus is not associated with acute bronchitis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443 | Table 17-3
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
27. The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which finding is unexpected?
a. Increased diaphragmatic excursion
b. Decreased tactile fremitus
c. Dull percussion tones
d. Pleural friction rub
ANS: A
Assessment findings associated with pleural effusion include dullness on percussion, decreased tactile fremitus, pleural friction rub,
and decreased diaphragmatic excursion. Increased diaphragmatic excursion is not associated with acute bronchitis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443 | Table 17-3
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. How does the patient history assist the nurse in developing the management plan? (Select all that apply, one, some, or all.)
a. Provides direction for the rest of the assessment
b. Exposes key clinical manifestations
c. Aids in developing the plan of care
d. The degree of the patient’s distress determines the extent of the interview
e. Determines length of stay in the hospital setting
ANS: A, B, C, D
The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the
history should be curtailed to just a few questions about the patient’s chief complaint and precipitating events.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
2. Deviation of the trachea occurs in which conditions? (Select all that apply, one, some, or all.)
a. Pneumothorax
b. Pulmonary fibrosis
c. Chronic obstructive pulmonary disease
d. Emphysema
e. Pleural effusion
ANS: A, B, E
Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural
effusion.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 433
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
3. Which conditions will commonly reveal breath sounds with inspiration greater than expiration on assessment? (Select all that
apply, one, some, or all.)
a. Normal lung
b. Bronchiectasis
c. Emphysema
d. Acute bronchitis
e. Diffuse pulmonary fibrosis
ANS: A, B, D
The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration greater than expiration ratio.
Acute bronchitis can also have inspiration that equals expiration ratio as also seen with emphysema, diffuse pulmonary fibrosis,
and consolidating pneumonia. Noting that many conditions present with the same findings affirms the need for further assessment
and evaluation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: pp. 439-443 | Table 17-3
7
Chapter 18: Pulmonary Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The patient’s arterial blood gas (ABG) values on room air are PaO 2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and HCO3¯, 24
mEq/L. What is the interpretation of the patient’s ABG?
a. Uncompensated metabolic alkalosis
b. Uncompensated respiratory acidosis
c. Compensated respiratory acidosis
d. Compensated respiratory alkalosis
ANS: B
The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH
below 7.35, PaCO2 above 45 mm Hg, and HCO3¯ of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of
7.35 to 7.39, PaCO2 greater than 45 mm Hg, and HCO3¯ greater than 26 mEq/L. Compensated respiratory alkalosis values include
a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and HCO3¯ below 22 mEq/L. Uncompensated metabolic alkalosis values include a
pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HCO3¯ above 26 mEq/L.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447 | Table 18-1
2. On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip breathing, heart rate of 96 beats/min in sinus
tachycardia, and a blood pressure of 110/68 mm Hg. The patient’s arterial blood gas (ABG) values on room air are PaO 2, 70 mm
Hg; pH, 7.38; PaCO2, 52 mm Hg; and HCO3¯, 34 mEq/L. What disease process is most consistent with the above arterial blood gas
values?
a. Acute pulmonary embolism
b. Acute myocardial infarction
c. Congestive heart failure
d. Chronic obstructive pulmonary disease
ANS: D
The fact that the HCO3¯ level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute
condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO 3¯ level. The
values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for
respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447 | Table 19-2
3. On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a
blood pressure of 140/72 mm Hg. The patient’s arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32;
PaCO2, 45 mm Hg; and HCO3¯, 26 mEq/L. What action should the nurse anticipate for this patient?
a. Initiate oxygen therapy.
b. Prepare for emergency intubation.
c. Administer 1 ampule of sodium bicarbonate.
d. Initiate capnography.
ANS: A
The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient’s arterial blood gas (ABG) values do not
warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level.
Capnography would not be indicated at this time as the patient’s CO 2 is normal. A repeat ABG may be ordered to assess the
patient’s ongoing respiratory status.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 446 | p. 447
4. The patient’s arterial blood gas (ABG) values on room air are PaO 2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and HCO3¯, 16
mEq/L. What is the interpretation of the patient’s ABG?
a. Uncompensated respiratory acidosis
b. Uncompensated metabolic acidosis
c. Compensated metabolic acidosis
d. Compensated respiratory acidosis
ANS: B
The pH is below normal range (7.35 to 7.45), so this is uncompensated acidosis. The PaCO2 normal and the HCO3¯ is markedly
low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2
of 35 to 45 mm Hg, and HCO3¯ below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2
above 45 mm Hg, and HCO3¯ of 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2
below 35 mm Hg, and HCO3¯ below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2
above 45 mm Hg, and HCO3¯ above 26 mEq/L.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 447 | Table 18-1
1
5. In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO 2 levels?
a. PaO2/FiO2 ratio
b. A-a gradient
c. Residual volume (RV)
d. End-tidal CO2
ANS: D
Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally,
alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient
who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is
greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for
patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in
clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to
1300 mL.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450 | p. 453
6. A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO 2, 106 mm Hg; PaCO2, 35 mm Hg; and
HCO3¯, 11 mEq/L. What is the interpretation of the patient’s ABG?
a. Uncompensated respiratory acidosis
b. Uncompensated metabolic acidosis
c. Uncompensated metabolic alkalosis
d. Uncompensated respiratory alkalosis
ANS: B
The pH indicates acidosis, and the HCO3¯ is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic
acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HCO3¯ below 22 mEq/L. Uncompensated respiratory
acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and HCO3¯ of 22 to 26 mEq/L. Uncompensated respiratory
alkalosis values include a pH above 7.45, PaCO2 below 35 mm Hg, and HCO3¯ of 22 to 26 mEq/L. Uncompensated metabolic
alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and HCO3¯ above 26 mEq/L.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447 | Table 18-1
7. A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO 2, 106 mm Hg; pCO2, 35 mm Hg; and HCO3¯, 11
mEq/L. What symptom would be most consistent with the ABG values?
a. Diarrhea
b. Shortness of breath
c. Central cyanosis
d. Peripheral cyanosis
ANS: A
Diarrhea is one mechanism by which the body can lose large amounts of HCO3¯. The other choices are indications of hypoxia,
which is not indicated with a PaO2 of 106 mm Hg.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447 | Table 18-2
8. What condition is a bronchoscopy indicated for?
a. Pulmonary edema
b. Ineffective clearance of secretions
c. Upper gastrointestinal bleed
d. Instillation of surfactant
ANS: B
Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help
adjust antibiotic therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 448
9. A patient reports feeling moderately short of breath. A chest radiographic examination reveals a large right pleural effusion with
significant atelectasis. Which procedure who the nurse anticipates an order for?
a. Thoracentesis
b. Bronchoscopy
c. Ventilation-perfusion (V/Q) scan
d. Repeat chest radiograph
ANS: A
Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used
most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No
evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest
radiograph is not indicated.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 449
2
10. A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses the patient’s rapid shallow
breathing index (RSBI). Which result best suggests that the patient is ready for a spontaneous breathing trial?
a. RSBI = 150
b. RSBI = 125
c. RSBI = 110
d. RSBI = 90
ANS: D
The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is considered predictive of
weaning success. If the patient is receiving sedation, the medication is discontinued at least 1 hour before the RSBI is measured. If
the patient meets criteria for weaning readiness and has an RSBI of less than 105, a spontaneous breathing trial can be performed.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 451 | Table 18-5
11. What disease process would a Ventilation-perfusion (V/Q) scans be ordered to evaluate?
a. Pulmonary emboli
b. Acute myocardial infarction
c. Emphysema
d. Acute respiratory distress syndrome
ANS: A
This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for
myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for
emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 451
12. A patient presents with absent lung sounds in the left lower lung fields and moderate shortness of breath. The nurse suspects
pneumothorax and notifies the provider. Orders for a STAT chest radiography and reading are obtained. Which finding best
supports the nurse’s suspicions?
a. Blackness in the left lower lung area
b. Whiteness in the left lower lung area
c. Blunted costophrenic angles
d. Elevated left hemidiaphragm
ANS: A
With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A
thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In
addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 452
13. A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the provider intubates the patient, the
nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining
endotracheal tube placement in this patient?
a. Stat chest radiographic examination
b. End-tidal CO2 monitor
c. Ventilation-perfusion (V/Q) scan
d. Pulmonary artery catheter insertion
ANS: B
Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient’s respiratory status
can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay
if incorrectly placed. The other tests are not for endotracheal tube placement.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 453
14. A patient’s pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform?
a. Prepare to intubate.
b. Assess the patient’s condition.
c. Turn off the alarm and reapply the oximeter sensor.
d. Increase O2 level to 4L/NC.
ANS: B
The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then
the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and
abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect
hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of
oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 454
3
15. Which patient would be considered hypoxemic?
a. A 70-year-old man with a PaO2 of 72
b. A 50-year-old woman with a PaO2 of 65
c. A 84-year-old man with a PaO2 of 96
d. A 68-year-old woman with a PaO2 of 80
ANS: B
Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60
years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg – 10
mm Hg = 70 mm Hg; 84 years old = 80 mm Hg – 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg – 8 mm Hg = 72 mm Hg.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 445
16. Which blood gas parameter is the acid–base component that reflects kidney function?
a. pH
b. PaO2
c. PaCO2
d. HCO3¯
ANS: D
The bicarbonate (HCO3¯) is the acid–base component that reflects kidney function. The bicarbonate is reduced or increased in the
plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2
measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO 2 measures the partial pressure of carbon dioxide
dissolved in arterial blood plasma.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 445 | p. 446
17. Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis?
a. pH, 7.29; PaCO2, 57 mm Hg; HCO3¯, 22 mEq/L
b. pH, 7.36; PaCO2, 33 mm Hg; HCO3¯, 18 mEq/L
c. pH, 7.22; PaCO2, 42 mm Hg; HCO3¯, 18 mEq/L
d. pH, 7.52; PaCO2, 38 mm Hg; HCO3¯, 29 mEq/L
ANS: C
A pH of 7.22 is below normal, reflecting acidosis. The metabolic component (HCO3¯) is low, indicating that the acidosis is
metabolic in origin. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and HCO3¯
below 22 mEq/L.
PTS:
REF:
OBJ:
MSC:
1
DIF: Cognitive Level: Analysis
p. 446 | Box 18-2 | p. 447 | Table 18-1
Nursing Process Step: Diagnosis
TOP: Pulmonary
NCLEX: Physiologic Integrity
18. Which ABG values reflect compensation?
a. pH, 7.26; PaCO2, 55 mm Hg; HCO3¯, 24 mEq/L
b. pH, 7.30; PaCO2, 32 mm Hg; HCO3¯, 18 mEq/L
c. pH, 7.48; PaCO2, 30 mm Hg; HCO3¯, 22 mEq/L
d. pH, 7.38; PaCO2, 58 mm Hg; HCO3¯, 30 mEq/L
ANS: D
The pH is within normal limits, and both the PaCO2 and the HCO3¯ values are abnormal. Compensated respiratory acidosis values
include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and HCO3¯ above 26 mEq/L.
PTS:
REF:
OBJ:
MSC:
1
DIF: Cognitive Level: Understanding
p. 446 | Box 18-3 | p. 448 | Table 18-1
Nursing Process Step: Assessment TOP: Pulmonary
NCLEX: Physiologic Integrity
19. Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known?
a. pH
b. PaCO2
c. HCO3¯
d. Hemoglobin (Hgb)
ANS: D
Proper evaluation of the oxygen saturation level is vital. For example, an SaO 2 of 97% means that 97% of the available hemoglobin
is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always
within normal limits and oxygen can bind only with what is available.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 446
4
20. A patient is intubated and sputum for culture and sensitivity is ordered. Which action is important for obtaining the best specimen?
a. After the specimen is in the container, dilute thick secretions with sterile water.
b. Apply suction when the catheter is advanced to obtain secretions from within the
c.
d.
endotracheal tube.
Do not apply suction while the catheter is being withdrawn because this can
contaminate the sample with sputum left in the endotracheal tube.
Do not clear the endotracheal tube of all local secretions before obtaining the
specimen.
ANS: C
To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply suction while the catheter is
being withdrawn. Clear the endotracheal or tracheostomy tube for all local secretions, avoiding deep airway penetration. This will
prevent contamination with upper airway flora. Do not dilute thick secretions with sterile water. This will compromise the
specimen.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 449 | Box 18-4
21. What medication may be included in the preprocedural medications for a diagnostic bronchoscopy?
a. Aspirin for anticoagulation
b. Vecuronium to inhibit breathing
c. Codeine to decrease the cough reflex
d. Cimetidine to decrease hydrochloric acid secretion
ANS: C
Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular codeine. Whereas atropine
lessens the vasovagal response and reduces the secretions, codeine decreases the cough reflex. When a bronchoscopy is performed
therapeutically to remove secretions, decreased cough and gag reflexes are present, which may impair secretion clearance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 449
22. Severe coughing and shortness of breath during a thoracentesis are indicative of what complication?
a. Re-expansion pulmonary edema
b. Pleural infection
c. Pneumothorax
d. Hemothorax
ANS: A
Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to 1500 mL) is removed from the pleural
space. Removal of the fluid increases the negative intrapleural pressure, which can lead to edema when the lung does not re-expand
to fill the space. The patient experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to
discontinue the thoracentesis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450
23. Which disorder is indicative of a static lung compliance of 40 mL/cm H2O?
a. Pneumonia
b. Bronchospasm
c. Pulmonary emboli
d. Upper airway obstruction
ANS: A
Static compliance is measured under no-flow conditions so that resistance forces are removed. Static compliance decreases with
any decrease in lung compliance, such as occurs with pneumothorax, atelectasis, pneumonia, pulmonary edema, and chest wall
restrictions. A normal value is 57 to 85 mL/cm of H2O.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450
24. A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test is most conclusive to determine
this diagnosis?
a. ABG
b. Bronchoscopy
c. Pulmonary function test
d. V/Q scan
ANS: D
A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests
oxygen levels in the blood, bronchoscopy is used to view the bronchi, and pulmonary function tests are used to measure lung
volume.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 451
5
25. What chest radiography finding is consistent with a left pneumothorax?
a. Flattening of the diaphragm
b. Shifting of the mediastinum to the right
c. Presence of a gastric air bubble
d. Increased radiolucency of the left lung field
ANS: B
Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 452
26. What does an intrapulmonary shunting value of 35% indicate?
a. Normal gas exchange of venous blood
b. An abnormal finding indicative of a shunt-producing disorder
c. A serious and potentially life-threatening condition
d. Metabolic alkalosis
ANS: C
A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a
serious and potentially life-threatening condition that requires pulmonary intervention.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447
27. A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas (ABG) values on the current ventilator
settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3¯, 27 mEq/L. What is the correct interpretation of the patient’s ABG values?
a. Compensated respiratory acidosis
b. Compensated metabolic alkalosis
c. Uncompensated respiratory alkalosis
d. Uncompensated metabolic acidosis
ANS: A
The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and
HCO3¯ above 26 mEq/L. Uncompensated respiratory alkalosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and
HCO3¯ of 22 to 26 mEq/L. Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above 45 mm Hg, and
HCO3¯ above 26 mEq/L. Uncompensated metabolic acidosis values include a pH above 7.35, PaCO2 of 35 to 45 mm Hg, and
HCO3¯ below 22 mEq/L.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447 | Table 18-1
28. Place the steps for analyzing arterial blood gases in the proper order.
1. Assess HCO3¯ level for metabolic abnormalities.
2. Assess PaO2 for hypoxemia.
3. Examine PaCO2 for acidosis or alkalosis.
4. Re-examine pH to determine level of compensation.
5. Examine pH for acidemia or alkalemia.
a. 5, 1, 2, 4, 3
b. 2, 5, 3, 1, 4
c. 1, 2, 4, 3, 5
d. 1, 3, 4, 5, 2
ANS: B
A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes
look at the PaO2 level, look at the pH level, look at the PaCO2 level, look at the HCO3¯, and look again at the pH level.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 446 | Box 18-1
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that apply, one, some, or all.)
a. Coagulation defects
b. Unstable hemodynamics
c. Pleural effusion
d. Uncooperative patient
e. Empyema
ANS: A, B, D
No absolute contraindications to thoracentesis exist, although some risks may contraindicate the procedure in all but emergency
situations. These risk factors include unstable hemodynamics, coagulation defects, mechanical ventilation, the presence of an
intraaortic balloon pump, and patients who are uncooperative. It is used most often as a diagnostic measure; it may also be
performed therapeutically for the drainage of a pleural effusion or empyema.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 449
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
2. Nursing management of a patient undergoing a diagnostic procedure entails what nursing actions? (Select all that apply, one, some,
or all.)
a. Positioning the patient for the procedure
b. Monitoring the patient’s responses to the procedure
c. Monitoring vital signs
d. Teaching the patient about the procedure
e. Medicating the patient before and after procedure
ANS: A, B, C, D, E
Preparing the patient includes teaching the patient about the procedure, answering any questions, and positioning the patient for the
procedure. Monitoring the patient’s responses to the procedure includes observing the patient for signs of pain and anxiety and
monitoring vital signs, breath sounds, and oxygen saturation. Assessing the patient after the procedure includes observing for
complications of the procedure and medicating the patient for any postprocedural discomfort.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 453
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
Chapter 19: Pulmonary Disorders
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs?
a. Alveolar hypoventilation
b. Dead space ventilation
c. Intrapulmonary shunting
d. Physiologic shunting
ANS: C
Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present,
depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation,
ventilation-perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes
through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 456
2. For which sign or symptom does a patient with acute lung failure require a bronchodilator?
a. Excessive secretions
b. Bronchospasms
c. Thick secretions
d. Fighting the ventilator
ANS: B
Bronchodilators aid in smooth muscle relaxation and are of particular benefit to patients with airflow limitations. Mucolytics and
expectorants are no longer used because they have been found to be of no benefit in this patient population.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 458
3. Supplemental oxygen administration is usually effective in treating hypoxemia related to which physiological process?
a. Physiologic shunting
b. Dead space ventilation
c. Alveolar hyperventilation
d. Ventilation-perfusion mismatching
ANS: D
Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation-perfusion
mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is
necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered v ia invasive and
noninvasive mechanical ventilation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 458
4. A patient has acute lung failure. What nursing intervention should the nurse use to optimize oxygenation and ventilation?
a. Provide adequate rest and recovery time between procedures.
b. Position the patient with the good lung up.
c. Suction the patient every hour.
d. Avoid hyperventilating the patient.
ANS: A
Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute
lung failure, the goal of positioning is to place the least affected area of the patient’s lung in the most dependent position. Patients
with unilateral lung disease should be positioned with the healthy lung in a dependent position. Hyperventilate the patient before
suctioning; suction patients as needed.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 460 | Box 19-4
1
5. A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs)
revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the provider orders a repeat ABG. Which set
of results would be indicative of the patient’s current condition?
a. Elevated pH and decreased PaCO2
b. Elevated pH and elevated PaCO2
c. Decreased pH and decreased PaCO2
d. Decreased pH and elevated PaCO2
ANS: D
Arterial blood gas analysis reveals a low PaO 2 despite increases in supplemental oxygen administration (refractory hypoxemia).
Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO 2 increases as the patient fatigues. The pH is high
initially but decreases as respiratory acidosis develops.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 463
6. Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (ARDS)?
a. Radiologic evidence of bibasilar atelectasis
b. PaO2/FiO2 ratio less than or equal to 200 mm Hg
c. Pulmonary artery wedge pressure greater than 18 mm Hg
d. Increase in static and dynamic compliance
ANS: B
The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory
symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of
edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude
hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg
with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O),
moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or
severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is
estimated to be 34% to 58%.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 461
7. Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting
associated with acute respiratory distress syndrome (ARDS)?
a. Sedating the patient to blunt noxious stimuli
b. Increasing the FiO2 on the ventilator
c. Administering positive-end expiratory pressure (PEEP)
d. Restricting fluids to 500 mL per shift
ANS: C
The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve
oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed
alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and
increases compliance.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 465
8. Patients with left-sided pneumonia may benefit from placing them in what position?
a. Reverse Trendelenburg
b. Supine
c. On the left side
d. On the right side
ANS: D
Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally
facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the
dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient’s lung in the most
dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 460
2
9. What nursing intervention can facilitate the prevention of aspiration?
a. Observing the amount given in the tube feeding
b. Assessing the patient’s level of consciousness
c. Encouraging the patient to cough and to breathe deeply
d. Positioning a patient in a semi recumbent position
ANS: D
Semi recumbency (elevation of the head of the bed 30 to 45 degrees) has been shown to decrease the risk of aspiration and inhibit
the development of hospital-associated pneumonia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 460
10. What is the major hemodynamic consequence of a massive pulmonary embolus?
a. Increased systemic vascular resistance leading to left heart failure
b. Pulmonary hypertension leading to right heart failure
c. Portal vein blockage leading to ascites
d. Embolism to the internal carotids leading to a stroke
ANS: B
The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the
effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the
injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 472
11. Which finding confirms the diagnosis of a pulmonary embolism (PE)?
a. Low-probability ventilation-perfusion (V/Q) scan
b. Negative pulmonary angiogram
c. High-probability V/Q scan
d. Absence of vascular markings on the chest radiograph
ANS: C
A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability ventilation-perfusion (V/Q) scan, an
abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on
lower extremity deep venous thrombosis studies.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 473 | p. 474
12. What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation?
a. Tension pneumothorax
b. Sucking chest wound
c. Open pneumothorax
d. Pulmonary interstitial empyema
ANS: A
A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot
escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural
space; it occurs because of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 478 | Table 19-6
13. What is the medical treatment for a pneumothorax greater than 15%?
a. Systemic antibiotics to treat the inflammatory response
b. An occlusive dressing to equalize lung pressures
c. Interventions to evacuate the air from the pleural space
d. Mechanical ventilation to assist with re-expansion of the collapsed lung
ANS: C
A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the
collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12 to 20 Fr) or large-bore
(24 to 40 Fr) chest tube.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 479
3
14. A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest
radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What
action should the nurse take next?
a. Lavage the airway with normal saline.
b. Place the patient supine in a semi-Fowler position.
c. Manually ventilate the patient.
d. Suction the airway.
ANS: D
When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The
patient’s head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the
gastric contents.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 484
15. A patient was admitted in acute lung failure. The patient is receiving 40% oxygen via a simple facemask. The morning chest
radiography study reveals right lower lobe pneumonia. Which test would the nurse expect the practitioner to order to identify the
infectious pathogen?
a. CBC with differential
b. Wound culture of surgical site
c. Sputum Gram stain and culture
d. Urine specimen
ANS: C
A sputum Gram stain and culture are done to facilitate the identification of the infectious pathogen. In 50% of cases, though, a
causative agent is not identified. A diagnostic bronchoscopy may be needed, particularly if the diagnosis is unclear or current
therapy is not working. In addition, a complete blood count (CBC) with differential, chemistry panel, blood cultures, and arterial
blood gas analysis is obtained.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 468
16. A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the
spread of infection between staff and patients?
a. Place the patient in respiratory isolation.
b. Ensure everyone is using proper hand hygiene.
c. Use personal protective equipment.
d. Initiate prompt administration of antibiotics.
ANS: B
Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 469 | Box 19-10
17. A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a
simple facemask. The patient has become increasingly agitated and confused. The patient’s oxygen saturation has dropped from
92% to 84%. The nurse notifies the practitioner about the change in the patient’s condition. What interventions should the nurse
anticipate?
a. Intubation and mechanical ventilation
b. Change in antibiotics orders
c. Suction and reposition the patient
d. Orders for a sedative
ANS: A
Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need
to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative
would not address the development of severe hypoxemia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 472-474
18. What two pathogens are most frequently associated with ventilator-associated pneumonia?
a. Staphylococcus aureus and Pseudomonas aeruginosa
b. Escherichia coli and Haemophilus influenzae
c. Acinetobacter baumannii and Haemophilus influenzae
d. Klebsiella spp. and Enterobacter spp.
ANS: A
Pathogens that can cause hospital-associated pneumonia (HAP) include Escherichia coli, H. influenzae, methicillin-sensitive S.
aureus, S. pneumoniae, P. aeruginosa, Acinetobacter baumannii, methicillin-resistant S. aureus (MRSA), Klebsiella spp., and
Enterobacter spp. Two of the pathogens most frequently associated with ventilator-associated pneumonia (VAP) are S. aureus and
P. aeruginosa.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 466
4
19. What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)?
a. Tachycardia and tachypnea
b. Hemoptysis and evidence of deep vein thromboses
c. Apprehension and dyspnea
d. Right ventricular failure and fever
ANS: A
The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being
tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic
component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and
hemoptysis. Syncope and hemodynamic instability can occur because of right ventricular failure.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 472
20. Depending on the patient’s risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once
they are discharged from the hospital?
a. 1 to 3 months
b. 3 to 6 months
c. 3 to 12 months
d. 12 to 36 months
ANS: C
The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 474
21. A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the
right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32
breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate?
a. Thoracentesis
b. Chest tube insertion
c. Pericardiocentesis
d. Emergent intubation
ANS: B
The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural
space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 479
MULTIPLE RESPONSE
1. Medical management of a patient with status asthmaticus includes which treatments? (Select all that apply, one, some, or all.)
a. Oxygen therapy
b. Bronchodilators
c. Corticosteroids
d. Antibiotics
e. Intubation and mechanical ventilation
ANS: A, B, C, E
Medical management of a patient with status asthmaticus is directed toward supporting oxygenation and ventilation.
Bronchodilators, corticosteroids, oxygen therapy, and intubation and mechanical ventilation are the mainstays of therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 476
5
2. Nursing management of the patient with acute lung failure includes which interventions? (Select all that apply, one, some, or all.)
a. Positioning the patient with the least affected side up
b. Providing adequate rest between treatments
c. Performing percussion and postural drainage every 4 hours
d. Controlling fever
e. Pharmaceutical medications to control anxiety
ANS: A, B, D, E
The goal of positioning is to place the least affected area of the patient’s lung in the most dependent position. Patients with
unilateral lung disease should be positioned with the healthy lung in a dependent position. Patients with diffuse lung disease may
benefit from being positioned with the right lung down because it is larger and more vascular than the left lung. For patients with
alveolar hypoventilation, the goal of positioning is to facilitate ventilation. These patients benefit from nonrecumbent positions
such as sitting or a semierect position. In addition, semirecumbency has been shown to decrease the risk of aspiration and inhibit
the development of hospital-associated pneumonia. Frequent repositioning (at least every 2 hours) is beneficial in optimizing the
patient’s ventilatory pattern and ventilation/perfusion matching. These include performing procedures only as needed,
hyperoxygenating the patient before suctioning, providing adequate rest and recovery time between various procedures, and
minimizing oxygen consumption. Interventions to minimize oxygen consumption include limiting the patient’s physical activity,
administering sedation to control anxiety, and providing measures to control fever.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 458 | p. 459
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Disorders
MSC: NCLEX: Physiologic Integrity
3. What psychologic factors contribute to long-term mechanical ventilation dependence? (Select all that apply, one, some, or all.)
a. Fear
b. Delirium
c. Lack of confidence
d. Depression
e. Trust in the stuff
ANS: A, B, C, D
Psychologic factors contributing to long-term mechanical ventilation dependence include a loss of breathing pattern control
(anxiety, fear, dyspnea, pain, ventilator asynchrony, lack of confidence in ability to breathe), lack of motivation and confidence
(inadequate trust in staff, depersonalization, hopelessness, powerlessness, depression, inadequate communication), and delirium
(sensory overload, sensory deprivation, sleep deprivation, pain medications).
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 482 | Box 19-26
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Disorders
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 20: Pulmonary Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which arterial blood gas (ABG) values would indicate a need for oxygen therapy?
a. PaO2 of 80 mm Hg
b. PaCO2 of 35 mm Hg
c. HCO3¯ of 24 mEq
d. SaO2 of 87%
ANS: D
The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient’s oxygenation status. In
most cases, the amount required should provide an arterial partial pressure of oxygen (PaO 2) of greater than 60 mm Hg or an
arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 487
2. Which oxygen administration device can deliver oxygen concentrations of 90%?
a. Nonrebreathing mask
b. Nasal cannula
c. Partial rebreathing mask
d. Simple mask
ANS: A
With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in
emergencies and short-term therapy requiring moderate to high FiO2.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 488 | Table 20-1
3. Which oxygen therapy device is used for a patient requiring the delivery of a precise low FiO 2?
a. Simple mask
b. Nasal cannula
c. Air-entrainment mask
d. Partial rebreathing mask
ANS: C
An air-entrainment mask is used in patients requiring the delivery of a precise low FiO 2. A simple mask, partial rebreathing mask,
and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 488 | Table 20-1
4. The nurse is caring for a patient who is hypercapnic. Which condition may occur when using oxygen therapy?
a. Oxygen toxicity
b. Absorption atelectasis
c. Carbon dioxide retention
d. Pneumothorax
ANS: C
Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the
proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2
accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 489
5. To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area?
a. Tip of the nose to the ear lobe
b. Middle of the mouth to the ear lobe
c. Tip of the nose to the middle of the trachea
d. Corner of the mouth to the angle of the jaw
ANS: D
An oropharyngeal airway’s proper size is selected by holding the airway against the side of the patient’s face and ensuring that it
extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway.
Nasopharyngeal airways are measured by holding the tube against the side of the patient’s face and ensuring that it extends from
the tip of the nose to the ear lobe.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 490 | Figure 20-1
1
6. When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds
on the left side of the chest. What problem should the nurse suspect?
a. Right mainstem intubation
b. Left pneumothorax
c. Right hemothorax
d. Gastric intubation
ANS: A
The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly
intubated patient is probably caused by a right mainstem intubation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 491
7. Which airway would be the most appropriate for a patient requiring intubation longer than 21 days?
a. Oropharyngeal airway
b. Esophageal obturator airway
c. Tracheostomy tube
d. Endotracheal intubation
ANS: C
Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or
is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 492
8. What nursing intervention can minimize the complications of suctioning?
a. Inserting the suction catheter no more than 5 inches
b. Premedicating the patient with atropine
c. Hyperoxygenating the patient with 100% oxygen
d. Increasing the suction to 150 mm Hg
ANS: C
Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO 2) with the ventilator
before the procedure and again after each pass of the suction catheter.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 497
9. Which oxygen delivery device is considered a low-flow system?
a. Nasal cannula
b. Simple face mask
c. Reservoir cannula
d. Air-entrainment nebulizer
ANS: A
A low-flow oxygen delivery system provides supplemental oxygen directly into the patient’s airway at a flow of 8 L/min or less.
Because this flow is insufficient to meet the patient’s inspiratory volume requirements, it results in a variable FiO 2 as the
supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 488 | Table 20-1
10. Which ventilator phase variable initiates the change from exhalation to inspiration?
a. Cycle
b. Trigger
c. Flow
d. Pressure
ANS: B
The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or
flow triggered based on the sensitivity setting of the ventilator and the patient’s inspiratory effort or time triggered based on the rate
setting of the ventilator.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 499
2
11. Which statement describes the assist-control mode of ventilation?
a. It delivers gas at preset volume, at a set rate, and in response to the patient’s
b.
c.
d.
inspiratory efforts.
It delivers gas at a preset volume, allowing the patient to breathe spontaneously at
his or her own volume.
It applies positive pressure during both ventilator breaths and spontaneous
breaths.
It delivers gas at preset rate and tidal volume regardless of the patient’s
inspiratory efforts.
ANS: A
Continuous mandatory (volume or pressure) ventilation (CMV), also known as assist-control (AC) ventilation, delivers gas at
preset tidal volume or pressure (depending on selected cycling variable) in response to patient’s inspiratory efforts and initiates
breath if patient fails to do so within preset time.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 500
12. What is the preset positive pressure used to augment the patient’s inspiratory effort known as?
a. Positive end-expiratory pressure (PEEP)
b. Continuous positive airway pressure (CPAP)
c. Pressure control ventilation (PCV)
d. Pressure support ventilation (PSV)
ANS: D
Preset positive pressure used to augment the patient’s inspiratory efforts is known as pressure support ventilation. With continuous
positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and
tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 500 | Table 20-5
13. Which statement best describes the effects of positive-pressure ventilation on cardiac output?
a. Positive-pressure ventilation increases intrathoracic pressure, which increases
b.
c.
d.
venous return and cardiac output.
Positive-pressure ventilation decreases venous return, which increases preload
and cardiac output.
Positive-pressure ventilation increases venous return, which decreases preload
and cardiac output.
Positive-pressure ventilation increases intrathoracic pressure, which decreases
venous return and cardiac output.
ANS: D
Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the h eart. Impaired
venous return decreases preload, which results in a decrease in cardiac output.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 500
14. What nursing interventions should be included in the nursing management of the patient receiving a neuromuscular blocking agent?
a. Withholding all sedation and narcotics
b. Protecting the patient from the environment
c. Keeping the patient supine
d. Speaking to the patient only when necessary
ANS: B
Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to
protect themselves from the environment. Special precautions should be taken to protect the patient at all times.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 505
15. A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room,
the ventilator inoperative alarm sounds. What action should the nurse take FIRST?
a. Troubleshoot the ventilator until the problem is found.
b. Take the patient off the ventilator and manually ventilate.
c. Call the respiratory therapist for help.
d. Silence the ventilator alarms until the problem is resolved.
ANS: B
Ensure emergency equipment is at bedside at all times (e.g., manual resuscitation bag connected to oxygen, masks, suction
equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed
from the ventilator and ventilated manually with a manual resuscitation bag.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 492
3
16. A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator
high-pressure limit alarm keeps alarming. What would cause this problem?
a. A leak in the patient’s endotracheal (ET) tube cuff
b. A kink in the ventilator tubing
c. The patient is disconnected from the ventilator
d. A faulty oxygen filter
ANS: B
High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator
(holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the endotracheal tube in the right mainstem
bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs,
and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension
pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or
abdominal distention.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 507 | Table 20-8
17. A patient was admitted with acute lung failure. The patient has been on a ventilator for 3 days and is being considered for weaning.
Which criteria would indicate that the patient is ready to be weaned?
a. FiO2 greater than 50%
b. Rapid shallow breathing index less than 105
c. Minute ventilation greater than 10 L/min
d. Vital capacity/kg greater than or equal to 15 mL
ANS: B
The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient’s
respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is
then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the
patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 503 | p. 504
18. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is
being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning?
a. A decrease in heart rate from 92 to 80 beats/min
b. An SpO2 of 92%
c. An increase in respiratory rate from 22 to 38 breaths/min
d. Spontaneous tidal volumes of 300 to 350 mL
ANS: C
Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or
decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5)
premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment
(usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory r ate increased by
10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30;
(11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14)
paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved
with reassurance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 505 | Box 20-5
19. Which action is considered a patient safety precaution when working with oxygen?
a. Observing for signs of oxygen-associated hyperventilation
b. Ensuring the oxygen device is properly positioned
c. Removal of all oxygen devices when eating
d. Administration of oxygen at the nurse’s discretion
ANS: B
Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness.
Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced
hypoventilation, monitoring the patient’s ability to tolerate removal of oxygen while eating, and changing the oxygen delivery
device from a mask to nasal prongs during meals as tolerated.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 489
4
20. Which route for endotracheal (ET) tube placement is usually used in an emergency intubation?
a. Orotracheal
b. Nasotracheal
c. Nasopharyngeal
d. Trachea
ANS: A
An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving
emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal
intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 490
21. The Passy-Muir valve is contraindicated in which patient?
a. A patient who is trying to relearn normal breathing patterns
b. A patient who has minimal secretions
c. A patient with laryngeal or pharyngeal dysfunction
d. A patient who wants to speak while on the ventilator
ANS: C
The Passy-Muir valve is contraindicated in patients with laryngeal or pharyngeal dysfunction, excessive secretions, or poor lung
compliance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 498
22. A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the
assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. What should the nurse do
and what is suspected?
a. Call the provider and pulmonary edema
b. Call the surgeon and hemorrhage
c. Call the pulmonologist and acute lung failure
d. Call the surgeon and bronchopleural fistula
ANS: B
Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or
intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal
excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this
frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/h, fresh blood is noted, or a sudden
increase in drainage occurs, hemorrhage should be suspected.
PTS: 1
DIF: Cognitive Level: Application
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 511
23. Which medication can cause bronchospasms and should be administered with a bronchodilator?
a. Beta-2 agonist
b. Mucolytics
c. Anticholinergic agents
d. Xanthines
ANS: B
Mucolytics may be administered with a bronchodilator because it can cause bronchospasms and inhibit ciliary function. Treatment
is considered effective when bronchorrhea develops and coughing occurs. Beta-2 agonists are used to relax bronchial smooth
muscle and dilate airways to prevent bronchospasms. Anticholinergic agents are used to block the constriction of bronchial smooth
muscle and reduce mucus production. Xanthines are used to dilate bronchial smooth muscle and reverse diaphragmatic muscle
fatigue.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 513 | Table 20-10
24. What is an indication for a pneumonectomy?
a. Peripheral granulomas
b. Bronchiectasis
c. Unilateral tuberculosis
d. Single lung abscess
ANS: C
A pneumonectomy is the removal of entire lung with or without resection of the mediastinal lymph nodes. Indications include
malignant lesions, unilateral tuberculosis, extensive unilateral bronchiectasis, multiple lung abscesses, massive hemoptysis, and
bronchopleural fistula.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 510 | Table 20-9
5
25. What is the therapeutic blood level for theophylline (Xanthines)?
a. 5 to 10 mg/dL
b. 10 to 20 mg/dL
c. 20 to 30 mg/dL
d. 35 to 45 mg/dL
ANS: B
Therapeutic blood level for theophylline is 10 to 20 mg/dL.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 513 | Table 20-10
MULTIPLE RESPONSE
1. Which of the following are complications of endotracheal tubes? (Select all that apply, one, some, or all.)
a. Tracheoesophageal fistula
b. Cricoid abscess
c. Tracheal stenosis
d. Tube obstruction
e. Hemorrhage
ANS: A, B, C, D
Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal
fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess. Hemorrhage is a complication of tracheostomy tubes.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 493 | Table 20-3
2. Which interventions minimize the complications associated with suctioning an artificial airway? (Select all that apply, one, some,
or all.)
a. Hyperoxygenate the patient prior to the start of the procedure
b. Hyperoxygenate the patient after each pass of the suction catheter
c. Limit the duration of each suction pass to 20 seconds
d. Instill 5 to 10 mL of normal saline to facilitate secretion removal
e. Use intermittent suction to avoid damaging tracheal tissue
ANS: A, B
Hyperoxygenation and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent
suction reduces damage, and saline instillation can increase the risk for infection.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 497
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Therapeutic Management
MSC: NCLEX: Physiologic Integrity
3. Which statements regarding rotation therapies are accurate? (Select all that apply, one, some, or all.)
a. Continuous lateral rotation therapy (CLRT) can be effective for improving
b.
c.
d.
e.
oxygenation if used for at least 18 hours/day.
Kinetic therapy can decrease the incidence of ventilator-acquired pneumonia in
neurologic and postoperative patients.
Use of rotational therapy eliminates the need for other pressure ulcer prevention
strategies.
CLRT helps avoid hemodynamic instability secondary to the continuous, gentle
turning of the patient.
CLRT has minimal pulmonary benefits for critically ill patients.
ANS: B, E
Studies have found that to achieve benefits with rotation therapy, rotation must be aggressive, and the patient must be at least 40
degrees per side, with a total arc of at least 80 degrees for at least 18 hours a day. Kinetic therapy has been shown to decrease the
incidence of ventilator-acquired pneumonia, particularly in neurologic and postoperative patients. Complications of the procedure
include dislodgment or obstruction of tubes, drains, and lines; hemodynamic instability; and pressure ulcers. Lateral rotation does
not replace manual repositioning to prevent pressure ulcers. Continuous lateral rotation therapy (CLRT) has been shown to be of
minimal pulmonary benefit for the critically ill patients.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 509
OBJ: Nursing Process Step: Planning
TOP: Pulmonary Therapeutic Management
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
4. What are the clinical manifestations associated with oxygen toxicity? (Select all that apply, one, some, or all.)
a. Substernal chest pain that increases with deep breathing
b. Moist cough and tracheal irritation
c. Pleuritic pain occurring on inhalation, followed by dyspnea
d. Increasing CO2
e. Sore throat and eye and ear discomfort
ANS: A, C, E
Several clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated
by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by
dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 489
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Therapeutic Management
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
Chapter 21: Neurologic Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which structure(s) form(s) the blood–brain barrier?
a. Postsynaptic terminals
b. Pia mater
c. Vascular endothelial cells
d. Myelin sheath
ANS: C
The blood–brain barrier operates on the concept of tight junctions between adjacent cells and actually consists of three separate
barriers: the endothelial cells of cerebral blood vessels, the epithelial cells of the choroid plexus, and the cells tha t form the
outermost layer of the arachnoid.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 526
2. Which neurologic structure carries nerve impulses from the central nervous system (CNS) to the periphery to produce a response
such as contraction of the skeletal muscles?
a. Efferent fibers
b. Afferent fibers
c. Sensory fibers
d. Neurotransmitters
ANS: A
Efferent fibers (motor fibers) transmit the central nervous system (CNS) response to the periphery to produce a motor response
such as contraction of skeletal muscles, contraction of the smooth muscles of organs, or secretion by endocrine glands. This
sensory information is transmitted to the CNS by afferent fibers (sensory fibers). Fibers enclosed in the sheath are called
myelinated fibers. Neurotransmitters help with nerve transmission from one neuron to the next.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 520
3. A patient has neurologic damage to the limbic system. Which assessment finding is specific to this type of deficit?
a. Flat affect with periods of emotional lability
b. Unable to recall early events
c. Disorientation to place and time
d. Unable to interpret written words
ANS: A
The limbic lobe’s primary functions are related to self-preservation and include functions such as recall of pleasurable as well as
unpleasant or potentially dangerous events, modification of mood and emotional responses in relation to perceived events,
interpretation of smell, and augmentation of visceral processes (e.g., heart rate, respiration) associated with emotion.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 530
4. Which type of hematoma results from traumatic injury involving the middle meningeal artery?
a. Subdural
b. Epidural
c. Subarachnoid
d. Intercerebral
ANS: B
The main blood supply for the dura mater is the middle meningeal artery. This artery lies on the surface of the dura in the epidural
space within grooves formed on the inside of the parietal bone. Traumatic disruption of the parietal bone may result in tearing of
the middle meningeal artery and development of an epidural hematoma.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 524
5. Which area of the ventricular system is usually cannulated for intracranial pressure monitoring?
a. Frontal horn of the lateral ventricle
b. Aqueduct of Sylvius
c. Foramen of Monro
d. Fourth ventricle
ANS: A
When cannulation of the ventricular system is required for intracranial pressure monitoring, cerebrospinal fluid (CSF) drainage, or
placement of a CSF shunt, the frontal horn of the lateral ventricle on the nondominant side of the brain is most often selected.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 524
1
6. What percentage of the body’s total resting cardiac output is used by the brain?
a. 5%
b. 10%
c. 20%
d. 40%
ANS: C
The brain constitutes 2% of the body’s weight but uses 20% of the body’s total resting cardiac output. It requires approximately 750
mL of blood flow per minute and can extract as much as 45% of arterial oxygen to meet normal metabolic needs.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 539
7. Which areas of the spinal cord have tenuous blood supply and are especially vulnerable to circulatory embarrassment?
a. C2 to C3
b. C5 to C6
c. T8 to T10
d. L4 to L5
ANS: A
Arterial supply to the spinal cord is segmented at best, making portions of the spinal cord that receive blood supply from two
separate sources vulnerable to low flow states. The most vulnerable of these areas are C2 to C3, T1 to T4, and L1 to L2.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 548
8. Damage to the upper portion of the reticular activating system results in which condition?
a. Seizures
b. Diabetes insipidus
c. Apnea
d. Impaired consciousness
ANS: D
The reticular activating system (RAS) works through activation of the hypothalamus, which results in diffuse cortical stimulation
and autonomic stimulation. Damage to the thalamic or hypothalamic RAS pathways results in impaired consciousness.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 539
9. A person with a cerebellar lesion will have difficulty with which physiologic mechanism?
a. Breathing
b. Equilibrium
c. Memory
d. Speech
ANS: B
Cerebellar impulses are communicated to descending motor pathways to integrate spatial orientation and equilibrium with posture
and muscle tone, ensuring synchronized adjustments in movement that maintain overall balance and motor coordination. Cerebellar
monitoring and adjustment of motor activity occurs simultaneously with movement, enabling significant control of fine motor
function.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 532
10. What is the large opening at the base of the cranium called?
a. Cisterna magna
b. Median foramen
c. Foramen magnum
d. Lateral foramen
ANS: C
The cranium is a solid, nonexpanding bony vault with only one large opening at the base called the foramen magnum, through
which the brainstem projects and connects to the spinal cord.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 524 | p. 528 | Figure 21-9
2
11. Which statement best describes the role of neuroglial cells?
a. They are fewer in number than neurons.
b. They provide support to the neuron in nutrients and structural formation.
c. They protect the central nervous system (CNS) from nonmetabolic primary
d.
neoplasms.
They produce a steady supply of neurotransmitters.
ANS: B
These cells provide the neuron with structural support, nourishment, and protection (Table 26-1). They also retain their ability to
replicate but can replicate abnormally and hence are the primary source of central nervous system neoplasms.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 520
12. What is the tissue that adheres directly to the brain called?
a. Dura mater
b. Arachnoid mater
c. Pia mater
d. Blood–brain barrier
ANS: C
The outermost layer of meninges directly beneath the skull is the dura mater. The arachnoid membrane is a delicate, fragile
membrane that loosely surrounds the brain. Cerebrospinal fluid (CSF) circulates freely in the subarachnoid space fragile membrane
that loosely surrounds the brain. The pia mater adheres directly to brain tissue. Rich in small blood vessels that supply a large
volume of arterial blood to the central nervous system, this membrane closely follows all folds and convolutions of the brain’s
surface.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 524
13. Obstructive hydrocephalus can occur in the presence of what abnormality?
a. Blockage in the arachnoid villi
b. Malformation of the falx cerebelli
c. Blockage of cerebrospinal fluid (CSF) flow in the ventricular system
d. Increased production of CSF
ANS: C
Blockage of cerebrospinal fluid (CSF) flow occurring within the ventricular system obstructs the normal circulation of CSF,
causing dilation of the ventricles, a condition called obstructive hydrocephalus.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 524
14. Substances most likely to pass across the blood–brain barrier have what characteristics?
a. Low pH compared with body fluids
b. Lipid solubility
c. Large particle size
d. A close relation to toxic metabolites
ANS: B
Passage of substances across the blood–brain barrier is a function of particle size, lipid solubility, and protein-binding potential.
Most drugs or compounds that are lipid soluble and stable at body pH rapidly cross the blood–brain barrier. The blood–brain
barrier is also very permeable to water, oxygen, carbon dioxide, and glucose.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 526
15. Control of the rate of respirations occurs in the in which brain center?
a. Apneustic center
b. Pneumotaxic center
c. Reticular activating system
d. Midbrain
ANS: B
Two respiratory control centers are located in the pons, namely the apneustic and pneumotaxic centers. Whereas the apneustic
center controls the length of inspiration and expiration, the pneumotaxic center controls respiratory rate.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 532
3
16. The sensory, motor, and cognitive functions are the primary functions of which area of the brain?
a. Diencephalon
b. Basal ganglia
c. Cerebellum
d. Cerebrum
ANS: D
The outermost aspect of the cerebrum is called the cerebral cortex. The primary functions of the cerebral cortex include sensory,
motor, and intellectual (cognitive) functions, making this area of the brain vital to normal human functioning and providing
capabilities that make humans unique as a species.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 527
17. What is the region of the brain that acts as a relay station for both motor and sensory activity called?
a. Cerebrum
b. Cerebellum
c. Thalamus
d. Hypothalamus
ANS: C
The thalamus consists of two connected ovoid masses of gray matter and forms the lateral walls of the third ventricle. The two
thalami serve as a relay station and gatekeeper for motor and sensory stimuli, preventing or enhancing transmission of impulses
based on the behavioral needs of the person.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 531 | Figure 21-12
18. A patient with neurologic damage continues with extremely high core body temperature despite interventions to lower temperature.
The nurse suspects the patient has sustained damage to which area of the brain?
a. Cerebrum
b. Cerebellum
c. Thalamus
d. Hypothalamus
ANS: D
Areas of the internal environment regulated and maintained by the hypothalamus include temperature regulation, autonomic
nervous system responses, food and water intake, hormonal secretions, and behavioral responses.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 531
19. A lack of which two substances can cause disruption in neuronal function and irreversible damage?
a. Oxygen and glucose
b. Protein and insulin
c. Oxygen and protein
d. Protein and glucose
ANS: A
No reserve of either oxygen or glucose is found in the cerebral tissues. A lack or inadequate amount of either one rapidly disrupts
cerebral function and produces irreversible damage.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 521
20. If the right internal carotid artery is blocked, what happens to the blood flow to the right side of the brain?
a. Blood flow is delivered via the circle of Willis.
b. Blood flow is diminished by 25%.
c. Blood flow is diminished by 50%.
d. Blood flow ceases.
ANS: A
When complete, the circle of Willis is capable of supporting some degree of collateral blood flow in the case of arterial occlusion,
although a sufficient arterial supply in the face of arterial obstruction is not guaranteed.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 540
4
21. The ability to access cerebrospinal fluid (CSF) by a lumbar puncture is attributable to the flow of CSF in which space?
a. Subdural
b. Subpia
c. Epidural
d. Subarachnoid
ANS: D
Cerebrospinal fluid fills the ventricular system and surrounds the brain and spinal cord in the subarachnoid space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 526
22. A patient is admitted after a stroke. The patient has an altered level of consciousness and garbled speech. A computed tomography
scan is performed to determine the cause of the stroke, and a lumbar puncture is performed for analysis of cerebrospinal fluid
(CSF). Because the patient’s speech is garbled, the nurse documents the occurrence of which type of aphasia?
a. Fluent
b. Receptive
c. Expressive
d. Global
ANS: C
The area involved in the formulation of verbal speech is the Broca’s area. Damage to this area results in an expressive or nonfluent
aphasia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 529
23. A patient has coherent speech but the words are illogical. Which part of the brain has been affected?
a. The cerebellum
b. The Broca’s area
c. The Wernicke area
d. The hypothalamus
ANS: C
The Wernicke area (Brodmann area 22) is partially located within the parietal lobe and partially in the temporal lobe, most
commonly on the left side of the cerebral cortex. This area is concerned with reception of written and verbal language and includes
many intricate connections to other parts of the brain associated with auditory and visual functions, cognitive appraisal, and
expressive language. Injury to this area of the brain may result in disability ranging from minor receptive language dysfunction to
receptive or fluent aphasia, in which expressive language function remains but is illogical in content or a “word salad.”
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 530 | Figure 21-9
24. Which lobe of the brain deals primarily with sensory function?
a. Frontal lobe
b. Temporal lobe
c. Occipital lobe
d. Parietal lobe
ANS: D
The parietal lobe is primarily concerned with sensory functions, including integration of sensory information; awareness of body
parts; interpretation of touch, pressure, and pain; and recognition of object size, shape, and texture. Injury to these areas may result
in tactile sensory loss on the opposite side of the body.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 529
25. The primary functions of which lobe are hearing, speech, behavior, and memory?
a. Frontal lobe
b. Temporal lobe
c. Occipital lobe
d. Parietal lobe
ANS: B
The temporal lobe lies beneath the temporal bone in the lateral portion of the cranium. Separated from the frontal and parietal lobes
by the lateral fissure, this lobe has the primary functions of hearing, speech, behavior, and memory.
PTS: 1
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MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 530
5
26. Cranial nerves IX, X, XI, and XII are located in which section of the brainstem?
a. Midbrain
b. Pons
c. Medulla oblongata
d. Reticular formation
ANS: C
The medulla oblongata forms the last section of the brainstem, situated between the pons and the spinal cord. The cell bodies of
cranial nerves IX (glossopharyngeal), X (vagus), XI (spinal accessory), and XII (hypoglossal) are located in the medulla oblongata.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 532 | p. 537 | Figure 21-14
27. Stimulation of what nerve will elicit the gag reflex?
a. Glossopharyngeal
b. Facial
c. Spinal accessory
d. Hypoglossal
ANS: A
The glossopharyngeal nerve is a sensory nerve whose functions are taste in the posterior third of the tongue and sensation in the
back of the throat; stimulation elicits the gag reflex.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: pp. 533-536 | Table 21-3
28. Which afferent pathway carries sensory impulses from the body into the spinal cord?
a. Subarachnoid
b. Spinal nerves
c. Ventral root
d. Dorsal root
ANS: D
The dorsal root is an afferent pathway that carries sensory impulses from the body into the spinal cord. The ventral root is an
efferent pathway that carries motor information from the spinal cord to the body.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 543
MULTIPLE RESPONSE
1. Which of these substances are examples of small-molecule transmitters? (Select all that apply, one, some, or all.)
a. Acetylcholine
b. Glucose
c. Norepinephrine
d. Dopamine
e. Epinephrine
f. GABA receptors
ANS: A, C, D, E
Examples of small-molecule transmitters include acetylcholine, dopamine, norepinephrine, epinephrine, serotonin, histamine,
γ-aminobutyric acid, glycine, and glutamate.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 523
2. Which cranial nerves are responsible for motor functions of the eye? (Select all that apply, one, some, or all.)
a. Optic nerve
b. Oculomotor
c. Trochlear
d. Trigeminal
e. Abducens
f. Acoustic
ANS: B, C, E
The oculomotor nerve is the motor nerve whose function is raising the eyelids and extraocular movement of the eyes. The trochlear
nerve is the motor nerve whose function is the extraocular movement of the eyes. The abducens nerve is the motor nerve that
functions with extraocular eye movement and rotates the eyeball outward. The optic nerve is the sensory nerve whose function is
vision. The trigeminal nerve is the sensory nerve that gives sensation to the cornea, ciliary body, iris, and lacrimal gland. The
acoustic nerve is the sensory nerve whose function is hearing.
PTS: 1
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OBJ: Nursing Process Step: N/A
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: pp. 533-536 | Table 21-3
6
Chapter 22: Neurologic Clinical Assessment and Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient with a closed head injury with a Glasgow Coma Scale (GCS) score of 6. What does this score
indicate about the patient’s neurologic status?
a. Patient is in a vegetative state.
b. Patient is a paraplegic.
c. Patient is in a coma.
d. Patient is able to obey commands.
ANS: C
The best possible score on the Glasgow Coma Scale (GCS) is 15, and the lowest score is 3. Generally, a score of 7 or less on the
GCS indicates coma. Originally, the scoring system was developed to assist in general communication concerning the severity of
neurologic injury.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 551
2. While the Glasgow Coma Scale (GCS) is part of the routine neurologic assessment, the nurse knows that it is not a valid measure
for certain types of patients. Which patient is the GCS invalid?
a. Patient with hemiplegia
b. Patient with Parkinson disease
c. Patient with dyslexia
d. Patient who is intoxicated
ANS: D
Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of
consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for
evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator
of lateralization of neurologic deterioration.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 551
3. The nurse is caring for a patient with a head injury who is unresponsive. The nurse is going to use noxious stimuli to elicit a
response. What is an acceptable method?
a. Nipple pinch
b. Nail bed pressure
c. Supraorbital pressure
d. Sternal rub
ANS: B
Nail bed pressure and trapezius pinch are acceptable methods of noxious stimulation. Nail bed pressure allows evaluation of
individual extremity function. Trapezius pinch is difficult to perform on large or obese adults. Repeated sternal rub can cause the
sternum to become excoriated, open, and infected. Supraorbital pressure must be avoided in patients with head injuries, frontal
craniotomies, or facial surgery. Nipple and testicle pinching are inappropriate and unnecessary.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 552 | p. 622 | Box 22-3
4. A patient with a serious head injury has been admitted. The nurse knows that certain neurologic findings can indicate the prognosis
for the patient. Which finding denotes the most serious prognosis?
a. Decorticate posturing
b. Decerebrate posturing
c. Absence of Babinski reflex
d. Glasgow Coma Scale (GCS) score of 14
ANS: B
Outcome studies indicate that abnormal flexion or decorticate posturing has a less serious prognosis than does extension, or
decerebrate posturing. Onset of posturing or a change from abnormal flexion to abnormal extension requires immediate physician
notification. The Babinski reflex is a pathologic finding; absence of this reflex is a normal neurologic finding in adults. The range
of scores for the Glasgow Coma Scale is 3 to 15. A score of 14 denotes a minimal deficit.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 553
1
5. The nurse knows that change in pupil size is a significant neurologic finding particularly in the patient with a head injury. How
much of a size difference between the two pupils is still considered normal?
a. 1 mm
b. 1.5 mm
c. 2 mm
d. 2.5 mm
ANS: A
Pupil size should be documented in millimeters with the use of a pupil gauge to reduce the subjectivity of description. Most people
have pupils of equal size, between 2 and 5 mm. A discrepancy up to 1 mm between the two pupils is normal.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 554
6. The nurse is caring for a patient immediately after a craniotomy. When assessing the size and shape of the patient’s pupils the nurse
notes the patient’s left pupil is oval. What does this finding indicate?
a. Cortical dysfunction
b. Intracranial hypertension
c. Hydrocephalus
d. Metabolic coma
ANS: B
Pupil shape is also noted in the assessment of pupils. Although the pupil is normally round, an irregularly shaped or oval pupil may
be noted in patients with eye surgery. Initial stages of cranial nerve III compression from elevated intracranial pressure can also
cause the pupil to have an oval shape.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 554
7. A patient is admitted with an anoxic brain injury. The nurse notes abnormal extension of both extremities to noxious stimuli.
Which area of the central nervous system indicates dysfunction?
a. Cerebral cortex
b. Thalamus
c. Cerebellum
d. Brainstem
ANS: D
Abnormal extension occurs with lesions in the area of the brainstem. Abnormal flexion occurs with lesions above the midbrain in
the region of the thalamus or cerebral hemispheres.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 553
8. The nurses are admitting a neurologically impaired patient. The patient’s family is present. How comprehensive should the initial
history be?
a. It should be limited to the chief complaint and personal habits.
b. It should be all-inclusive, including events preceding hospitalization.
c. It should be confined to current medications and family history.
d. It should be restricted to only information that the patient can provide.
ANS: B
The one factor common to all neurologic assessment is the need to obtain a comprehensive history of events preceding
hospitalization.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 550
9. Why is assessment of level of conscious (LOC) the most important aspect of the neurologic examination?
a. The LOC is the most prognostic indicator of the patient’s outcome.
b. The LOC is generally limited to the Glasgow Coma Scale making it the quickest
c.
d.
part of the assessment.
In most situations the LOC deteriorates before any other neurologic changes are
noted.
The LOC is the easiest part of the neurologic exam and thus is generally
performed first.
ANS: C
Assessment of the level of consciousness is the most important aspect of the neurologic examination.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 550
2
10. Which statement best describes assessment of arousal?
a. It measures content of consciousness and is a higher-level function.
b. It is an evaluation of the reticular activating system and its connection with the
c.
d.
thalamus and the cerebral cortex.
It becomes a valid parameter when the patient is able to respond to verbal stimuli,
such as squeezing the hands-on command.
Noxious stimuli are not to be used as an assessment parameter.
ANS: B
Assessment of the arousal component of consciousness is an evaluation of the reticular activating system and its connection with
the thalamus and the cerebral cortex. Arousal is the lowest level of consciousness, and observation centers on the patient’s ability to
respond to verbal or noxious stimuli in an appropriate manner.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 550
11. The nurse is caring for a critically injured patient who can only be aroused by vigorous external stimuli. Which category should the
nurse use to document the patient’s level of consciousness?
a. Lethargic
b. Obtunded
c. Stuporous
d. Comatose
ANS: C
Stuporous means the patient can be aroused only by vigorous and continuous external stimuli. Motor response is often withdrawal
or localizing to stimulus. Obtunded means the patient displays dull indifference to external stimuli, and response is minimally
maintained. Questions are answered with a minimal response. Lethargic means the patient displays a state of drowsiness or inaction
in which the patient needs an increased stimulus to be awakened. Comatose means vigorous stimulation fails to produce any
voluntary neural response in the patient.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 552 | Box 22-2
12. The nurse is starting a peripheral intravenous catheter in the right hand of an unconscious patient. During the procedure the patient
reaches over with his left hand and tries to remove the noxious stimuli. How would the nurse document this response?
a. Decorticate posturing
b. Decerebrate posturing
c. Withdrawal
d. Localization
ANS: D
Localization occurs when the extremity opposite to the extremity receiving pain crosses the midline of the body in an attempt to
remove the noxious stimulus from the affected limb.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 552 | Box 22-4
13. The nurse is precepting a nursing student. The student asks about testing of extraocular eye movements. What should the nurse tell
the student?
a. “It tests the pupillary response to light.”
b. “It tests function of the three cranial nerves.”
c. “It tests the ability of the eyes to accommodate.”
d. “It tests the oculocephalic reflex.”
ANS: B
Control of eye movements occurs with interaction of three cranial nerves: oculomotor (III), trochlear (IV), and abducens (VI).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 554
14. The nurse is caring for a patient who has sustained a traumatic head injury. The neurologist asks the nurse to test the patient’s
oculocephalic reflex. What must the nurse verify prior to performing the test?
a. The absence of cervical injury
b. The depth and rate of respiration
c. The patient’s ability to swallow
d. The patient’s ability to follow a verbal command
ANS: A
In an unconscious patient, assessment of ocular function and innervation of the medial longitudinal fasciculus (MLF) is performed
by eliciting the doll’s eyes reflex. If the patient is unconscious as a result of trauma, the nurse must ascertain the absence of cervical
injury before performing this examination.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 556
3
15. The nurse is caring for a patient who has sustained a traumatic head injury. The provider asks the nurse to test the patient’s
oculocephalic reflex. Which findings indicate that the patient has an intact oculocephalic reflex?
a. The patient’s eyes move in the same direction the head is turned.
b. The patient’s eyes move in the opposite direction to the movement of the patient’s
head.
c. The patient’s eyes rove and move in opposite directions from each other.
d. The patient’s eyes move up and down and then back and forth.
ANS: B
To assess the oculocephalic reflex, the nurse holds the patient’s eyelids open and briskly turns the head to one side while observing
the eye movements and then briskly turns the head to the other side and observes. If the eyes deviate to the opposite direction in
which the head is turned, doll’s eyes are present, and the oculocephalic reflex arc is intact. If the oculocephalic reflex arc is not
intact, the reflex is absent.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 556 | Figure 22-6
16. The nurse is precepting a new graduate nurse. The new graduate asks about testing the oculovestibular reflex. What should the
nurse tell the new graduate?
a. “The test should not be performed on an unconscious patient because of the risk
of aspiration.”
b. “An abnormal response is manifested by conjugate, slow, tonic nystagmus,
deviating toward the irrigated ear.”
c. “This test should be included in the nursing neurologic examination of a patient
with a head injury.”
d. “This test is one of the final clinical assessments of brainstem function.”
ANS: D
The oculovestibular reflex is one of the final clinical assessments of brainstem function and is only performed by a provider. After
confirmation that the tympanic membrane is intact, the head is raised to a 30-degree angle. Then 20 to 100 mL of ice water is
injected into the external auditory canal. In a normal response, eye movement is in the direction of the injection site. An abnormal
response is disconjugate eye movement, which indicates a brainstem lesion, or no response, which indicates little to no brainstem
function.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 556
17. The nurse is caring for a patient with a head injury and observes a rhythmic increase and decrease in the rate and depth of
respiration followed by brief periods of apnea. What should the nurse document under breathing pattern?
a. Central neurogenic hyperventilation
b. Apneustic breathing
c. Ataxic respirations
d. Cheyne-Stokes respirations
ANS: D
Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration, including brief periods of
apnea. These respirations are usually seen with bilateral deep cerebral lesions or some cerebellar lesions. Central neurogenic
hyperventilations are very deep, very rapid respirations with no apneic periods. They are usually seen with lesions of the midbrain
and upper pons. Apneustic breathing includes clusters of irregular, gasping respirations separated by long periods of apnea. They
are usually seen in lesions of the lower pons or upper medulla. Ataxic respirations are irregular, random patterns of deep and
shallow respirations with irregular apneic periods. They are usually seen in lesions of the medulla.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 558 | Table 22-3
18. The nurse is caring for a severely head injured comatose patient who is dying. The nurse knows the patient has entered the late
stages of intracranial hypertension when the nurse observes which signs?
a. Pupils are equal and reactive
b. Widening pulse pressure
c. Eupnea
d. Decreased intracranial pressure
ANS: B
Attention must also be paid to the pulse pressure because widening of this value may occur in the late stages of intracranial
hypertension. With the loss of autoregulation as blood pressure increases, cerebral blood flow (CBF) and cerebral blood volume
increase and intracranial pressure (ICP) therefore increases. The mean arterial pressure must be maintained at a level sufficient to
produce adequate CBF in the presence of elevated ICP.
PTS: 1
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OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 558
4
19. The nurse is caring for a severely head injured comatose patient who is dying. The provider asks to be notified when the patient
starts to exhibit signs of Cushing reflex. What signs are the nurse assessing for?
a. Bradycardia, systolic hypertension, and widening pulse pressure
b. Tachycardia, systolic hypotension, and tachypnea
c. Headache, nuchal rigidity, and hyperthermia
d. Bradycardia, aphasia, and visual field disturbances
ANS: A
The Cushing reflex is a set of three clinical manifestations (bradycardia, systolic hypertension, and widening pulse pressure) related
to pressure on the medullary area of the brainstem.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 558
20. A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient’s Glasgow Coma Scale
(GCS) score. Which statement is true concerning the GCS?
a. It provides data about level of consciousness only.
b. It is considered equivalent to a complete neurologic examination.
c. It is a sensitive tool for evaluation of an altered sensorium.
d. It is the most critical assessment parameter to account for possible aphasia.
ANS: A
Several points should be kept in mind when the Glasgow Coma Scale is used for serial assessment. It provides data about level of
consciousness only, and it should never be considered a complete neurologic examination. Additionally, it is not a sensitive tool for
evaluation of an altered sensorium, and it does not account for possible aphasia or mechanical intubation. It is also a poor indicator
of lateralization of neurologic deterioration.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 551
21. A patient is admitted to the critical care unit with a subdural hematoma. The nurse is assessing the patient’s Glasgow Coma Scale
(GCS) score. When assessing the patient’s best motor response, which movement would receive the lowest score?
a. Abnormal extension
b. Localizing pain
c. Withdrawing from pain
d. Decorticate posturing
ANS: A
Abnormal extension (decerebrate posturing) receives a score of 2 on the Glasgow Coma Scale (GCS). The only lower score is 1,
which is for a flaccid response.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 552 | p. 553 | Table 22-1
22. The nursing is caring for a comatose patient with a brain tumor. When the nurse touches the palm of the patient’s hand, the patient
grasps the nurse’s hand. What is this sign indicative of?
a. There is damage to the brainstem.
b. It’s a normal finding.
c. The patient is getting better.
d. Cortical damage is present.
ANS: D
The grasp reflex is present when tactile stimulation of the palm of the hand produces a grasp response that is not a conscious
voluntary act. The grasp reflex is a primitive reflex that normally disappears with maturational development; thus, the presence of
the grasp reflex in the adult indicates cortical damage.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 553
23. Considering anatomic location, which cranial nerve will be affected first by downward pressure onto the infratentorial structures?
a. III
b. VI
c. IX
d. X
ANS: A
With the location of the oculomotor nerve (cranial nerve [CN] III) at the notch of the tentorium, pupil size, and reactivity play a key
role in the physical assessment of intracranial pressure changes and herniation syndromes. In addition to CN III compression,
changes in pupil size occur for other reasons. Large pupils can result from the instillation of cycloplegic agents, such as atropine or
scopolamine, or can indicate extreme stress. Extremely small pupils can indicate narcotic overdose, lower brainstem compression,
or bilateral damage to the pons.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 554
5
24. A patient has been admitted with acute confusion and other focal neurologic signs. The provider is planning to perform a lumbar
puncture. What is an abnormal finding in the cerebrospinal fluid?
a. Clear and colorless
b. Glucose of 60 mg/dL
c. Protein of 20 mg/dL
d. 30 mg/dL red blood cells
ANS: D
Cerebrospinal fluid is normally a clear, colorless, odorless solution that contains 50 to 75 mg/dL of glucose, 5 to 25 mg/dL of
protein, and no red blood cells.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 568 | Table 22-5
25. Which procedure is the diagnostic study of choice for acute head injury?
a. Magnetic resonance imaging
b. Computed tomography
c. Transcranial Doppler
d. Electroencephalography
ANS: B
Computed tomography offers rapid, convenient, noninvasive visualization of structures and is the diagnostic study of choice for an
acute head injury.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 560
26. A patient has been admitted with acute confusion and other focal neurologic signs. The provider orders magnetic resonance
imaging (MRI). Which physiological problem is the MRI superior to the computed tomography CT as a diagnostic tool?
a. Brain death determination
b. Detection of central nervous system infection
c. Estimation of intracranial pressure
d. Identification of subarachnoid hemorrhage
ANS: B
Magnetic resonance imaging (MRI) produces images with greater detail than computed tomography (CT) and provides views of
several planes (sagittal, coronal, axial, and oblique) that are not possible with CT. MRI with contrast is the preferred study for
detection of infectious and inflammatory processes of the central nervous system (CNS). MRI can detect areas of cerebral infarct
within a few hours of the incident and can identify small areas of plaque in patients with multiple sclerosis. MRI with contrast is
the preferred study for detection of infectious and inflammatory processes of the CNS, malignancy, and metastatic lesions; cervical
spine imaging; and postoperative evaluation of tumor recurrence. MRI also is the diagnostic study of choice in the evaluation of
spinal cord injury.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 560
27. A patient is having a digital subtraction angiography. Which instruction is included for the patient to prepare for the procedure ?
a. Inform the patient that the procedure is very noisy and earplugs will be provided
b. Tell the patient that repositioning will be required at appropriate intervals
c. Instruct the patient to remaining motionless during the entire procedure
d. Let the patient know he will be expected to swallow frequently during the
procedure
ANS: C
The major disadvantage of digital subtraction angiography involves the patient’s ability to remain motionless during the entire
procedure. Even swallowing significantly interferes with the imaging process.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 564
28. Cerebral infarction is a serious complication of which procedure?
a. Extracranial Doppler
b. Evoked potential testing
c. Myelography
d. Cerebral angiography
ANS: D
Complications associated with cerebral angiography include cerebral embolus caused by the catheter dislodging a segment of
atherosclerotic plaque in the vessel, hemorrhage or hematoma formation at the insertion site, vasospasm caused by the irritation of
catheter placement, thrombosis of the extremity distal to the injection site, and allergic or adverse reaction to the contrast medium.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 564
6
29. A patient is undergoing a preoperative evaluation for carotid arteries. What two tests should the nurse expect to see ordered for the
patient?
a. Ultrasound and magnetic resonance angiography
b. Conventional angiography and evoked potential
c. Computed tomography (CT) and magnetic resonance angiography
d. Transcranial Doppler and extracranial Doppler
ANS: A
Magnetic resonance angiography of the carotid arteries has become an established complement to preoperative ultrasound
evaluation. It helps determine the area of salvageable tissue (or penumbra) after acute stroke and head injury.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 564
30. The provider wishes to evaluate the functional integrity of cerebral motor pathways in a brain-injured patient. Which test should the
nurse anticipate the provider will order?
a. Electroencephalography
b. Xenon computed tomography (CT)
c. Motor-evoked potentials
d. Emission tomography
ANS: C
Motor-evoked potentials assess the functional integrity of descending motor pathways. The motor cortex is stimulated via direct
high-voltage electric stimulation through the scalp or use of a magnetic field to induce an electrical current within the brain.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 567
31. Which nuclear medicine study should the nurse anticipate a provider’s order for in a patient who is being evaluated for a brain
tumor?
a. PET
b. MRI
c. MRA
d. SPECT
ANS: D
The single-photon emission computed tomography (SPECT) test differs from positron emission tomography (PET) in that tracer
stays in the bloodstream rather than being absorbed by surrounding tissue, thereby limiting the images to areas where blood flows.
SPECT is cheaper and more readily available than higher resolution PET. The major clinical uses of SPECT are to detect
cerebrovascular disease, seizures, and tumors. Magnetic resonance imaging and magnetic resonance angiography are radiographic
imaging examinations.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Physiologic Integrity
REF: p. 566
TOP: Neurologic
32. A patient has been admitted with acute confusion and other focal neurologic signs. The provider plans to perform a lumbar
puncture. What is the most serious complication of lumbar puncture?
a. Meningitis
b. Dural tear
c. Brainstem herniation
d. Spinal cord trauma
ANS: C
Two life-threatening risks associated with lumbar puncture include possible brainstem herniation, if intracranial pressure is
elevated, and respiratory arrest associated with neurologic deterioration.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 567
33. The patient is ordered a computed tomography (CT) scan with contrast. Which question should the nurse ask the conscious patient
before the procedure?
a. “Are you allergic to penicillin?”
b. “Are you allergic to iodine-based dye?”
c. “Are you allergic to latex?”
d. “Are you allergic to eggs?”
ANS: B
If the patient is scheduled to receive contrast for computed tomography (CT) scanning, questions about possible sensitivity to
iodine-based dye must be asked beforehand, if possible. During infusion of the dye and for 10 to 30 minutes afterward, the patient
is observed closely for an anaphylactic reaction. Fewer than 1% of all patients undergoing contrast-enhanced CT have severe
anaphylactic reactions, shock, or cardiac arrest.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 560
7
34. Which patient may need sedation before having a magnetic resonance imaging (MRI) scan?
a. Claustrophobic patient
b. Comatose patient
c. Elderly patient
d. Patient with a spinal cord injury
ANS: A
The magnetic resonance imaging procedure is lengthy and requires the patient to lie motionless in a tight, enclosed space. Mild
sedation, a blindfold, or both may be necessary for claustrophobic patients.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 561
35. The nurse is caring for a patient who has just had a cerebral angiogram. Which intervention should be part of the nursing
management plan?
a. Ensuring that the patient is adequately hydrated
b. Maintaining the patient on an NPO status
c. Administering antibiotics to the patient
d. Keeping the patient flat in bed for 24 hours
ANS: A
After the cerebral angiogram, adequate hydration is necessary to assist the kidneys in clearing the heavy dye load. Inadequate
hydration may lead to renal dysfunction and renal shutdown.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 564
36. The nurse is caring for a patient who is going to have digital subtraction angiography. The patient asks what is the difference
between conventional and digital subtraction angiography. What should the nurse tell the patient?
a. Digital subtraction angiography has fewer complications.
b. Digital subtraction angiography is noninvasive.
c. Digital subtraction angiography uses significantly less dye.
d. Digital subtraction angiography is done through the femoral vein.
ANS: C
Digital subtraction angiography uses significantly less dye than arterial angiography. Dye is injected in the venous or arterial
system. The patient must remain motionless during the procedure. Complications are the same as those for cerebral angiography.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 564
37. The nursing management plan for a patient undergoing a water-based contrast myelogram should include intervention?
a. Maintain the patient flat in bed for 4 to 6 hours
b. Observe the puncture sight every 15 minutes for 2 hours for signs of bleeding
c. Keep the patient’s head elevated 30 to 45 degrees for 8 hours
d. Administer a sedative to keep the patient from moving around
ANS: C
Postprocedure care includes keeping the patient’s head elevated 30 to 45 degrees for 8 hours, monitoring neurologic status, and
encouraging oral fluids.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 565
38. The provider has ordered a carotid Doppler study for a patient. The patient asks the nurse what the test is for. How should the nurse
respond?
a. The test evaluates blood flow in the anterior, middle, or posterior cerebral
arteries.
b. The test estimates blood flow velocity thought the carotid arteries.
c. The test assesses arteriovenous circulation in the intracranial space.
d. The test gauges global cerebral blood flow.
ANS: B
Ultrasound technology, although not an absolute measure of cerebral blood flow, uses a noninvasive technique to provide
information about the flow velocity of blood through carotid vessels. Carotid duplex studies are used as a routine screening
procedure for intraluminal narrowing of the common and internal carotid arteries as a result of atherosclerotic plaques.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 566
8
39. The nurse is precepting a new graduate nurse. The new graduate asks about the difference between electroencephalography and
evoked potentials. What should the nurse tell the new graduate?
a. Evoked potentials measure and record electric and muscle activity in response to
noxious stimuli.
b. Electroencephalography measures cerebral blood flow and oxygen extraction.
c. Evoked potentials measure cerebral electrical impulses generated in response to
sensory stimuli.
d. Electroencephalography measures the biochemical changes in the brain to assess
metabolic activity.
ANS: C
Evoked potentials involve the recording of electrical impulses generated by a sensory stimulus as it travels through the brainstem
and into the cerebral cortex. Electroencephalography (EEG) records electric impulses, commonly called brain waves, generated by
the brain.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 566
40. The nurse is caring for a patient with an intracranial pressure-monitoring device that provides access to cerebrospinal fluid (CSF)
for sampling. What type of device does the patient have?
a. Subarachnoid bolt
b. Epidural catheter
c. Intraventricular catheter
d. Fiber-optic catheter
ANS: C
An intraventricular catheter allows accurate intracranial pressure (ICP) measurement and provides access to cerebrospinal fluid
(CSF) for drainage or sampling. A subarachnoid bolt, epidural catheter, and fiber-optic catheter provide no access for CSF
sampling.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 567 | p. 568
41. The patient was admitted with a head injury and an intracranial pressure (ICP) monitoring device was placed. The nurse knows to
notify the provider if what type of wave start to appear on the monitor?
a. A waves
b. B waves
c. C waves
d. D waves
ANS: A
A waves are the most clinically significant of the three types. They usually occur in an already elevated baseline intracranial
pressure (ICP) (>20 mm Hg) and are characterized by sharp increases in ICP of 30 to 69 mm Hg, which plateau for 2 to 20 minutes
and then return to baseline. B waves appear to reflect fluctuations in cerebral blood. C waves are small, rhythmic waves that occur
every 4 to 8 minutes at normal levels of ICP. They are related to normal fluctuations in respiration and systemic arterial pressure.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 570
42. A patient is being prepared for a neurologic work-up. The provider is getting ready to perform a lumbar puncture. What is the best
position for the nurse to place the patient in for the procedure?
a. Prone
b. Reverse Trendelenburg
c. High Fowlers with knees bent and slightly tucked
d. Lateral recumbent position with knees and head slightly tucked
ANS: D
Patients undergoing a lumbar puncture are placed either in the lateral recumbent position, with the knees and head tightly tucked, or
in the sitting position, leaning over a bedside table or some other support.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 567
43. A critical care patient is diagnosed with massive head trauma. The patient is receiving brain tissue oxygen pressure (PbtO2)
monitoring. The nurse recognized that the goal of this treatment is to maintain PbtO 2
a. greater than 20 mm Hg.
b. less than 15 mm Hg.
c. between 15 and 20 mm Hg.
d. between 10 and 20 mm Hg.
ANS: A
In a patient with head injury, the goal of treatment is to maintain the PbtO 2 greater than 20 mm Hg. Factors that decrease PbtO2
include tissue hypoxia, hypocapnia, hypovolemia, decreased blood pressure, low hemoglobin levels, intracranial hypertension, and
hyperthermia. Treatment is directed at the underlying cause.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 572
9
44. The patient’s intracranial pressure (ICP) reading has gradually climbed from 15 to 23 mm Hg. What is the nurse’s primary action?
a. drain off 7 mm of cerebrospinal fluid (CSF) from the catheter.
b. notify the physician.
c. place the patient in a high Fowler position to decrease the pressure.
d. check level of consciousness.
ANS: B
Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can
decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant
factor associated with a fatal outcome.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 567
45. According to the 2007 Brain Trauma Foundation guidelines, the recommended CPP range is
a. 10 to 30 mm Hg.
b. 30 to 50 mm Hg.
c. 50 to 70 mm Hg.
d. 70 to 85 mm Hg.
ANS: C
The 2007 Brain Trauma Foundation guidelines now recommend a cerebral perfusion pressure (CPP) in the range of 50 to 70 mm
Hg and consideration of cerebral autoregulation status when selecting a CPP target in a specific patient.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 570
MULTIPLE RESPONSE
1. Indications for the use of electroencephalography (EEG) include (Select all that apply, one, some, or all.)
a. cerebral infarct.
b. metabolic encephalopathy.
c. confirmation of brain death.
d. altered consciousness.
e. all head injuries.
ANS: A, B, C, D
Indications for the use of electroencephalography include suspected seizure activity, cerebral infarct, metabolic encephalopathies,
altered consciousness, infectious disease, some head injuries, and confirmation of brain death.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 566
2. Which statements are correct regarding the assessment of motor function in the neurologically impaired patient? (Select all that
apply, one, some, or all.)
a. The presence of a Babinski reflex is an abnormal finding in an adult.
b. Lower extremity muscle tone is assessed by asking the patient to push or pull his
or her foot against resistance.
c. When using noxious stimuli to elicit a motor response, each limb is tested
separately.
d. The presence of abnormal extension indicates a less positive outcome for the
patient than abnormal flexion.
e. The evaluation of deep tendon reflexes is an essential part of the nursing
neurologic assessment.
ANS: A, C, D
The presence of a Babinski response in an adult is indicative of neurologic dysfunction, pushing or pulling against resistance tests
muscle strength not tone, and deep tendon reflexes are not routinely checked by the critical care nurse during assessment.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: pp. 552-554
Nursing Process Step: Assessment
Neurologic Clinical Assessment and Diagnostic Procedures
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
10
3. The nurse and a new graduate nurse are caring for a comatose patient on continuous electroencephalography (cEEG) monitor. The
new graduate says “This monitor is great. How come we don’t use it on all the neuro patients?” What are the drawbacks to using
this type of monitor? (Select all that apply, one, some, or all.)
a. Size of machine
b. Expensive
c. Labor-intensive program
d. Requires expertise for interpretation
e. Artifacts from ICU environment
ANS: B, C, D, E
The drawbacks to the use of continuous electroencephalography (cEEG) are that it is an expensive, labor-intensive program that
requires expertise for interpretation, and is subject to artifacts from the intensive care unit environment. More research on cEEG is
needed to determine its cost-saving potential and impact on outcome.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 572
4. What sites can be used for monitoring intracranial pressure (ICP)? (Select all that apply, one, some, or all.)
a. Intraventricular space
b. Epidural space
c. Jugular veins
d. Subdural space
e. Parenchyma
ANS: A, B, D, E
The five sites for monitoring intracranial pressure are (1) the intraventricular space, (2) the subarachnoid space, (3) the epidural
space, (4) the subdural space, and (5) the parenchyma.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 567 | p. 569 | Figure 22-14
11
Chapter 23: Neurologic Disorders and Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is one cause of metabolic coma?
a. Trauma
b. Ischemic stroke
c. Drug overdose
d. Intracerebral hemorrhage
ANS: C
Causes of metabolic coma include drug overdose, infectious diseases, endocrine disorders, and poisonings. Structural causes of
coma include ischemic stroke, intracerebral hemorrhage, trauma, and brain tumors.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 589 | Box 23-9
2. Emergency treatment of coma of unknown cause includes rapid intravenous administration of which three agents?
a. Epinephrine, hydrocortisone, and Benadryl
b. Dopamine, 10% dextrose in distilled water, and calcium chloride
c. Mannitol, dexamethasone, and sodium bicarbonate
d. Thiamine, glucose, and opioid antagonist
ANS: D
The goal of medical management of the patient in coma is identification and treatment of the underlying cause of the condition.
Initial medical management includes emergency measures to support vital functions and prevent further neurologic deterioration.
Protection of the airway and ventilatory assistance are often needed. Administration of thiamine (at least 100 milligrams [mg]),
glucose, and an opioid antagonist is suggested when the cause of coma is not immediately known.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 590
3. Which patient has the best prognosis based on the cause of coma?
a. A 36-year-old man with closed head injury
b. A 50-year-old woman with hepatic encephalopathy
c. A 46-year-old woman with subarachnoid hemorrhage
d. A 72-year-old man with hypertensive intracerebral hemorrhage
ANS: A
Prognosis depends on the cause of coma and the length of time unconsciousness persists. Only 15% of patients in nontraumatic
coma make a satisfactory recovery. Metabolic coma usually has a better prognosis compared with coma caused by a structural
lesion, and traumatic coma usually has a better outcome compared with nontraumatic coma.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 590
4. Which assessment finding in a patient in coma 10 to 12 hours after cardiopulmonary arrest is indicative of unlikely survival?
a. Decorticate posturing
b. Absent pupillary light reflexes
c. Decerebrate posturing
d. Central hyperventilation
ANS: B
Much research has been directed toward identifying the prognostic indicators for the patient in coma after a cardiopulmonary arrest.
In a meta-analysis, the best predictors of poor outcome after cardiac arrest were lack of corneal or papillary response at 24 hours
and lack of motor movement at 72 hours. However, regardless of the cause or duration of coma, the outcome for an individual
cannot be predicted with 100% accuracy.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 590
5. How often should lubricating eye drops be administered to a patient in coma to prevent corneal epithelial breakdown?
a. 2 hours
b. 4 hours
c. 8 hours
d. 12 hours
ANS: A
Instillation of saline or methylcellulose drops every 2 hours prevents corneal breakdown in the coma patient. In addition, taping a
polyethylene film over the eyes, extending from beyond the orbit to over the eyebrow, creates a moisture chamber and has been
effective in keeping the eyes moist.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 591
1
6. Appropriate therapy for ischemic stroke depends on rapid completion of which diagnostic study?
a. Magnetic resonance imaging
b. Noncontrast computed tomography
c. Contrast computed tomography
d. Lumbar puncture
ANS: B
Confirmation of the diagnosis of ischemic stroke is the first step in the emergent evaluation of these patients. Differentiation from
intracranial hemorrhage is vital. Noncontrast computed tomography (CT) scanning is the method of choice for this purpose, and it
is considered the most important initial diagnostic study. In addition to excluding intracranial hemorrhage, CT can assist in
identifying early neurologic complications and the cause of the insult. Magnetic resonance imaging (MRI) can demonstrate
infarction of cerebral tissue earlier than can CT but is less useful in the emergent differential diagnosis. Lumbar puncture is
performed only if subarachnoid hemorrhage is suspected and the CT scan findings are normal.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 577
7. Ideally fibrinolytic therapy should be administered within how many hours of the onset of stroke symptoms?
a. 1
b. 3
c. 6
d. 10
ANS: B
National guidelines for the management of stroke are based on the results of the National Institute of Neurologic Disorders and
Stroke rtPA Stroke Study. This study demonstrated that administration of recombinant tissue plasminogen activator within 3 hours
of onset of the stroke was an effective and safe therapy for ischemic stroke. This time frame has now been expanded from 3 to 4.5
hours with additional excursion criteria.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 577
8. A patient presents with aphasia, decreased level of consciousness, and right-sided weakness. The patient has a history of heart
disease, hyperlipidemia, and transient ischemic attacks. Based on the history, the nurse suspects that the patient has sustained which
type of stroke?
a. Hemorrhagic stroke
b. Intracerebral hemorrhages
c. Subarachnoid hemorrhages
d. Ischemic stroke
ANS: D
Ischemic stroke results from interruption of blood flow to the brain and accounts for 80% to 85% of all strokes. The interruption
can be the result of a thrombotic or embolic event. Thrombosis can form in large vessels (large-vessel thrombotic strokes) or small
vessels (small-vessel thrombotic strokes). Embolic sources include the heart (cardioembolic strokes) and atherosclerotic plaques in
larger vessels (atheroembolic strokes). In 30% of the cases, the underlying cause of the stroke is unknown (cryptogenic strokes).
Strokes are classified as ischemic and hemorrhagic. Hemorrhagic strokes can be further categorized as subarachnoid hemorrhages
and intracerebral hemorrhages.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 575
9. Which statement is true regarding the occurrence of subarachnoid hemorrhages (SAHs)?
a. Occurrence is greater in men than women younger than the age of 40 years old.
b. Occurrence is greater in men than women older than the age of 40 years old.
c. 90% of SAHs are caused by traumatic injury.
d. Patients with SAHs have a better survival rate than patients with arteriovenous
malformations.
ANS: A
Among people younger than 40 years, more men than women are likely to have subarachnoid hemorrhages (SAHs); among those
older than 40 years, more women have SAHs. Hemorrhage from arteriovenous malformation rupture has a better chance of survival
and is associated with an overall mortality rate of 10% to 15%. Ninety percent of aneurysms are congenital, the cause of which is
unknown. The other 10% can be the result of traumatic injury (that stretches and tears the muscular middle layer of the arterial
vessel) or infectious material.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 578 | p. 579
2
10. What is a pathologic consequence of an unruptured cerebral aneurysm?
a. It shunts blood away from the surrounding tissues.
b. It leaks blood into the subarachnoid space.
c. It causes damage the middle layer of the arterial wall.
d. It places pressure on the surrounding tissues.
ANS: D
An unruptured aneurysm may be problematic because it places pressure on the surrounding tissues. The aneurysm becomes
clinically significant when the vessel wall becomes so thin that it ruptures, sending arterial blood at a high pressure into the
subarachnoid space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 579
11. The incidence of rebleeding after a ruptured cerebral aneurysm is highest during which of the following time periods?
a. First 24 hours
b. 4 to 12 days
c. 3 to 4 weeks
d. 3 to 6 months
ANS: A
Rebleeding is the occurrence of a second subarachnoid hemorrhage in an unsecured aneurysm or, less commonly, an arteriovenous
malformation. The incidence of rebleeding during the first 24 hours after the first bleed is 4%, with a 1% to 2% chance per day for
the following month. Mortality with aneurysmal rebleeding is approximately 70%.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 582
12. Nursing management of a patient with a clipped cerebral aneurysm receiving hemodynamic augmentation includes which
intervention?
a. Administering osmotic diuretics and vasodilator agents
b. Providing the patient with a quiet environment
c. Maintaining the patient's systolic blood pressure at 150 to 160 mm Hg
d. Keeping the patient's central venous pressure at 5 to 8 mm Hg
ANS: C
Hemodynamic augmentation therapy involves increasing the patient’s blood pressure and cardiac output with vasoactive
medications. Systolic blood pressure is maintained between 150 and 160 mm Hg. The increase in pressure forces blood through the
vasospastic area at higher pressures.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 583
13. A ventriculoperitoneal shunt may be placed in a poststroke patient to treat which complication?
a. Hyponatremia
b. Intracerebral hemorrhage
c. Spontaneous intracerebral hemorrhage
d. Hydrocephalus
ANS: D
Treatment for hydrocephalus consists of placing a drain to remove cerebrospinal fluid. This can be accomplished temporarily by
inserting a ventriculostomy or permanently by placing a ventriculoperitoneal shunt. Treatment for hyponatremia is sodium
replenishment with isotonic fluids.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 584
14. A male patient post right-sided stroke is experiencing hemiagnosia. This is evidenced by which finding?
a. The patient only reads the right side of the newspaper.
b. The patient refuses to acknowledge the left side of his body.
c. The patient is hyperresponsive when approached on the right side.
d. The patient attempts to comb his hair with a toothbrush.
ANS: B
Agnosia is a disturbance in the perception of familiar sensory (e.g., verbal, tactile, visual) information. Unilateral neglect is a form
of agnosia characterized by an unawareness or denial of the affected half of the body. This denial may range from inattention to
refusing to acknowledge a paralysis by neglecting the involved side of the body or by denying ownership of the side, attributing the
paralyzed arm or leg to someone else. The neglect also may extend to extrapersonal space. This defect most often results from right
hemispheric brain damage that causes left hemiplegia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 586 | p. 587
3
15. When an object is placed in the hand of a patient with neurologic impairment during assessment, the patient is unable to recognize
the placement. What is this complication called?
a. Homonymous hemianopsia
b. Aphasia
c. Agnosia
d. Apraxia
ANS: C
Agnosia is a disturbance in the perception of familiar sensory (e.g., verbal, tactile, visual) information. Unilateral neglect is a form
of agnosia characterized by an unawareness or denial of the affected half of the body. Tactile agnosia is a perceptual disorder in
which a patient is unable to recognize an object that has been placed in his or her hand by touch alone. Lesions in the parietal lobe
and in other cortical structures can result in apraxia, an inability to perform a learned movement voluntarily. Optic radiations
extend back to the occipital lobes. Visual defects restricted to a single field, right or left, are called homonymous hemianopsia.
Aphasia is a loss of language abilities caused by brain injury, usually to the dominant hemisphere.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 586 | p. 587
16. A patient has had an ischemic stroke and now having difficulty with speech. The nurse knows the patient is experiencing what
problem?
a. Expressive aphasia
b. Global aphasia
c. Receptive aphasia
d. Apraxia
ANS: A
Expressive aphasia, also known as motor, Broca, or nonfluent aphasia, is primarily a deficit in language output or speech
production. Global aphasia results when a massive lesion affects the motor and sensory speech areas. The patient cannot transform
sounds into words and cannot comprehend spoken words. Receptive aphasia, also referred to as sensory, Wernicke, or fluent
aphasia, occurs when the connection between the primary auditory cortex in the temporal lobe and the angular gyrus in the parietal
lobe is destroyed. Lesions in the parietal lobe and in other cortical structures can result in apraxia, an inability to perform a learned
movement voluntarily.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 587
17. Which of the following statements regarding Guillain-Barré syndrome (GBS) supports the admission to a critical care unit?
a. The demyelination process of the peripheral nerves is irreversible.
b. The demyelination process is limited to the peripheral nervous system only.
c. The paralysis associated with the syndrome occurs in a descending pattern.
d. The most common cause of death is respiratory arrest.
ANS: D
Most patients with Guillain-Barré syndrome (GBS) do not require admission to the critical care unit. However, the prototype of
GBS, known as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), involves a rapidly progressive, ascending
peripheral nerve dysfunction, which leads to paralysis that may produce respiratory failure. Because of the need for ventilatory
support, AIDP is one of the few peripheral neurologic diseases that necessitates care in a critical care environment.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 591
18. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) of the patient’s head
reveals a large left parietal area bleed. Patient assessment includes temperature (T), 98.7° F; pulse (P), 98 beats/min and thready;
respirations (R), 8 breaths/min; and blood pressure (BP), 168/100 mm Hg. Initial management of the patient includes which
intervention?
a. Placing the patient in the Trendelenburg position
b. Administering an antihypertensive agent
c. Initiating induced hypertensive therapy
d. Intubating and ventilating the patient
ANS: D
Intracerebral hemorrhage is a medical emergency. Initial management requires attention to airway, breathing, and circulation.
Intubation is usually necessary. Blood pressure management must be based on individual factors. Reduction in blood pressure is
usually necessary to decrease ongoing bleeding, but lowering blood pressure too much or too rapidly may compromise cerebral
perfusion pressure, especially in a patient with elevated intracranial pressure. National guidelines recommend keeping the mean
arterial blood pressure below 130 mm Hg in patients with a history of hypertension by moderate blood pressure reduction to a mean
arterial pressure below 110 mm Hg. Vasopressor therapy after fluid replenishment is recommended if systolic blood pressure falls
below 90 mm Hg.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 585
4
19. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient’s
head reveals a large left parietal area bleed. Based on the type of stroke, which signs and symptoms might the patient exhibit?
a. Right-sided hemiplegia and receptive aphasia
b. Left-sided hemiplegia and tactile agnosia
c. Decorticate posturing and unequal pupils
d. Unilateral neglect and dressing apraxia
ANS: A
Damage to the dominant hemisphere produces problems with speech and language and abstract and analytic skills.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 585 | p. 586
20. A right-handed patient has been admitted with an intracerebral hemorrhage. A computed tomography (CT) scan of the patient’s
head reveals a large left parietal area bleed. While assisting with personal care, the nurse notes that the patient is unable to comb
the hair with the left hand. The nurse suspects the patient may be experiencing which complication?
a. Agnosia
b. Apraxia
c. Broca aphasia
d. Wernicke aphasia
ANS: B
Lesions in the parietal lobe, as well as in other cortical structures, can result in apraxia, an inability to perform a learned movement
voluntarily.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 587
21. A patient has been experiencing drowsiness, confusion, and slight focal deficits for several days. The initial noncontract computed
tomography (CT) findings are negative. The patient is being prepared for a lumbar puncture. What appearance does the nurse
anticipate that the cerebrospinal fluid (CSF) would look?
a. Cloudy
b. Bloody
c. Yellow
d. Clear
ANS: B
If the initial computed tomography findings are negative, a lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for
analysis. CSF after subarachnoid hemorrhage (SAH) appears bloody and has a red blood cell count greater than 1000 cells/mm3. If
the lumbar puncture is performed more than 5 days after the SAH, the CSF fluid is xanthochromic (dark amber) because the blood
products have broken down. Cloudy CSF usually indicates some type of infectious process such as bacterial meningitis, not SAH.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 581 | Box 23-7
22. Downward displacement of the hemispheres, basal ganglia, and diencephalon through the tentorial notch is indicative of what type
of herniation?
a. Central
b. Uncal
c. Cingulate
d. Infratentorial
ANS: A
These effects are indicative of central herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes.
In uncal herniation, a unilateral, expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral
displacement of the tip of the temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere
shifts laterally and forces the cingulate gyrus under the falx cerebri. The two infratentorial herniation syndromes are upward
transtentorial herniation and downward cerebellar herniation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 603
23. Which medical treatment should be considered LAST in treating uncontrolled intracranial hypertension?
a. Sedatives
b. Analgesics
c. Barbiturates
d. Oxygen
ANS: C
Barbiturate therapy is a treatment protocol developed for the management of uncontrolled intracranial hypertension that has not
responded to the conventional treatments previously described. The two most commonly used drugs in high-dose barbiturate
therapy are pentobarbital and thiopental. The goal with either of these drugs is a reduction of intracranial pressure to 15 to 20 mm
Hg while a mean arterial pressure of 70 to 80 mm Hg is maintained.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 602
5
24. Which medication is a fast-acting, short-duration agent used for breakthrough seizures?
a. Lorazepam
b. Phenytoin
c. Phenobarbital
d. Midazolam
ANS: A
Lorazepam is a fast-acting, short-duration agent that may be indicated for breakthrough seizures until therapeutic drug levels can be
reached. Phenytoin is the recommended medication for seizure prophylaxis. Phenobarbital is a barbiturate whose action produces
central nervous system depression and reduces the spread of an epileptic focus.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 601
25. Which patient position is optimal to prevent elevated intracranial (ICP) pressures?
a. The head of the bed elevated 30 to 40 degrees
b. Supine with the patient’s neck in a neutral alignment
c. Individualized head position to minimize ICP measurements
d. The head of the bed elevated with flexion of the hips
ANS: C
The recent trend is to individualize the head position to maximize cerebral perfusion pressure and minimize intracranial pressure
measurements.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 596 | Box 23-20
26. What is the target range for PaCO2 in the patient with intracranial hypertension?
a. 25 to 30 mm Hg
b. 25 to 35 mm Hg
c. 35 to 40 mm Hg
d. 33 to 37 mm Hg
ANS: D
The current trend is to maintain PaCO2 levels on the lower side of normal (35 ± 2 mm Hg) by carefully monitoring arterial blood
gas measurements and by adjusting ventilator settings.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 599
27. After neurosurgery, the patient is at risk of developing what problem?
a. Aspiration
b. Diabetes mellitus
c. Seizures
d. Corneal abrasions
ANS: C
After neurosurgery, the patient is at risk for infection, corneal abrasions, and injury from falls or seizures. After neurosurgery,
patients are at risk for a variety of infections, including meningitis, cerebral abscesses, bone flap infections, and subdural empyema.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 597
28. Which nursing intervention will help prevent spikes in intracranial pressure in the post-neurosurgical patient?
a. Keep the head of the bed elevated 45 to 90 degrees.
b. Administer an antiemetic to prevent vomiting.
c. Provide fluid restriction.
d. Help with turn, cough, and deep breathe exercises.
ANS: B
Postoperative vomiting must be avoided to prevent sharp spikes in intracranial pressure (ICP) in the postoperative neurosurgical
patient. Antiemetics are administered as soon as nausea is apparent. Fluid restriction may be ordered as a routine measure to lessen
the severity of cerebral edema or as treatment for the fluid and electrolyte imbalances associated with the syndrome of
inappropriate antidiuretic hormone secretion. Most craniotomy patients can be turned from side to side within these restrictions,
using pillows for support, except in some cases of extensive tumor removal, cranioplasty, and when the bone flap is not replaced.
Routine pulmonary care is used to maintain airway clearance and prevent pulmonary complications. To prevent dangerous
elevations in ICP, this care measure must be performed using proper technique and at time intervals that are adequately spaced
from other patient care activities.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 597
6
29. The nurse is caring for a patient who is had trans-sphenoidal surgery for removal of a pituitary tumor. The nurse observes a large
amount of clear drainage from the nose. The provider requests the drainage be tested for the presence of glucose. Why did the
physician order this test?
a. To assess for an infection
b. To check for a shift in osmolality
c. To check for occult blood
d. To assess for a cerebrospinal fluid leak
ANS: D
To differentiate cerebrospinal fluid (CSF) drainage from postoperative serous drainage, a specimen is tested for glucose content. A
CSF leak is confirmed by glucose values of 30 mg/dL or greater.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 596
30. What is one of the earliest signs of increased intracranial pressure (ICP)?
a. Cushing triad
b. Decerebrate posturing (abnormal extension)
c. Change in level of consciousness
d. Increase in pupillary size
ANS: C
One of the earliest and most important signs of increased intracranial pressure is a decrease in the level of consciousness.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 577
31. Which medical intervention can assist in reducing increased intracranial pressure (ICP)?
a. Decreasing the ventilator rate
b. Decreasing noxious stimuli
c. Frequent orientation checks
d. Administration of loop diuretics
ANS: B
A treatment modality that increases the incidence of noxious stimulation to the patient carries with it the potential for increasing
intracranial pressure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 602
32. Which diuretic is the most effective in the reduction of increased intracranial pressure (ICP)?
a. Mannitol
b. Furosemide
c. Urea
d. Glycerol
ANS: A
The most widely used diuretic is mannitol, a large-molecule agent that is retained almost entirely in the extracellular compartment
and has little of the rebound effect observed with other osmotic diuretics. Administration of mannitol increases cerebral blood flow
and thus induces cerebral vasoconstriction as part of the brain’s autoregulatory response to keep blood flow constant.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 602
33. What are the most common medications used in high-dose barbiturate therapy?
a. Phenytoin and fosphenytoin
b. Mannitol and nimodipine
c. Lidocaine and phenobarbital
d. Pentobarbital and thiopental
ANS: D
The goal with either drug is a reduction of intracranial pressure to 15 to 20 mm Hg while a mean arterial pressure of 70 to 80 mm
Hg is maintained. Phenytoin and fosphenytoin are anticonvulsants. Mannitol is an osmotic diuretic, lidocaine is a local anesthetic,
and nimodipine is a calcium channel blocker.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 602 | p. 603 | Table 23-5
7
34. Which medication is prescribed to decrease cerebral vasospasm?
a. Phenytoin
b. Phenobarbital
c. Nimodipine
d. Vecuronium
ANS: C
Nimodipine is used to decrease cerebral vasospasm.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 604 | Box 23-5
35. A patient is admitted with an acute head injury after a motor vehicle accident. The patient is intubated and ventilated, and a
ventriculostomy is placed. In addition to monitoring of intracranial pressure, what treatment can be provided with the
ventriculostomy?
a. Instillation of mannitol
b. Drainage of subdural hematoma
c. Brain tissue sampling
d. Cerebrospinal fluid drainage
ANS: D
Advantages of a ventriculostomy include access for cerebrospinal fluid drainage and sampling, access for determination of
volume-pressure curves, direct measurement of pressure, and access for medication instillation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 596
36. The extrusion of cerebral tissue through the cranium is what type of herniation?
a. Transcalvarial
b. Uncal
c. Cingulate
d. Transtentorial
ANS: A
Transcalvarial herniation is the extrusion of cerebral tissue through the cranium. In the presence of severe cerebral edema,
transcalvarial herniation occurs through an opening from a skull fracture or craniotomy site. These effects are indicative of central
herniation from an expanding mass lesion of the midline, frontal, parietal, or occipital lobes. In uncal herniation, a unilateral,
expanding mass lesion, usually of the temporal lobe, increases intracranial pressure, causing lateral displacement of the tip of the
temporal lobe (uncus). Cingulate herniation occurs when an expanding lesion of one hemisphere shifts laterally and forces the
cingulate gyrus under the falx cerebri.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 603
37. A patient becomes flaccid with fixed and dilated pupils. The patient’s intracranial pressure (ICP) falls from 65 to 12 mm Hg. What
should the nurse suspect is happening?
a. The patient is having a seizure.
b. The patient’s brain has herniated.
c. The patient’s cerebral edema is resolving.
d. The patient is excessively dehydrated from the mannitol.
ANS: B
Herniation of intracerebral contents results in the shifting of tissue from one compartment of the brain to another and places
pressure on cerebral vessels and vital function centers of the brain. If unchecked, herniation rapidly causes death as a result of the
cessation of cerebral blood flow and respirations. Signs and symptoms of brain herniation include fixed and dilated pupils,
flaccidity, and respiratory arrest. The intracranial pressure drops as the pressure is relieved by shifting the intracra nial components
downward.
PTS: 1
DIF: Cognitive Level: Analysis
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 602
38. A patient’s ICP is 34 mm Hg, and his cerebral perfusion pressure is 65 mm Hg. Given that the provider has left appropriate orders,
which action should the nurse take next?
a. No action is required.
b. Administer mannitol 1 to 2 g/kg IV.
c. Place the patient supine and flat in bed.
d. Suction the patient.
ANS: B
Mannitol is an osmotic diuretic and will pull swelling out of edematous brain tissue, thereby decreasing intracranial pressure (ICP).
Having the patient lie flat in bed will impair venous drainage from the head and worsen ICP. Suctioning will cause increased
intrathoracic pressure, which will also worsen the already elevated ICP.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 602 | p. 604 | Table 23-5
8
39. The patient has uncontrolled intracranial pressure and now is receiving high-dose barbiturate therapy. The nursing management
plan for this patient should include monitoring the patient for what complication?
a. Hypothermia
b. Hypotension
c. Myocardial depression
d. Dehydration
ANS: B
Hypotension, the most common complication in barbiturate therapy, results from peripheral vasodilation and can be compounded in
an already dehydrated patient who has received large doses of an osmotic diuretic in an attempt to control intracranial pressure.
Myocardial depression results from cardiac muscle suppression and can be avoided by frequent monitoring of fluid status, cardiac
output, and serum drug levels.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 602
40. A patient has been admitted post craniotomy for a brain tumor. The nursing management plan should include monitoring the patient
for what complication?
a. Diabetes mellitus
b. Fluid retention
c. Intracranial hypotension
d. Surgical hemorrhage
ANS: D
Complications associated with a craniotomy include intracranial hypertension, surgical hemorrhage, fluid imbalance, cerebrospinal
fluid leak, and deep venous thrombosis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 595
41. A patient has been told he has a nonencapsulated tumor that has infiltrated the brain tissue. Why type of tumor does the nurse
suspect the patient has?
a. Angioma
b. Pituitary adenoma
c. Meningioma
d. Glioma
ANS: D
Gliomas are nonencapsulated; tend to infiltrate brain tissue; arise in any part of brain connective tissue; infiltrate primarily cerebral
hemisphere tissue; are not well outlined, so they are difficult to excise completely; and grow rapidly. Angiomas arise from vascular
structures and are usually difficult to resect. Pituitary adenomas arise from various tissues. Meningiomas arise from meningeal
coverings of brain and are usually encapsulated.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Neurologic
MSC: NCLEX: Physiologic Integrity
REF: p. 594 | Table 23-3
MULTIPLE RESPONSE
1. The patient has sustained an ischemic stroke involving the left cerebral hemisphere. Which of the following neurologic
abnormalities would you expect to see? (Select all that apply, one, some, or all.)
a. Aphasia
b. Left visual field defect
c. Difficulty balancing his checkbook
d. Ataxic gait
e. Somnolence
ANS: A, C
With strokes in the left (dominant) hemisphere, patients may have aphasia; right hemiparesis; right-sided sensory loss; right visual
field defect; poor right conjugate gaze; dysarthria; and difficulty in reading, writing, or calculating. With strokes in the right
(nondominant) hemisphere, patients may have neglect of the left visual space, left visual field defect, left hemiparesis, left-sided
sensory loss, poor left conjugate gaze, extinction of left-sided stimuli, dysarthria, and spatial disorientation. With strokes in the
brainstem, cerebellum, and posterior hemisphere, patients may have motor or sensory loss in all four limbs, crossed signs, limb or
gait ataxia, dysarthria, disconjugate gaze, nystagmus, amnesia, and bilateral visual field defects.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Assessment
Neurologic Disorders and Therapeutic Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 577 | Box 23-1
9
2. A patient has been admitted with an ischemic stroke. The patient received recombinant tissue plasminogen activator (rtPA) in the
emergency department. The nurse checks the medication administration record to make sure the patient does not have which
medications for the next 24 hours? (Select all that apply, one, some, or all.)
a. Aspirin
b. Sodium nitroprusside
c. Warfarin
d. Labetalol
e. Any antiplatelet drugs
ANS: A, C, E
The major risk and complication of rtPA therapy is bleeding, especially intracranial hemorrhage. Unlike fibrinolytic protocols for
acute myocardial infarction, subsequent therapy with anticoagulant or antiplatelet agents is not recommended after rtPA
administration in ischemic stroke. Patients receiving fibrinolytic therapy for stroke should not receive aspirin, heparin, warfarin,
ticlopidine, or any other antithrombotic or antiplatelet drugs for at least 24 hours after treatment. Sodium nitroprusside and labetalol
are used to manage blood pressure after a stroke.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Assessment
Neurologic Disorders and Therapeutic Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 577
10
Chapter 24: Kidney Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The initial filtering of the blood occurs in which structure?
a. The distal tubule
b. The proximal tubule
c. The glomerulus
d. The collecting tubule
ANS: C
The first structure of each nephron is the glomerulus, a high-pressure capillary bed that serves as the filtering point for the blood.
Positive filtration pressure in the glomerulus is achieved as a result of the high arterial pressure as the blood enters the afferent
arteriole and the resistance created by the smaller efferent arteriole as the blood exits the glomerulus. As a result of the
positive-pressure gradient, fluid and solutes are filtered through the glomerular capillary walls.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 609
2. Where does the concentration and dilution of urine occur?
a. In the juxtamedullary nephrons
b. In the cortical nephrons
c. In the peritubular capillaries
d. In the internal nephron
ANS: A
The juxtamedullary nephrons have long loops of Henle that have an important role in the concentration and dilution of urine. The
peritubular capillaries, known as the vasa recta, surround the juxtamedullary nephrons, maintaining a concentration gradient to
concentrate the urine. Most nephrons are cortical nephrons. Both types of cortical nephrons perform excretory and regulatory
functions.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 609 | Figure 24-3
3. A patient has been admitted with a severe kidney infection. The nurse suspects the patient has damage to the glomerular membrane.
Which substance in the urine would confirm the nurse’s suspicion?
a. Creatinine
b. Bicarbonate ions
c. Sodium
d. Albumin
ANS: D
Large molecules such as albumin and red blood cells are prevented from entering the filtrate. The presence of large molecules in
the urine is a signal that the glomerular membrane is damaged or affected by disease.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 610
4. When a patient’s blood pressure drops, which physiologic mechanism helps maintain adequate glomerular blood flow?
a. Constriction of the afferent arteriole
b. Dilation of the efferent arteriole
c. Dilation of the collecting tubule
d. Constriction of the efferent arteriole
ANS: D
When the mean arterial blood pressure is decreased, the afferent arteriole dilates and the efferent arteriole constricts to maintain a
higher pressure in the glomerular capillary bed and maintain the glomerular filtration rate at 125 mL/min. The ability of the kidneys
to autoregulate blood flow begins to fail when the mean arterial blood pressure is less than 80 mm Hg or greater than 180 mm Hg.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 611
1
5. A patient has been admitted with acute kidney injury. Which parameter would the nurse expect to find to confirm this diagnosis?
a. Decreased blood urea nitrogen
b. Bibasilar lung crackles
c. Peripheral edema
d. Decreased creatinine clearance
ANS: D
Creatinine is used as a measure of the glomerular filtration rate (GFR) because it is a waste product produced at a fairly constant
rate by the muscles, is freely filtered by the glomerulus, and is minimally resorbed or secreted by the tubules. Therefore, most of the
creatinine produced by the body is excreted by the kidneys, making the creatinine clearance a good screening and follow-up test for
estimating the GFR. A creatinine clearance less than 100 mL/min reflects a GFR of less than 100 mL/min and is a signal of
decreased kidney function. A creatinine clearance (and GFR) less than 20 mL/min results in symptoms of kidney failure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 611
6. The following substances, among others, are found in a patient’s urine sample: urea, creatinine, sodium, chlorine, potassium,
glucose, and bicarbonate ions. Which patient situation could account for this abnormal finding?
a. Blood pressure of 76/30 mm Hg
b. Blood glucose of 456 mg/dL
c. Blood glucose of 40 mg/dL
d. Blood potassium level of 4.1 mEq/L
ANS: B
This glucose reading is above the threshold concentration. Glucose is normally completely reabsorbed from the tubules. Above the
threshold level, the tubules are unable to reabsorb all of the glucose, and some spills into the urine. All of the other findings in this
urine sample are normal findings.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 612
7. To prevent acid–base disturbances, what is the ratio between carbonic acid and bicarbonate?
a. 10 mEq of carbonic acid to 20 mEq of bicarbonate
b. 20 mEq of carbonic acid to 10 mEq of bicarbonate
c. 1 mEq of carbonic acid to 20 mEq of bicarbonate
d. 20 mEq of carbonic acid to 1 mEq of bicarbonate
ANS: C
Bicarbonate levels in the body are in balance with carbonic acid (H 2CO3) levels. The ratio between the two must remain
proportional at 1 mEq of carbonic acid to 20 mEq of bicarbonate; otherwise, acid–base disturbances will result.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 618
8. A patient is admitted with severe hypokalemia. On admission the patient’s laboratory values are serum K +, 2.2 mEq/L; blood urea
nitrogen (BUN), 15 mg/dL; and creatinine, 1.2 mg/dL. Urine output is averaging 45 mL/h. The patient is given a total of 80 mEq of
potassium over 4 hours. The potassium level is repeated and the result is K +, 2.4 mEq/L. What other information would be
beneficial at this time?
a. Magnesium level
b. Repeat creatinine level
c. Calcium level
d. Hemoglobin level
ANS: A
The levels of other intracellular electrolytes, such as calcium and potassium, are affected by the level of magnesium. The most
important functions of magnesium are ensuring the transport of sodium and potassium across the cell membrane and as a co-factor
in many intracellular enzyme reactions. Depletion of magnesium liberates potassium to the extracellular fluid, which causes an
increase in the excretion of potassium by the kidney and hypokalemia. If the patient has a low magnesium level, it could explain the
lack of response to the potassium infusions. The other levels have little effect on serum potassium level or its response to infusions.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 617 | p. 618 | Box 24-11
9. What is the functional unit of the kidney called?
a. Bowman capsule
b. Glomerulus
c. Nephron
d. Distal tubule
ANS: C
Each kidney is made up of about 1 million nephrons, the functional units of the kidneys. Each nephron is made up of several
distinct structures, which are the glomerulus, Bowman capsule, proximal tubule, loop of Henle, distal tubule, and collecting duct.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 608 | p. 609 | Figure 24-3
2
10. Ammonia, hydrogen, and ammonium are secreted in what part of the kidney?
a. Loop of Henle
b. Collecting duct
c. Glomerulus
d. Proximal tubule
ANS: D
In addition to its major role in resorbing water and solutes from the filtrate, the proximal tubule secretes organic anions and cations
into the tubular lumen. Ammonia is produced from the metabolism of glutamine in the mitochondria of the proximal tubule cells,
where ammonia (NH3) combines with hydrogen (H+) to form ammonium (NH4+), which is secreted into the proximal tubule lumen.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 609 | p. 610 | Figure 24-3
11. What is the primary function of aldosterone?
a. Excretion of potassium through the renal tubules
b. Control of sodium and water
c. Regulation of bicarbonate
d. Reabsorption of sodium and potassium
ANS: B
Aldosterone acts on the distal tubule to facilitate sodium and water resorption, resulting in an expanded circulating blood volume
and increased blood pressure. When the arterial blood pressure increases, the juxtaglomerular apparatus reduces the release of
renin, and the renin-angiotensin-aldosterone system is less active.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 613
12. Which condition would result in an increased release of renin?
a. Increased release of angiotensin I
b. Increased release of angiotensin II
c. Increased amount of sodium in the distal convoluted tubule
d. Reduced pressure in the glomerulus
ANS: D
Renin is released in response to reduced pressure in the glomerulus, sympathetic stimulation of the kidneys, and a decrease in the
amount of sodium in the distal convoluted tubule. Renin is converted to angiotensin I, which is converted to the powerful
vasoconstrictor angiotensin II. Angiotensin II stimulates the adrenal glands to secrete aldosterone, which acts on the distal tubules
to resorb sodium from the tubular lumen into the circulation. When sodium is retained, so is water. Angiotensin II also constricts
the renal vasculature, reducing kidney blood flow and available glomerular filtrate, sending a signal to the posterior pituitary to
release antidiuretic hormone. The two systems intertwine to maintain fluid and electrolyte balance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 612 | p. 613 | Figure 24-4
13. The mobilization of calcium from bone stores is accomplished through the influence of which hormone?
a. Antidiuretic hormone (ADH)
b. Parathyroid hormone (PTH)
c. Thyroid-stimulating hormone (TSH)
d. Erythropoietin
ANS: B
The mobilization of calcium from bone stores is accomplished through the influence of parathyroid hormone. The kidneys secrete
erythropoietin, the hormone that controls erythrocyte (red blood cell) production in the bone marrow.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 617
14. Which type of intravenous fluid will not create a shift of fluids within the vascular space?
a. Hypertonic
b. Hypotonic
c. Isotonic
d. Osmotic pressure
ANS: C
An isotonic solution has roughly the same concentration of particles as the blood plasma; cells within an isotonic solution maintain
consistency and do not lose or gain fluid to their surroundings. A hypertonic solution contains a greater concentration of particles
than that inside the cell and causes fluid to be drawn out of the cells. Used inappropriately, too much fluid may be withdrawn,
causing a withering of the cell (crenation). A hypotonic solution contains a lesser concentration of particles than that inside the cell
and causes fluid to be drawn into the cells. If used incorrectly, a hypotonic solution can cause too much fluid to enter the cell,
causing the cells to swell and burst (hemolysis). Osmotic pressure is created by solutes and other substances (e.g., albumin,
globulin, fibrinogen) suspended in fluid.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 614 | p. 615 | Figure 24-6
3
15. What substance is the most responsible for maintaining the colloid osmotic pressure?
a. Intravascular plasma proteins
b. Intracellular potassium
c. Extracellular sodium
d. Interstitial potassium
ANS: A
Osmotic pressure is created by solutes and other substances (e.g., albumin, globulin, fibrinogen) suspended in fluid. Colloid
osmotic pressure is created primarily by the presence of plasma proteins in the intravascular space. Plasma proteins exert a pull on
water molecules and therefore produce osmotic pressure, which retains fluid within the intravascular compartment.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 615
16. A patient has been admitted with acute kidney injury. Which serum laboratory values would the nurse expect to be ordered to
confirm this diagnosis?
a. Sodium and potassium
b. Creatinine and calcium
c. Blood urea nitrogen (BUN) and creatine
d. Potassium and magnesium
ANS: C
Urea and creatinine are the primary waste products that are measured in determining kidney function. Urea is measured as blood
urea nitrogen and is the end product of protein metabolism and results from the breakdown of ammonia in the liver. Like urea,
creatinine accumulates when the glomerulus is unable to filter it from the blood.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 612
17. Maintaining a normal range of serum potassium is important for what physiologic process?
a. Fluid regulation
b. Acid–base buffering
c. Nervous impulse conduction
d. Triggering antidiuretic hormone (ADH) release
ANS: C
Potassium functions in the body to aid in nervous impulse conduction and muscle contraction.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 616 | Box 24-6
18. Chloride plays a major role in maintaining what physiologic process?
a. Cellular immunity
b. Serum osmolality
c. Bone strength
d. Adenosine triphosphate (ATP)
ANS: B
Chloride plays a major role in maintaining serum osmolality, water balance, and acid–base balance. The primary function of
phosphorus is the formation of adenosine triphosphate, which provides intracellular energy for active transport mechanisms across
the cell membrane. Additional functions of phosphorus include cell membrane structure, acid–base balance, oxygen delivery to the
tissues, cellular immunity, and bone strength.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 617
19. Which electrolytes are cations?
a. Sodium, potassium, and chloride
b. Sodium, chloride, and bicarbonate
c. Bicarbonate, chloride, and calcium
d. Sodium, potassium, and magnesium
ANS: D
A balance exists between cations (positively charged ions), anions (negatively charged ions), and other substances in the fluid
compartments. Cations are sodium, potassium, magnesium, and calcium. Anions are chloride and bicarbonate.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 614 | Figure 24-5
4
20. Stimulation from what receptors will cause contraction of the detrusor muscle of the bladder?
a. Bladder wall and ureters
b. Bladder wall and urethra
c. Ureters and urethra
d. Urethra and bladder neck
ANS: B
Nervous system control in the urinary tract is reflected in the process of micturition, or the release of urine. Bladder fullness
stimulates stretch receptors in the bladder wall and a portion of the urethra. Signals are carried through nerves in the sacral area and
return as parasympathetic messages to contract the detrusor muscle of the bladder.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 611
21. When renin eventually stimulates angiotensin II, the adrenal glands then secrete what hormone?
a. Aldosterone
b. Adrenal stimulating hormone
c. Antidiuretic hormone
d. Vasopressin
ANS: A
A reduction in vascular volume stimulates the release of renin. Renin converts to angiotensin I, which converts to the powerful
vasoconstrictor angiotensin II. In turn, angiotensin II stimulates the adrenal glands to secrete aldosterone, which acts on the distal
tubules to resorb sodium from the tubular lumen into the circulation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 615 | Figure 24-4
22. Which statement regarding kidney function and aging is accurate?
a. Kidney function declines with age but this usually does not affect homeostasis.
b. Serum creatinine rises with age due to increased catabolism of red muscle.
c. Glomerular filtration rate falls at a rate of 2 mL/min/year.
d. Older adults are less susceptible to acute kidney dysfunction but more susceptible
to chronic kidney dysfunction.
ANS: A
Kidney function declines gradually with age, but this usually does not affect homeostasis in the healthy older adult unless
proteinuria is present. Proteinuria is associated with complication in both the kidney and cardiovascular systems. However, despite
the gradual decrease in the glomerular filtration rate (GFR) and the associated reduction in clearance of creatinine, serum creatinine
levels may not rise. With aging, the GFR declines by about 0.75 mL/min/year. When older adults become ill, the decline in kidney
function can be accelerated, making older adults especially susceptible to acute and chronic kidney dysfunction.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 618
23. Which electrolyte abnormality is evident early in the course of kidney failure?
a. Sodium
b. Potassium
c. Chloride
d. Phosphorus
ANS: D
Phosphorus abnormalities are evident early in the course of kidney failure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 616
MULTIPLE RESPONSE
1. Which factors stimulate the release of antidiuretic hormone (ADH)? (Select all that apply, one, some, or all.)
a. Hypovolemia
b. Hypernatremia
c. Hypothermia
d. Opioids
e. Emotional stress
ANS: A, D, E
Factors stimulating release of antidiuretic hormone include hyperosmolality of extracellular fluid, hypovolemia, increased body
temperature, medications (opioids, antineoplastic, oral hypoglycemics, β-adrenergics), and severe emotional or physical stress.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 615 | Box 24-3
5
2. What are the functions of the kidneys? (Select all that apply, one, some, or all.)
a. Formation of urine
b. Blood pressure regulation
c. Erythrocyte destruction
d. Breakdown of prostaglandins
e. Regulation of acid–base balance
ANS: A, B, E
The kidneys are complex organs responsible for numerous functions and substances necessary to maintain homeostasis. The
primary roles of the kidneys are to remove metabolic wastes, maintain fluid and electrolyte balance, and help achieve acid–base
balance. Hormones produced by the kidneys have an important role in blood pressure control, red blood cell production, and bone
metabolism. The kidneys are important in maintaining the intracellular and extracellular environment required by all cells to
function effectively.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 608
OBJ: Nursing Process Step: N/A
TOP: Renal Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 25: Kidney Clinical Assessment and Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient was admitted with multiple trauma who has been volume resuscitated. The nurse suspects the patient is fluid overloaded.
Which assessment findings would confirm the nurse’s suspicion?
a. Venous filling of the hand veins greater than 5 seconds
b. Distended neck veins in the supine position
c. Presence of orthostatic hypotension
d. Presence of a third heart sound
ANS: D
Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often
accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
2. Loss of albumin from the vascular space may result in which condition?
a. Peripheral edema
b. Extra heart sounds
c. Hypertension
d. Hyponatremia
ANS: A
Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift, creating peripheral edema. A decreased
albumin level can occur as a result of protein-calorie malnutrition, which occurs in many critically ill patients in whom available
stores of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts from the vascular space to the
interstitial space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 627
3. A patient was admitted with acute heart failure who has been receiving diuretic therapy. The nurse suspects the patient is
hypovolemic. What auscultatory parameter would confirm the nurse’s suspicion?
a. Hypertension
b. Third or fourth heart sound
c. Orthostatic hypotension
d. Vascular bruit
ANS: C
A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of 10 mm Hg or more, or a rise in pulse
rate of more than 15 beats/min from lying to sitting or from sitting to standing indicates orthostatic hypotension. The drop in blood
pressure occurs because a sufficient preload is not immediately available when the patient changes position. The heart rate
increases in an attempt to maintain cardiac output and circulation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
4. Percussion of kidneys is usually done to assess what parameter?
a. Size and shape of the kidneys
b. Presence of pain in the renal area
c. Presence of a fluid wave
d. Patient’s overall fluid status
ANS: B
Percussion is performed to detect pain in the area of a kidney or to determine excess accumulation of air, fluid, or solids around the
kidneys. Percussion of the kidneys also provides information about kidney location, size, and possible problems.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
5. In a patient with a distended abdomen, differentiating ascites from solid bowel contents is accomplished by performing what
assessment?
a. Auscultation of bowel sounds
b. Palpation of the liver margin
c. Measuring abdominal girth
d. Eliciting a fluid wave
ANS: D
Differentiating ascites from distortion by solid bowel contents is accomplished by producing what is called a fluid wave. The fluid
wave is elicited by exerting pressure to the abdominal midline while one hand is placed on the right or left flank. Tapping the
opposite flank produces a wave in the accumulated fluid that can be felt under the hands.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 623
1
6. A patient has been admitted with acute kidney injury. Which parameter is most important for evaluating the patient’s fluid status?
a. Daily weights
b. Urine and serum osmolality
c. Intake and output
d. Hemoglobin and hematocrit levels
ANS: A
One of the most important assessments of kidney and fluid status is the patient’s weight. In the critical care unit, weight is
monitored for each patient every day and is an important vital signs measurement.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
7. A patient has been admitted in acute heart failure. Which parameter would indicate the patient is fluid overloaded?
a. Central venous pressure of 4 mm Hg
b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg
c. Cardiac index of 2.5 L/min/m2
d. Mean arterial pressure of 40 mm Hg
ANS: B
The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required to fill the left ventricle. When the left
ventricle is full at the end of diastole, this represents the volume of blood available for ejection. It is also known as left ventricular
preload and is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess, PAOP rises. In fluid volume
deficit, PAOP is low.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 624
8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release of what substance?
a. Ketones
b. Glucagon
c. Antidiuretic hormone
d. Potassium
ANS: C
When the serum osmolality level increases, antidiuretic hormone is released from the posterior pituitary gland and stimulates
increased water resorption in the kidney tubules. This expands the vascular space, returns the serum osmolality level back to
normal, and results in more concentrated urine and an elevated urine osmolality level.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 626
9. A patient was admitted with acute kidney failure. Which urinalysis value reflects a decreased ability of the kidneys to concentrate
urine?
a. pH of 5.0
b. Specific gravity of 1.000
c. No casts
d. Urine sodium of 140 mEq/24 h
ANS: B
Specific gravity measures the density or weight of urine compared with that of distilled water. The normal urinary specific gravity
is 1.005 to 1.025. For comparison, the specific gravity of distilled water is 1.000. Because urine is composed of many solutes and
substances suspended in water, the specific gravity should always be higher than that of water.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 627
10. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his
urine output has decreased, and he has developed peripheral edema and ascites. The nurse suspects the main cause of ascites is
what condition?
a. Hypervolemia
b. Dehydration
c. Volume overload
d. Liver damage
ANS: C
Individuals with kidney failure may have ascites caused by volume overload, which forces fluid into the abdomen because of
increased capillary hydrostatic pressures. However, ascites may or may not represent fluid volume excess. Severe ascites in persons
with compromised liver function may result from decreased plasma proteins. The ascites occurs because the increased vascular
pressure associated with liver dysfunction forces fluid and plasma proteins from the vascular space into the interstitial space and
abdominal cavity. Although the individual may exhibit marked edema, the intravascular space is volume depleted, and the patient is
hypovolemic.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 623
2
11. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his
urine output has decreased, and he has developed peripheral edema and ascites. Which diagnostic tests would provide the best
information about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder?
a. Kidney–ureter–bladder (KUB)
b. Intravenous pyelography (IVP)
c. Renal ultrasonography (ECHO)
d. Renal angiography
ANS: B
Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces, pelvis, ureters, and bladder.
Kidney–ureter–bladder flat-plate radiography of the abdomen determines the position, size, and structure of the kidneys, urinary
tract, and pelvis. It is useful for evaluating the presence of calculi and masses and is usually followed by additional tests. In
ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary tract, and the image is viewed on an
oscilloscope. This noninvasive procedure identifies fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is
useful for evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial blood perfusing the kidneys. It
allows for visualization of renal blood flow and may also visualize stenosis, cysts, clots, trauma, and infarctions.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 630 | Table 25-4
12. A patient is admitted with renal failure. The patient’s weight upon admission was 176 lb, and the next day it is 184 lb. What is the
approximate amount of fluid retained with this weight gain?
a. 800 mL
b. 2200 mL
c. 3600 mL
d. 8000 mL
ANS: C
One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 L; 3.6 L is equal to 3600 mL.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 624
13. When calculating the anion gap, what is the predominant cation?
a. Sodium
b. Potassium
c. Chloride
d. Bicarbonate
ANS: A
The anion gap is a calculation of the difference between the measurable extracellular plasma cations (sodium and potassium) and
the measurable anions (chloride and bicarbonate). In plasma, sodium is the predominant cation, and chloride is the predominant
anion.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 626
14. A patient was admitted with acute heart failure a few days ago. Today the patient’s urine has a specific gravity of 1.040. What
could be the potential cause for this value?
a. Volume overload
b. Volume deficit
c. Acidosis
d. Urine ketones
ANS: B
Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values include volume deficit, glycosuria, proteinuria,
and prerenal acute kidney injury (AKI). Possible causes for decreased values include volume overload and interrenal AKI.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 628 | Table 25-3
15. A patient was admitted with heart failure. The nurse is assessing the patient for peripheral edema. The nurse presses two fingers
over the tibial area, and it takes 1 minute before the indention disappears. What would the nurse document in the electronic medical
record?
a. +1 pitting edema
b. +2 pitting edema
c. +3 pitting edema
d. +4 pitting edema
ANS: C
The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15 seconds); +3 = 6-mm depth (lasting up to 60
seconds); and +4 = 8-mm depth (lasting longer than 60 seconds).
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 622 | Table 25-1
3
16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that the patient developed which problem?
a. Glycosuria
b. Proteinuria
c. Myoglobin
d. Uremia
ANS: D
A history of recent onset of nausea and vomiting or appetite loss caused by taste changes (uremia often causes a metallic taste) may
provide clues to the rapid onset of kidney problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence
of protein in the urine. Myoglobin is the presence of red blood cells in the urine.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 620
17. A patient has been on complete bed rest for 3 days. The practitioner has left orders to get the patient out of bed for meals. The
patient complains of feeling dizzy and faint while sitting at the bedside. The nurse suspects that the patient is experiencing which
problem?
a. Orthostatic hypertension
b. Orthostatic hypotension
c. Hypervolemia
d. Electrolyte imbalance
ANS: B
Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness. Orthostatic hypotension occurs with
hypovolemia or prolonged bed rest or as a side effect of medications that affect blood volume or blood pressure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
MULTIPLE RESPONSE
1. What causes the presence of myoglobin in urine? (Select all that apply, one, some, or all.)
a. Bleeding
b. Traumatic damage to the skeletal muscle
c. Asthmatic attack
d. Rhabdomyolysis
e. Cocaine abuse
ANS: A, B, D, E
Although a few red blood cells (RBCs) in the urine are normal, discernibly bloody urine usually indicates bleeding within the
urinary tract or kidney trauma. The presence of myoglobin can make the urine appear red. Microscopic examination of the urine
fails to reveal RBCs, with myoglobin being present instead. Myoglobin in the urine may result from skeletal muscle damage (e.g.,
traumatic crush injury) or rhabdomyolysis. Rhabdomyolysis may develop in patients admitted to a critical care unit for many
reasons, including traumatic injury, cocaine abuse, status epilepticus, heat prostration, or collapse during intense physical exercise
(e.g., running a marathon race on a hot day).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 629
2. Which findings may be present in the patient with significant fluid volume overload? (Select all that apply, one, some, or all.)
a. S3 or S4 may develop.
b. Distention of the hand veins will disappear if the hand is elevated.
c. When testing the quality of skin turgor, the skin will not return to the normal
d.
e.
position for several seconds.
Tachycardia with hypotension may be present.
Dependent edema may be present.
ANS: A, E
A gallop and dependent edema are indicative of fluid excess; the other signs are indicative of fluid volume deficit.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Assessment
Renal Clinical Assessment and Diagnostic Procedures
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 625 | Box 25-3
4
3. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient reports that over the past few weeks, his
urine output has decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure is made. The nurse
would expect to see elevated values in which laboratory results? (Select all that apply, one, some, or all.)
a. Blood urea nitrogen (BUN)
b. Creatinine
c. Glucose
d. Hemoglobin and hematocrit
e. Protein
ANS: A, B, D
With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease in the glomerular filtration rate and
resulting decrease in urea excretion. Elevations in the BUN can be correlated with the clinical manifestations of uremia; as the
BUN rises, symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are affected by fewer factors
than BUN. As a result, the serum creatinine level is a more sensitive and specific indicator of kidney function than BUN.
Creatinine excess occurs most often in persons with kidney failure resulting from impaired excretion. Decreased hematocrit value
can indicate fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also can result from anemias,
blood loss, liver damage, or hemolytic reactions. In individuals with acute kidney failure, anemia may occur early in the disease.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 625 | p. 627
5
Chapter 26: Kidney Disorders and Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. An elderly patient is in a motor vehicle accident and sustains a significant internal hemorrhage. The nurse knows the patient is at
risk for developing what type of acute kidney injury (AKI)?
a. Intrinsic
b. Postrenal
c. Prerenal
d. Intrarenal
ANS: C
Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that
supplies the kidney may be anatomically described as prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by
low cardiac output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the kidney, glomerular filtration
decreases, and consequently urine output decreases. Any condition that produces an ischemic or toxic insult directly at
parenchymal nephron tissue places the patient at risk for development of intrarenal AKI. Any obstruction that hinders the flow of
urine from beyond the kidney through the remainder of the urinary tract may lead to postrenal AKI.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 632 | Box 26-2
2. A patient has developed acute kidney injury (AKI) secondary to cardiogenic shock. Which laboratory value would the nurse find
helpful in evaluating patient’s renal status?
a. Serum sodium
b. Serum creatinine
c. Serum potassium
d. Urine potassium
ANS: B
Serum creatinine is the most reliable predictor of kidney function. In the acutely ill patient, small changes in the serum creatinine
level and urine output may signal important declines in the glomerular filtration rate and kidney function.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 631 | Table 26-1
3. A patient has developed acute kidney injury (AKI) secondary to hemorrhage shock. Which intravenous solution would the nurse
expect to be ordered for this patient?
a. Dextrose in water
b. Normal saline
c. Albumin
d. Lactated Ringer solution
ANS: B
Prerenal acute kidney injury (AKI) is caused by decreased perfusion and flow to the kidney. It is often associated with trauma,
hemorrhage, hypotension, and major fluid losses. If contrast dye is used, aggressive fluid resuscitation with normal saline is
recommended.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 639
4. One therapeutic measure for treating hyperkalemia is the administration of dextrose and regular insulin. Which statement regarding
how this treatment works is accurate?
a. Glucose and insulin force potassium out of the cells, lowering it on a cellular
level.
b. Glucose and insulin promote higher excretion of potassium in the urine.
c. Glucose and insulin bind with potassium, lowering available amounts.
d. Glucose and insulin force potassium into the cells, lowering it on a serum level.
ANS: D
Acute hyperkalemia can be treated temporarily by intravenous administration of insulin and glucose. An infusion of 50 mL of 50%
dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 639
1
5. A patient was admitted with liver failure and acute kidney injury (AKI). Which intravenous solution should the nurse question if it
were ordered for this patient?
a. D5W
b. 0.9% NaCl
c. Lactated Ringer solution
d. 0.45% NaCl
ANS: C
Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or in lactic acidosis.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 640 | Table 26-6
6. To assess whether or not an arteriovenous fistula is functioning, what must the nurse do and why?
a. Palpate the quality of the pulse distal to the site to determine whether a thrill is
b.
c.
d.
present; auscultate with a stethoscope to appreciate a bruit to assess the quality of
the blood flow.
Palpate the quality of the pulse proximal to the site to determine whether a thrill is
present; auscultate with a stethoscope to appreciate a bruit to assess the quality of
the blood flow.
Palpate gently over the site of the fistula to determine whether a thrill is present;
listen with a stethoscope over this site to appreciate a bruit to assess the quality of
the blood flow.
Palpate over the site of the fistula to determine whether a thrill is present; check
whether the extremity is pink and warm.
ANS: C
The nurse frequently assesses the quality of blood flow through the fistula. A patent fistula has a thrill when palpated gently with
the fingers and a bruit when auscultated with a stethoscope. The extremity should be pink and warm to the touch. No blood
pressure measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm with the fistula.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 647
7. To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the blood and a negative hydrostatic pressure is
applied to the dialysate bath. What is this process called?
a. Ultrafiltration
b. Hemodialysis
c. Reverse osmosis
d. Colloid extraction
ANS: A
To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative hydrostatic pressure is applied to the
dialysate bath. The two forces together, called transmembrane pressure, pull and squeeze the excess fluid from the blood. The
difference between the two values (expressed in millimeters of mercury [mm Hg]) represents the transmembrane pressure and
results in fluid extraction, known as ultrafiltration, from the vascular space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 645
8. A patient with chronic kidney disease was admitted with severe electrolyte disturbances. The patient had been ill and missed
several hemodialysis sessions. The patient is disoriented, dizzy, cold, clammy, and complains of severe abdominal cramping. The
patient’s electrocardiogram appears normal. Which electrolyte disturbance would the nurse suspect the patient may be
experiencing?
a. Hyponatremia
b. Hypokalemia
c. Hypercalcemia
d. Hypochloremia
ANS: A
Hyperkalemia, hypocalcemia, hyponatremia, hyperphosphatemia, and acid–base imbalances occur in kidney disease. Signs of
hyponatremia include disorientation, muscle twitching, nausea, vomiting, abdominal cramps, headaches, dizziness, cold, clammy
skin, tachycardia, and seizures.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 634 | p. 644 | Table 26-4
2
9. A patient who receives peritoneal dialysis is admitted after a 3-day history of flulike symptoms. The patient reports muscle cramps
and is noted to have a low blood pressure and tachycardia. The nurse suspects the patient may be experiencing what condition?
a. Dehydration
b. Peritonitis
c. Fluid obstruction
d. Hernias
ANS: A
This patient has dehydration. This patient is showing signs and symptoms of muscle cramps and low blood pressure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 654 | Table 26-12
10. A patient was admitted with an infection that had to be treated with gentamicin, an aminoglycoside antibiotic. After 3 days of
administration, the patient developed oliguria, and an elevated blood urea nitrogen and creatinine levels. The nurse suspects the
patient has developed what type of kidney injury?
a. Prerenal
b. Intrarenal
c. Anuric
d. Postrenal
ANS: B
Any condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue places the patient at risk for
development of intrarenal. Ischemic damage may be caused by prolonged hypotension or low cardiac output. Toxic injury reaction
may occur in response to substances that damage the kidney tubular endothelium, such as some antimicrobial medications and the
contrast dye used in radiologic diagnostic studies.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 632 | Box 26-2
11. A patient was admitted with an infection that had to be treated with an aminoglycoside antibiotic. After a few days the patient
developed oliguria and elevated blood urea nitrogen and creatinine levels. The patient’s vital signs are stable. The nurse would
anticipate the practitioner ordering which dialysis method for this patient?
a. Peritoneal dialysis
b. Hemodialysis
c. Continuous renal replacement therapy
d. Intermittent ultrafiltration
ANS: B
As a treatment, hemodialysis separates and removes from the blood excess electrolytes, fluids, and toxins by means of a
hemodialyzer. Hemodialysis would be the first choice for managing this patient with medication toxicity.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 645 | Box 26-6
12. A patient is admitted with sepsis and acute kidney injury (AKI). The patient is started on continuous renal replacement therapy
(CRRT). The nurse knows that fluid that is removed each hour is charted as what on the CRRT flowsheet?
a. Convection
b. Diffusion
c. Replacement fluid
d. Ultrafiltrate
ANS: D
The fluid that is removed each hour is not called urine; it is known as ultrafiltrate. Typically, some of the ultrafiltrate is replaced
through the continuous renal replacement therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along
a concentration gradient from a high concentration to a low concentration across a semipermeable membrane. Convection occurs
when a pressure gradient is set up so that the water is pushed or pumped across the dialysis filter and carries the solutes from the
bloodstream with it.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 649
13. What is the most common site for short-term vascular access for immediate hemodialysis?
a. Subclavian artery
b. Subclavian vein
c. Femoral artery
d. Radial vein
ANS: B
Subclavian and femoral veins are catheterized when short-term access is required or when a graft or fistula vascular access is
nonfunctional in a patient requiring immediate hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside.
Most temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows back to the patient through the same
catheterized vein. A dual-lumen venous catheter is most commonly used.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 646
3
14. The practitioner has ordered dialysis for a patient with acute heart failure who is unresponsive to diuretics. Which type of dialysis
would the nurse anticipate being started on this patient?
a. Intermittent ultrafiltration
b. Continuous venovenous hemofiltration (CVVH)
c. Continuous venovenous hemodialysis (CVVHD)
d. Continuous venovenous hemodiafiltration (CVVHDF)
ANS: A
Intermittent ultrafiltration using a peripheral venous catheter is more likely to be used to remove excess volume from patients with
acute decompensated heart failure when the kidneys are unresponsive to diuretics.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 649
15. The practitioner has ordered continuous renal replacement therapy (CRRT) for a patient with acute kidney injury. The patient needs
both the removal of fluids and a moderate amount of solutes. Which type of CRRT would the nurse anticipate being started on this
patient?
a. Slow continuous ultrafiltration (SCUF)
b. Continuous venovenous hemofiltration (CVVH)
c. Continuous venovenous hemodialysis (CVVHD)
d. Continuous venovenous hemodiafiltration (CVVHDF)
ANS: B
Continuous venovenous hemofiltration (CVVH) is indicated when the patient’s clinical condition warrants removal of significant
volumes of fluid and solutes. Fluid is removed by ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 h. Removal of
solutes such as urea, creatinine, and other small non–protein-bound toxins is accomplished by convection.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 648 | p. 649 | Table 27-9
16. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse
understands the patient should be closely monitored for what patient-related complications of the therapy?
a. Air embolism, access failure, and blood leaks
b. Decreased inflow pressure, air bubbles, and power surge
c. Infection, hypotension, and electrolyte imbalances
d. Catheter dislodgement, decreased outflow pressure, and acid–base imbalances
ANS: C
Patient-related complications of continuous renal replacement therapy (CRRT) include dehydration, hypotension, electrolyte
imbalances, acid–base imbalances, blood loss, hemorrhage, hypotension, and infection.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 653 | Box 26-9
17. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse
understands that this type of continuous renal replacement therapy (CRRT) is indicated for the patient who needs what type of
treatment?
a. Fluid removal only
b. Fluid removal and moderate solute removal
c. Fluid removal and maximum solute removal
d. Maximum fluid and solute removal
ANS: D
Continuous venovenous hemodialysis (CVVHD) is indicated for patients who require large-volume removal of fluid and solutes.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 648 | Table 26-9
18. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodialysis (CVVHD). The nurse knows the
hemodialyzer filter used in this type of therapy is permeable to what substance?
a. Electrolytes
b. Red blood cells
c. Protein
d. Lipids
ANS: A
A continuous venovenous hemodialysis filter is permeable to solutes such as urea, creatinine, uric acid, sodium, potassium, ionized
calcium, and drugs not bound by proteins.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 645
4
19. A patient with acute kidney injury (AKI) has been started on continuous venovenous hemodiafiltration (CVVHDF). The nurse
understands the patient should be closely monitored for what circuit-related complications of the therapy?
a. Hypervolemia, hypothermia, and hyperkalemia
b. Access dislodgment, decreased outflow pressures, and bleeding
c. Filter clotting, access failure, and air embolism
d. Increased overflow pressure, dehydration, and calcium loss
ANS: C
Circuit-related complications of continuous renal replacement therapy include air embolism, clotted hemofilter, poor ultrafiltration,
blood leaks, broken filter, disconnection, access failure, and catheter dislodgement.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 653 | Box 26-8
20. What is the recommended nutritional intake of protein to control azotemia in the patient with acute kidney injury?
a. 0.5 to 1.0 g/kg/day
b. 1.2 to 1.5 g/kg/day
c. 1.7 to 2.5 g/kg/day
d. 2.5 to 3.5 g/kg/day
ANS: B
The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5 g/kg of protein per day to control azotemia
(increased blood urea nitrogen level).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 643
21. Which diuretics maybe combined to work on different parts of the nephron?
a. Loop and thiazide diuretics
b. Loop and osmotic diuretics
c. Osmotic and carbonic anhydrase inhibitor diuretics
d. Thiazide and osmotic diuretics
ANS: A
A thiazide diuretic such as chlorothiazide (Diuril) or metolazone (Zaroxolyn) may be administered and followed by a loop diuretic
to take advantage of the fact that these medications work on different parts of the nephron. Sometimes a thiazide diuretic is added
to a loop diuretic to compensate for the development of loop diuretic resistance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 641
22. What is the dose for low-dose dopamine?
a. 1 to 2 mcg/kg/min
b. 1 to 2 mg/kg/min
c. 2 to 3 mcg/kg/min
d. 2 to 3 mg/kg/min
ANS: C
Low-dose dopamine (2 to 3 mcg/kg/min), previously known as renal-dose dopamine, is frequently infused to stimulate blood flow
to the kidney. Dopamine is effective in increasing urine output in the short term, but tolerance of the dopamine renal receptor to the
medication is theorized to develop in the critically ill patients who are most at risk for acute kidney injury.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 643
23. Laboratory results come back on a newly admitted patient: Serum blood urea nitrogen, 64 mg/dL; serum creatinine, 2.4 mg/dL;
urine osmolality, 210 mOsm/kg; specific gravity, 1.002; and urine sodium, 96 mEq/L. The patient’s urine output has been 120 mL
since admission 2 hours ago. These values are most consistent with which diagnosis?
a. Prerenal acute kidney injury
b. Postrenal acute kidney injury
c. Oliguric acute kidney injury
d. Intrarenal acute kidney injury
ANS: D
Urinary sodium less than 10 mEq/L (low) suggests a prerenal condition. Urinary sodium greater than 40 mEq/L (in the presence of
an elevated serum creatinine and the absence of a high salt load) suggests intrarenal damage has occurred. The urine output does
not seem to suggest oliguria. The other options do not fit the data as presented.
PTS:
REF:
OBJ:
MSC:
1
DIF: Cognitive Level: Applying
p. 632 | Table 26-2 | p. 633 | Table 26-3
Nursing Process Step: Diagnosis
TOP: Renal
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
24. A patient is admitted with acute kidney injury (AKI). Which event from the patient’s history was the most probable cause of the
patient’s AKI?
a. Recent computed tomography of the brain with and without contrast
b. Recent bout of acute heart failure after an acute myocardial infarction
c. Twice-daily prescription of Lasix 40 mg by mouth
d. Recent bout of benign prostatic hypertrophy and transurethral resection of the
prostate
ANS: A
Intravenous contrast media can be nephrotoxic, especially with the patient’s preexisting cardiac disease. The other choices,
although possible causes, are less likely than the intravenous contrast media.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 637
25. An alert and oriented patient presents with a pulmonary artery occlusion pressure (PAOP) of 4 mm Hg, blood pressure of 88/50
mm Hg, cardiac index of 1.8, and urine output of 15 mL/h. The patient’s blood urea nitrogen (BUN) is 44 mg/dL and creatinine is
3.2 mg/dL. Lungs are clear to auscultation with no peripheral edema noted. Which treatment would the nurse expect the
practitioner to order?
a. Lasix 40 mg intravenous push
b. 0.9% normal saline at 125 mL/h
c. Dopamine 15 mcg/kg/min
d. Transfuse 1 U of packed red blood cells
ANS: B
The patient’s hemodynamic parameters are most consistent with hypovolemia. The acute kidney injury would probably be prerenal
from inadequate blood flow. The treatment of choice for hypovolemia is fluid resuscitation. Important criteria when calculating
fluid volume replacement include baseline metabolism, environmental temperature, and humidity. The rate of replacement depends
on cardiopulmonary reserve, adequacy of kidney function, urine output, fluid balance, ongoing loss, and type of fluid replaced.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 639
26. A patient with acute kidney injury has a potassium level of 6.9 mg/dL. The patient has had no urine output in the past 4 hours
despite administration of Lasix 40 mg intravenous push. To correct the hyperkalemia the patient is given 50 mL of 50% dextrose in
water and 10 U of regular insulin intravenous push. A repeat potassium level 2 hours later shows a potassium level of 4.5 mg/dL.
What order would the nurse expect now?
a. Sodium Kayexalate 15 g PO
b. Nothing; this represents a normal potassium level
c. Lasix 40 mg IVP
d. 0.9% normal saline at 125 mL/h
ANS: A
Acute hyperkalemia can be treated temporarily by intravenous (IV) administration of insulin and glucose. An infusion of 50 mL of
50% dextrose accompanied by 10 units of regular insulin forces potassium out of the serum and into the cells. However, the
potassium was not eliminated from the body; it was simply shifted intracellularly. Soon the potassium will return to the
bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is not expected to work in the presence of
anuria. The patient’s vital signs do not support hypovolemia. In the presence of anuria, a large fluid infusion can precipitate acute
heart failure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 639
27. A patient with chronic kidney disease receives hemodialysis treatments 3 days a week. Every 2 weeks, the patient requires a
transfusion of 1 or 2 U of packed red blood cells. What is the probable reason for this patient’s frequent transfusion needs?
a. Too much blood phlebotomized for tests
b. Increased destruction of red blood cells because of the increased toxin levels
c. Lack of production of erythropoietin to stimulate red blood cell formation
d. Hemodilution secondary to fluid retention
ANS: C
In chronic kidney disease, the kidneys do not produce sufficient amounts of erythropoietin in response to normal stimuli such as
anemia or hypotension. The other choices are not reasons for frequent blood transfusions in this patient.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 644
6
28. Which medication is classified as a loop diuretic?
a. Acetazolamide
b. Furosemide
c. Mannitol
d. Metolazone
ANS: B
Loop diuretics include furosemide, bumetanide, and torsemide. Furosemide is the most frequently used diuretic in critical care
patients. It may be administered orally, as an intravenous (IV) bolus, or as a continuous IV infusion. Diamox is a carbonic
anhydrase inhibitor diuretic. Mannitol is an osmotic diuretic, and metolazone is a thiazide diuretic.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 641
MULTIPLE RESPONSE
1. A patient is admitted with respiratory failure and is being mechanically ventilated. The nurse understands there is a significant
association between acute kidney injury and respiratory failure. How does mechanical ventilation alter kidney function? (Select all
that apply, one, some, or all.)
a. Decreases blood flow to the kidney
b. Decreases glomerular filtration rate (GFR)
c. Damages the kidney tubular endothelium
d. Decreases urine output
e. Hinders flow of urine from the kidneys
ANS: A, B, D
Mechanical ventilation can alter kidney function. Positive-pressure ventilation reduces blood flow to the kidney, lowers the
glomerular filtration rate (GFR), and decreases urine output. These effects are intensified with the addition of positive
end-expiratory pressure (PEEP).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 635
2. The nursing management plan for the patient with a urinary drainage catheter would include which interventions to prevent
catheter-associated urinary tract infection (CAUTI)? (Select all that apply, one, some, or all.)
a. Insert urinary catheters using aseptic techniques.
b. Change the urinary catheter daily.
c. Review the need for the urinary catheter daily and remove promptly.
d. Flush the urinary catheter q8 hours to maintain patency.
e. Avoid unnecessary use of indwelling urinary catheters.
ANS: A, C, E
The key components of catheter-associated urinary tract infection (CAUTI) prevention are to avoid unnecessary use of urinary
catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards for maintenance of urinary catheters,
review the need for the urinary catheter daily, and remove the catheter promptly.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 637 | p. 638 | Box 26-3
7
Chapter 27: Gastrointestinal Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What purpose does saliva serve in the process of digestion?
a. Washes away bacteria
b. Provides the body’s main source of potassium
c. Contains hydrochloric acid for breakdown of protein
d. Stimulates the sympathetic nervous system
ANS: A
Salivation has an important role in the first stage of digestion because it lubricates the mouth, facilitates the movement of the lips
and the tongue during swallowing, and washes away bacteria. Saliva consists of approximately 99.5% water that contains a large
amount of ions such as potassium, chloride, bicarbonate, thiocyanate, and hydrogen, as well as immunoglobulin A, which is vital
for destroying oral bacteria and mucus.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 657
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. Stimulation of the parasympathetic nervous system produces which effect on the gastrointestinal system?
a. Decreased peristalsis
b. Increased secretion of watery saliva
c. Decreased colonic activity
d. Increased release of gastrointestinal hormones
ANS: B
The salivary glands are regulated by the autonomic nervous system, with parasympathetic effects predominating. Whereas
increased parasympathetic stimulation results in profuse secretions of watery saliva, decreased parasympathetic stimulation results
in inhibition of salivation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 657
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
3. How is food propelled through the esophagus?
a. Gravity
b. Salivary fluids
c. Cardiac sphincter suction
d. Peristalsis
ANS: D
The functions of the esophagus are to accept a bolus of food from the oropharynx, transport the bolus through the esophageal body
by gravity and peristalsis, and release the bolus into the stomach through the lower esophageal sphincter. This process is known as
swallowing.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 657
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
4. What is the name of the portion of the stomach that allows for expansion and secretion of gastric juice?
a. Serosa
b. Muscularis
c. Submucosa
d. Mucosa
ANS: D
The innermost layer, the mucous layer (mucosa), consists of a muscular layer that is arranged in longitudinal folds, or rugae, that
can expand as the stomach fills. This layer also contains glands that secrete up to 3000 mL of gastric juice per day.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 658
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
5. What is the pH of gastric juices prior to being mixed with food?
a. 1.0
b. 3.0
c. 5.0
d. 7.0
ANS: A
The pH of gastric juice is 1.0, but when mixed with food, it rises to 2.0 to 3.0. Gastric juice dissolves soluble foods and has
bacteriostatic action against swallowed microorganisms. The composition of gastric secretions varies depending on a variety of
factors, including flow rate, volume, and time of day. In addition, whereas pain, fear, and rage inhibit gastric secretion, aggression
and hostility stimulate it.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 660
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
6. Which organ lies obliquely beneath the cardiac sphincter and above the pyloric sphincter?
a. Esophagus
b. Stomach
c. Duodenum
d. Ileum
ANS: B
The stomach lies obliquely beneath the cardiac sphincter at the esophagogastric junction and above the pyloric sphincter. The
duodenum and ileum are part of the small intestine. The esophagus is located below the epiglottis and empties into the stomach at
the cardioesophageal sphincter.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 658 | p. 659 | Figure 27-2
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
7. What intestinal hormone is responsible for stimulating the pancreas to secrete fluid into the duodenum?
a. Secretin
b. Chyme
c. Gastrin
d. Pepsin
ANS: A
The entry of chyme into the duodenum stimulates the production of secretin, which in turn stimulates the pancreas to secrete a
highly alkaline fluid into the duodenum. In the small intestine, the chyme mixes with pancreatic enzymes, intestinal enzymes, and
bile from the liver and gallbladder and is then reduced to absorbable elements of proteins, fats, and carbohydrates. The nutrients are
absorbed through the villi and transported to the liver via the portal system for further processing.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 660 | p. 662 | Table 27-1
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
8. What role does the liver play in maintaining normal blood sugar levels?
a. Produces insulin to breakdown glucose
b. Synthesizes amino acids from ketoacids
c. Converts glycogen to glucose
d. Synthesizes glycogen from carbohydrates
ANS: C
Glycogen is broken down to glucose by the liver to maintain normal blood glucose levels. The liver also has a vital role in amino
acid metabolism and can synthesize amino acids from metabolites of carbohydrates and fats or can deaminate (not synthesize)
amino acids to produce ketoacids and ammonia, from which urea is formed. The liver does not produce insulin. The liver does
synthesize glycogen from carbohydrates for storage, not blood sugar maintenance. Glycogen, the stored form of glucose, can be
synthesized from glucose or from protein, fat, or lactic acid.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 665
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
9. What is the main function of bile?
a. Emulsify fat globules
b. Serve as a reservoir for bilirubin
c. Maintain triglyceride levels in the blood
d. Aid in detoxification of drugs in the liver
ANS: A
Bile emulsifies fat globules and absorbs fat-soluble vitamins.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 665
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
10. A patient has been admitted in acute liver failure. The nurse knows that the synthesis of fibrinogen is affected and will result in
what problem?
a. Jaundice
b. Fluid retention and ascites
c. Delayed clotting
d. Hepatomegaly
ANS: C
The liver synthesizes the clotting factors of fibrinogen and prothrombin. Liver failure could affect this synthesis, which may result
in delayed clotting or hemorrhage.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 665
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
11. A patient has been admitted in acute liver failure. Which laboratory value would the nurse expect to support this diagnosis?
a. Elevated blood glucose level
b. High levels of unconjugated bilirubin
c. Decreased prothrombin time
d. Decreased partial thromboplastin time
ANS: B
High levels of unconjugated or indirect bilirubin in the blood suggest hepatocellular dysfunction. In comparison, high levels of
conjugated or direct bilirubin suggest biliary tract obstruction.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 665
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
12. What is the name of the portion of the stomach that connects the antrum to the duodenum?
a. Fundus
b. Body
c. Cardiac orifice
d. Pylorus
ANS: D
The anatomic divisions of the stomach are the cardia (proximal end), fundus (portion above and to the left of the cardiac sphincter),
body (middle portion), antrum (elongated, constricted portion), and pylorus (distal end connecting the antrum to the duodenum).
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 658 | p. 659 | Figure 27-3
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
13. Which component of gastric juice is necessary for the breakdown of proteins?
a. Hydrochloric acid (HCl)
b. Pepsin
c. Intrinsic factor
d. Potassium
ANS: B
Gastric juice is composed of hydrochloric acid (HCl), pepsin (necessary for the breakdown of protein), mucus, intrinsic factor
(necessary for vitamin B12 absorption), sodium, and potassium.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 660
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
14. When the ileum is distended, the ileogastric reflex inhibits what process?
a. Gastric absorption
b. Absorption in the jejunum
c. Gastric motility
d. Ileum motility
ANS: C
The ileogastric reflex inhibits gastric motility when the ileum is distended.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 660
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
15. Which layer of the large intestine consists of longitudinal and circular muscles?
a. Serosa layer
b. Muscularis layer
c. Submucosa layer
d. Mucosa layer
ANS: B
The outermost layer, the serous layer (serosa), is formed from the visceral peritoneum and covers most of the large intestine, with
the exclusion of the sigmoid colon. The second layer, the muscular layer (muscularis), consists of two smooth muscle layers: the
longitudinal and the circular muscles. The third layer, the submucous layer (submucosa), consists of connective tissue that contains
blood vessels, lymphatics, glands, and nerve plexuses. The innermost layer, the mucous layer (mucosa), is lined with simple
columnar epithelial cells and contains deep crypts of Lieberkühn that are lined with mucus-producing goblet cells. The mucus eases
the passage of the fecal material and protects the mucosal surface from trauma.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 662
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
16. Where in the gastrointestinal tract are Bacteroides, Lactobacillus, and Clostridium organisms commonly found?
a. Stomach
b. Small intestine
c. Colon
d. Liver
ANS: C
The colon contains billions of anaerobic bacteria that putrefy remaining proteins and indigestible residue; synthesize folic acid,
vitamin K, nicotinic acid, riboflavin, and some B vitamins; and convert urea salts to ammonium salts and ammonia for absorption
into the portal circulation. Common colonic bacteria include Bacteroides, Lactobacillus, and Clostridium organisms.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 664
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
17. What vessel delivers nutrient-rich blood from the gut, pancreas, spleen, and stomach to the liver?
a. Hepatic artery
b. Hepatic vein
c. Portal vein
d. Interlobular veins
ANS: C
The liver receives one-third of the total cardiac output from two major sources: the hepatic artery, which provides oxygenated
blood, and the portal vein, which is supplied with nutrient-rich blood from the gut, pancreas, spleen, and stomach. The portal vein,
which accounts for 75% of the total liver blood flow, branches into sinusoids to transport blood to each lobule. Interlobular veins
empty into larger veins and then into the hepatic vein, which empties on the posterior surface of the liver and eventually into the
vena cava. The hepatic artery also divides and subdivides between the lobules, supplying sinusoids with oxygenated blood before
emptying into the hepatic vein.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 665
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. The gastrointestinal system plays a vital role in detoxification and elimination of what substances? (Select all that apply, one, some,
or all.)
a. Viruses
b. Chemical toxins
c. Drugs
d. Bacteria
e. Bile
ANS: A, B, C, D
The gastrointestinal system also plays a vital role in detoxification and elimination of bacteria, viruses, chemical toxins, and drugs.
Bile is produced in the liver.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 657
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. Which statements are correct regarding epithelial cells of the gastric mucosa? (Select all that apply, one, some, or all.)
a. They prevent diffusion of hydrogen into the mucosa.
b. They secrete bicarbonate to neutralize hydrogen ions.
c. They have the ability to increase blood flow to facilitate removal of toxic
d.
e.
metabolites.
They break down prostaglandins.
They are impervious to alcohol and aspirin.
ANS: A, B, C
The epithelial cells of the gastric mucosa are packed very close together and serve as a protective barrier, preventing diffusion of
hydrogen ions into the mucosa. The mucus further protects the gastric mucosa by delaying back diffusion of hydrogen ions and
trapping them for neutralization by the secreted bicarbonate. The gastric mucosa also has the ability to increase blood flow,
providing an additional buffer for acid neutralization and aiding in the removal of toxic metabolites and chloride ions from injured
mucosa. The gastric mucosal cells synthesize a family of unsaturated fatty acids known as prostaglandins. The cells are not
impervious to alcohol and aspirin.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 658 | p. 659
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
3. The pancreas has both exocrine and endocrine properties. Which substances are produced by the exocrine function? (Select all that
apply, one, some, or all.)
a. Gastrin
b. Trypsin
c. Amylase
d. Lipase
e. Insulin
ANS: B, C, D
Enzymes produced in the pancreas include trypsin, chymotrypsin, carboxypeptidase, amylase, and lipase. The pancreas also
produces a trypsin inhibitor that prevents activation of trypsinogen (inactive form of trypsin), which inhibits autodigestion. The
production of gastrin and insulin is an endocrine function.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 668
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
Chapter 28: Gastrointestinal Clinical Assessment and Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient was admitted with pancreatitis. In which order would the nurse perform an assessment of the gastrointestinal system?
a. Inspection, palpation, percussion, auscultation
b. Palpation, percussion, inspection, auscultation
c. Inspection, auscultation, percussion, palpation
d. Palpation, inspection, auscultation, percussion
ANS: C
To prevent stimulation of gastrointestinal activity, the order for the assessment should be inspection, auscultation, percussion, and
palpation.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 669
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. A patient was admitted with pancreatitis. The nurse is auscultating the patient’s abdomen. How long must the nurse listen to be able
to accurately chart that bowel sounds are absent?
a. 30 seconds
b. 1 minute
c. 3 minutes
d. 5 minutes
ANS: D
Normal bowel sounds include high-pitched, gurgling sounds that occur approximately every 5 to 15 seconds or at a rate of 5 to 34
times per minute. Abnormal findings include the absence of bowel sounds throughout a 5-minute period, extremely soft and widely
separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic rush).
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 671
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
3. A patient was admitted with an abdominal mass. Which assessment technique would the nurse find most useful in detecting this
pathologic condition?
a. Percussion
b. Palpation
c. Inspection
d. Auscultation
ANS: B
Palpation is the assessment technique that is most useful in detecting abdominal pathologic conditions. Both light and deep
palpation of each organ and quadrant should be completed. Deep palpation is most helpful in detecting abdominal masses. Areas in
which the patient complains of tenderness should be palpated last.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 672
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
4. Which finding is considered an abnormal gastrointestinal assessment finding?
a. Visible peristaltic waves
b. Hyper-resonance of the intestine
c. High-pitched gurgling sounds in the small intestine
d. Dull sounds over the liver and spleen
ANS: A
Visible pulsations or peristaltic waves are considered an abnormal assessment finding.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 674
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
5. A patient was admitted with pancreatitis. Which laboratory value would the nurse expect the practitioner order to confirm this
diagnosis?
a. Bilirubin
b. Amylase
c. Lactate dehydrogenase
d. Ammonia
ANS: B
Serum amylase will rise with acute pancreatitis. The other values are affected by hepatocellular disease.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 676 | Table 28-5
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
6. The nurse is caring for a patient with an upper gastrointestinal bleed. What procedure would the nurse expect the practitioner to
order to confirm this diagnosis?
a. Endoscopic retrograde cholangiopancreatography (ERCP)
b. Colonoscopy
c. Endoscopy
d. Angiography
ANS: C
Endoscopy is the procedure of choice for the diagnosis of upper gastrointestinal (GI) bleeding. Colonoscopy permits viewing of the
lower GI tract from the rectum to the distal ileum, and it is used to evaluate sources of lower GI bleeding. Angiography is used as a
diagnostic and a therapeutic procedure. Diagnostically, it is used to evaluate the status of the GI circulation. Endoscopic retrograde
cholangiopancreatography (ERCP) enables viewing of the biliary and pancreatic ducts, and it is used in the evaluation of
pancreatitis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 674 | p. 676 | Figure 28-5
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
7. Upon auscultation, the nurse hears borborygmi. The nurse suspects the patient may be developing which problem?
a. A complete ileus
b. Early intestinal obstruction
c. Abnormality of blood flow
d. Peritonitis
ANS: B
Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by hunger, gastroenteritis, or early intestinal
obstruction. Decreased (hypoactive) bowel sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality
of blood flow.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 671 | Table 28-1
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
8. What intervention should be included in the nursing management of the patient undergoing an angiogram?
a. Maintain the patient flat for 24 hours.
b. Insert a nasogastric tube before the procedure.
c. Administer tap water enemas until clear.
d. Check the pulse distal to the injection site every 15 minutes.
ANS: D
Postprocedural assessment involves monitoring vital signs, observing the injection site for bleeding, and assessing neurovascular
integrity distal to the injection site every 15 minutes for the first 1 to 2 hours. Depending on how the puncture site is stabilized after
the procedure, the patient may have to remain flat in bed for a specified length of time.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 676 | Table 28-5
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
9. A patient has been admitted with abdominal pain. The practitioner suspects the patient has gallstones. Which diagnostic procedure
would the nurse expect the practitioner to order to confirm this diagnosis?
a. Ultrasonography
b. Abdominal radiography
c. Angiography
d. Liver scan
ANS: A
Abdominal ultrasonography is useful in evaluating the status of the gallbladder and biliary system, the liver, the spleen, and the
pancreas. It plays a key role in the diagnosis of many acute abdominal conditions, such as acute cholecystitis and biliary
obstructions, because it is sensitive in detecting obstructive lesions, as well as ascites. Ultrasonography is used to i dentify
gallstones and hepatic abscesses, candidiasis, and hematomas.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 678
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
10. The nurse is caring for a patient with acute liver failure. What laboratory value would the nurse expect to decrease in this situation?
a. Albumin
b. Total bilirubin
c. Alkaline phosphatase
d. Aspartate aminotransferase
ANS: A
In a patient with hepatocellular injury (which occurs with acute liver failure), total bilirubin, alkaline phosphatase, aspartate
aminotransferase, and alanine aminotransferase values all show elevation, but albumin values drop as a result of the catabolism.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 675 | Table 28-4
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
11. A patient is undergoing a hepatobiliary scan to assess the progression of cirrhosis of the liver. The nurse would anticipate which
result?
a. Nonvisualization
b. Little or no uptake
c. Increased uptake
d. Normal uptake
ANS: B
In a hepatobiliary scan, the liver cells take up 80% to 90% of the radiotracer, which is then secreted into the bile and transported
throughout the biliary system, allowing visualization of the biliary tract, gallbladder, and duodenum. Pooling of the iminodiacetic
agent around the liver indicates poor uptake and hepatocellular dysfunction.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 679
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
12. Preprocedural teaching of a patient undergoing a liver scan should include which instruction?
a. Drink at least 500 mL of fluids before the procedure.
b. Remain flat in bed for 12 hours after the procedure.
c. Stay flat and still during the procedure.
d. Sedation will be provided during the procedure.
ANS: C
The patient may need to maintain NPO (nothing by mouth) status for 2 to 4 hours before the procedure. Sedation is usually not
required, but the patient must be able to lie flat and still for 60 minutes during the scanning procedure. No special interventions are
required after the procedure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 679
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
13. What is the most common location for a male to have a hernia?
a. Femoral
b. Umbilical
c. Inguinal
d. Abdominal
ANS: C
Strangulated hernia can occur at any age. They are most commonly found in the femoral area for women and inguinal area for men.
Symptoms include severe localized pain or, if a bowel is obstructed, a generalized pain.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 673 | Table 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
14. A patient has been admitted with abdominal pain with right lower quadrant guarding and tenderness, fever, and an elevated white
blood cell count. The nurse suspects that the patient has which disorder?
a. Appendicitis
b. Hepatitis
c. Cecal volvulus
d. Perforated duodenal ulcer
ANS: A
Signs and symptoms of appendicitis include anorexia, nausea, and vomiting; early vague epigastric, periumbilical, or generalized
pain after 12 to 24 hours; right lower quadrant (RLQ) at McBurney point; localized RLQ guarding and tenderness after 12 to 24
hours; a white blood cell count of 10,000/mm or left shift; and low-grade fever. Signs are highly variable.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 673 | Table 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
15. The practitioner has ordered a magnetic resonance imaging (MRI) of the liver. What would the nurse do to prepare the patient for
the examination?
a. Explain the patient must lie still during the procedure.
b. Explain the patient may experience deep pressure sensation.
c. Inform the patient that he or she will have to drink contrast.
d. Inform the patient that the procedure will be performed at the bedside.
ANS: A
The magnetic resonance imaging (MRI) procedure is lengthy and requires that the patient be transported to the scanner. The patient
must lie motionless in a tight, enclosed space (if a closed MRI scanner is used), and sedation may be necessary. The patient should
not experience any sensations during the procedure. The patient will not have to drink contrast during the procedure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 679
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
16. The practitioner has ordered a test for steatorrhea. The nurse knows this is determined by which laboratory study?
a. Gastric acid stimulation
b. Urea breath test
c. Culture and sensitivity
d. Stool studies
ANS: D
Steatorrhea (an increase of fat in the stool) results from malabsorption or pancreatic insufficiency and is determined with stool
studies. The result of the urea breath test is positive if the patient has a Helicobacter pylori infection. Gastric acid stimulation is
used for the detection of duodenal ulcers, gastric atrophy, and gastric carcinoma.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 675 | Table 28-3
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
17. The nurse has been caring for a patient with severe pancreatitis. The practitioner suspects the patient has developed a pseudocyst.
Which diagnostic procedure would the nurse expect the practitioner to order to confirm this diagnosis?
a. Plain film radiography
b. Abdominal ultrasonography
c. Computed tomography (CT) of abdomen
d. Magnetic resonance imaging (MRI) of the abdomen
ANS: C
Computed tomography (CT) detects mass lesions more than 2 cm in diameter and allows visualization and evaluation of many
different aspects of gastrointestinal (GI) disease. It is particularly useful in identifying pancreatic pseudocysts, abdominal
abscesses, biliary obstructions, and a variety of GI neoplastic lesions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 678
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
18. The nurse has been caring for a patient with liver dysfunction. The practitioner has just performed a liver biopsy at the bedside.
Following a liver biopsy, how would the nurse position the patient?
a. Left side for 2 hours
b. Right side for 2 hours
c. Left side for 6 to 8 hours
d. Right side for 6 to 8 hours
ANS: B
After the procedure, the patient is positioned on the right side for 2 hours and kept on complete bed rest for the next 6 to 8 hours.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 679
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
19. A patient has been admitted with perforated duodenal ulcer. Which findings would the nurse expect to note to support this
diagnosis?
a. Tenderness in the epigastric area
b. Jaundice
c. Vomiting
d. Cullen sign
ANS: A
A patient with a perforated duodenal ulcer will present with tenderness in the epigastric area or right lower quadrant. Jaundice,
vomiting, and Cullen sign are not associated with this disorder.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 673 | Table 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
20. A patient has been admitted with pyloric obstruction. Which findings would the nurse expect to note to support this diagnosis?
a. Left lower quadrant tenderness
b. Jaundice
c. Diarrhea
d. Visible peristaltic waves
ANS: D
Signs of a pyloric obstruction include visible peristaltic waves. Left lower quadrant tenderness, jaundice, and diarrhea are not
associated with this disorder.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 673 | Table 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
21. A patient has been admitted with ulcerative colitis. Which information from the patient’s history would be consistent with this
diagnosis?
a. Drug abuse
b. Jewish ancestry
c. Pericardial disease
d. Asian ancestry
ANS: B
Jewish ancestry has been linked to ulcerative colitis, and this disorder is found at a higher rate in patients of Jewish descent. A
history of drug abuse has been linked to hepatitis. A history of pericardial disease has been linked with acute hepatic congestion.
Asian ancestry has not been linked to any specific gastrointestinal disorder.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 673 | Table 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
22. The nurse is caring for a patient with gastrointestinal bleeding. The practitioner was unable to locate the bleed with an endoscopy.
Which procedure would the nurse expect the practitioner to order next?
a. Plain abdominal series
b. Magnetic resonance imaging
c. Angiogram
d. Computed tomography
ANS: C
Angiography may be used for lower gastrointestinal bleeding and as a way to isolate the bleeding source prior to surgery.
Angiography is used in the diagnosis of upper gastrointestinal (UGI) bleeding only when endoscopy fails, and it is used to treat
patients (approximately 15%) whose GI bleeding is not stopped with medical measures or endoscopic treatment. Angiography also
is used to evaluate cirrhosis, portal hypertension, intestinal ischemia, and other vascular abnormalities.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 676
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. Which anatomic structures are found in the right upper quadrant? (Select all that apply, one, some, or all.)
a. Duodenum
b. Portion of the transverse colon
c. Liver
d. Stomach
e. Cecum
ANS: A, B, C
The right upper quadrant includes the liver and gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, portion of
the right kidney, hepatic flexure of colon, and a portion of the ascending and transverse colon. The stomach is located in the left
upper quadrant, and the cecum is located in the right lower quadrant.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 671 | Box 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. Which anatomic structures are found in the right lower quadrant? (Select all that apply, one, some, or all.)
a. Sigmoid colon
b. Portion of the ascending colon
c. Portion of the descending colon
d. Distended bladder
e. Enlarged uterus
ANS: B, D, E
The right lower quadrant includes the lower pole of the right kidney, cecum and appendix, portion of the ascending colon, bladder
(if distended), ovary and salpinx, uterus (if enlarged), right spermatic cord, and right ureter. The sigmoid colon and portion of the
descending colon are found in the left lower quadrant.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 671 | Box 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
3. Which anatomic structures are found in the left upper quadrant? (Select all that apply, one, some, or all.)
a. Stomach
b. Spleen
c. Portion of the transverse and descending colon
d. Head of the pancreas
e. Body of the pancreas
ANS: A, B, C, E
The left upper quadrant includes the left lobe of the liver, spleen, stomach, body of the pancreas, left adrenal gland, portion of the
left kidney, splenic flexure of the colon, and portions of the transverse and descending colon. The head of the pancreas is found in
the right upper quadrant.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 671 | Box 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
4. Which anatomic structures are found in the left lower quadrant? (Select all that apply, one, some, or all.)
a. Distended uterus
b. Cecum and appendix
c. Left ureter
d. Portion of the descending colon
e. Sigmoid colon
ANS: A, C, D, E
The left lower quadrant includes the lower pole of the left kidney, sigmoid colon, portion of the descending colon, bladder (if
distended), ovary and salpinx, uterus (if distended), left spermatic cord, and left ureter. The cecum and appendix is found in the
right lower quadrant.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 671 | Box 28-2
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
5. The nurse is caring for a patient with an upper gastrointestinal bleed. The practitioner has just performed an endoscopy at the
bedside. What complications would the nurse monitor the patient for after the procedure? (Select all that apply, one, some, or all.)
a. Perforation
b. Hemorrhage
c. Oversedation
d. Constipation
e. Aspiration
ANS: A, B, C, E
Fiberoptic endoscopy may present risks for the patient. Although rare, potential complications include perforation of the
gastrointestinal (GI) tract, hemorrhage, aspiration, vasovagal stimulation, and oversedation. Signs of perforation include abdominal
pain and distention, GI bleeding, and fever.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 676
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
6. What anatomic structures are part of inspection of the gastrointestinal system? (Select all that apply, one, some, or all.)
a. Teeth
b. Gums
c. Skin
d. Spleen
e. Abdomen
ANS: A, B, C, E
Although assessment of the gastrointestinal system classically begins with visual inspection of the abdomen, the patient’s oral
cavity also must be inspected to determine any unusual findings. The skin should be observed for pigmentation, lesions, striae,
scars, petechiae, signs of dehydration, and venous pattern. The spleen is not assessed on inspection; however, it may be assessed
through palpation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 669
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 29: Gastrointestinal Disorders and Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient is admitted with an upper gastrointestinal bleed. Which disorder is the leading cause of upper gastrointestinal (GI)
hemorrhage?
a. Stress ulcers
b. Peptic ulcers
c. Nonspecific erosive gastritis
d. Esophageal varices
ANS: B
Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of the gastro mucosal lining, is the leading cause
of upper gastrointestinal (GI) hemorrhage, accounting for approximately 21% of cases.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 681
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused
by which pathophysiologic mechanism?
a. Portal hypertension resulting in diversion of blood from a high-pressure area to a
low-pressure area
b. Superficial mucosal erosions because of increased stress levels
c. Loss of protective mechanisms resulting in the breakdown the mucosal resistance
d. Inflammation and ulceration secondary to nonsteroidal anti-inflammatory drug
use
ANS: A
Esophagogastric varices are engorged and distended blood vessels of the esophagus and proximal stomach that develop because of
portal hypertension secondary to hepatic cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids.
Without adequate sinusoid function, resistance to portal blood flow is increased, and pressures within the liver are elevated. This
leads to a rise in portal venous pressure (portal hypertension), causing collateral circulation to divert portal blood f rom areas of
high pressure within the liver to adjacent areas of low pressure outside the liver, such as into the veins of the esophagus, spleen,
intestines, and stomach.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 681 | p. 682
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
3. A patient is admitted with a severe head injury. The nurse knows that critically ill patients are at risk for gastrointestinal
hemorrhage due to stress-related mucosal disease. The nurse would monitor the patient for which signs and symptoms?
a. Metabolic acidosis and hypovolemia
b. Decreasing hemoglobin and hematocrit
c. Hyperkalemia and hypernatremia
d. Hematemesis and melena
ANS: D
The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage is that of a patient in hypovolemic shock;
the clinical presentation depends on the amount of blood lost. Hematemesis (bright red or brown, coffee grounds emesis),
hematochezia (bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI hemorrhage.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 682
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
4. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. What medication would the nurse expect
the provider to order for this patient?
a. Histamine2 (H2) antagonists
b. Vasopressin
c. Heparin
d. Antacids
ANS: B
In acute variceal hemorrhage, control of bleeding can be accomplished by using pharmacologic agents. Intravenous vasopressin,
somatostatin, and octreotide have been shown to reduce portal venous pressure and slow variceal hemorrhaging by constricting the
splanchnic arteriolar bed.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 684
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. Which nursing intervention is a priority for a patient with gastrointestinal hemorrhage?
a. Positioning the patient in a high-Fowler position
b. Ensuring the patient has a patent airway
c. Irrigating the nasogastric tube with iced saline
d. Maintaining venous access so that fluids and blood can be administered
ANS: B
Priorities in the medical management of a patient with gastrointestinal hemorrhage include airway protection, fluid resuscitation to
achieve hemodynamic stability, correction of comorbid conditions (e.g., coagulopathy), therapeutic procedures to control or stop
bleeding, and diagnostic procedures to determine the exact cause of the bleeding.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 682
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
6. The nurse is caring for a patient with acute liver failure. The provider asks the nurse to assess the patient for asterixis. How should
the nurse assess for this symptom?
a. Inflate a blood pressure cuff on the patient’s arm.
b. Have the patient bring the knees to the chest.
c. Have the patient extend the arms and dorsiflex the wrists.
d. Dorsiflex the patient’s foot.
ANS: C
The patient should be evaluated for the presence of asterixis, or “liver flap,” best described as the inability to voluntarily sustain a
fixed position of the extremities. Asterixis is best recognized by downward flapping of the hands when the patient extends the arms
and dorsiflexes the wrists.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 693
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
7. A patient was admitted with acute pancreatitis. The nurse understands that pancreatitis occurs because of what pathophysiologic
mechanism?
a. Uncontrolled hypoglycemia caused by an increased release of insulin
b. Loss of storage capacity for senescent red blood cells
c. Premature activation of inactive digestive enzymes, resulting in autodigestion
d. Release of glycogen into the serum, resulting in hyperglycemia
ANS: C
In acute pancreatitis, the normally inactive digestive enzymes become prematurely activated within the pancreas itself, creating the
central pathophysiologic mechanism of acute pancreatitis, namely autodigestion.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 687
OBJ: Nursing Process Step: General
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
8. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. What intervention would the nurse include in
the patient’s plan of care?
a. Monitor the patient for hypovolemic shock from plasma volume depletion.
b. Observe the patient for hypoglycemia and hypercalcemia.
c. Initiate enteral feedings after the nasogastric tube is placed.
d. Place the patient on a fluid restriction to avoid the fluid sequestration.
ANS: A
Because pancreatitis is often associated with massive fluid shifts, intravenous crystalloids and colloids are administered
immediately to prevent hypovolemic shock and maintain hemodynamic stability. Electrolytes are monitored closely, and
abnormalities such as hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia develops, exogenous
insulin may be required.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 688
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
9. A patient with acute pancreatitis is complaining of a pain in the left upper quadrant. Using a 1- to 10-point pain scale, the patient
states the current level is at an 8. What intervention would the nurse include in the patient’s plan of care to facilitate pain control?
a. Administer analgesics only as needed.
b. Administer analgesics around the clock.
c. Educate the patient and family on lifestyle changes.
d. Teach relaxation and distraction techniques.
ANS: B
Pain management is a major priority in acute pancreatitis. Administration of around-the-clock analgesics to achieve pain relief is
essential. Morphine, fentanyl, and hydromorphone are the commonly used narcotics for pain control. Relaxation techniques and the
knee–chest position can also assist in pain control. However, the patient’s pain needs to be addressed first.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 691 | Box 29-9
OBJ: Nursing Process Step: Evaluation
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. A patient with a history of chronic alcoholism was admitted with acute pancreatitis. The nurse is developing a patient education
plan. Which topic would the nurse include in the plan?
a. Diabetes management
b. Alcohol cessation
c. Occult blood testing
d. Anticoagulation management
ANS: B
As the patient moves toward discharge, teaching should focus on the interventions necessary for preventing the recurrence of the
precipitating disorder. If an alcohol abuser, the patient should be encouraged to stop drinking and be referred to an alcohol
cessation program.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 692
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
11. A Salem sump nasogastric tube has two lumens. The first lumen is for suction and drainage. What is the purpose of the second
lumen?
a. Allows for administration of tube feeding
b. Allows for testing of gastric secretions
c. Prevents the tube from adhering to the gastric wall
d. Prevents the tube from advancing
ANS: C
The Salem sump has one lumen that is used for suction and drainage and another that allows air to enter the patient’s stomach and
prevents the tube from adhering to the gastric wall and damaging the mucosa.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 698
OBJ: Nursing Process Step: Evaluation
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
12. The nurse is caring for a patient with acute liver failure. The patient has elevated ammonia levels. Which medication would the
nurse expect the provider to order for this patient?
a. Insulin
b. Vitamin K
c. Lactulose
d. Lorazepam
ANS: C
Lactulose, a synthetic ketoanalogue of lactose split into lactic acid and acetic acid in the intestine, is given orally through a
nasogastric tube or as a retention enema. The result is the creation of an acidic environment that results in ammonia being drawn
out of the portal circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to help control bleeding.
Insulin would be given to control hyperglycemia. Use of benzodiazepines and other sedatives is discouraged in a patient with acute
liver failure because pertinent neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 694
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
13. A patient was admitted with severe epigastric pain and has been diagnosed with cancer. The patient is scheduled for an
esophagectomy. The patient asks about the procedure. What is the best response by the nurse?
a. “This procedure is usually performed for cancer of the proximal esophagus and
gastroesophageal junction.”
b. “This procedure is usually performed for cancer of the distal esophagus and
gastroesophageal junction.”
c. “This procedure is usually performed for cancer of the pancreatic head.”
d. “The procedure is usually performed for varices of the distal esophagus and
gastroesophageal junction.”
ANS: B
Esophagectomy is usually performed for cancer of the distal esophagus and gastroesophageal junction.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 695
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
14. A patient was admitted after a Roux-en-Y gastric bypass (RYGBP). A nursing student asks the nurse what type of surgery an
RYGBP is. What is the best response by the nurse?
a. “It is an esophagectomy performed using the transthoracic approach.”
b. “It is an esophagectomy performed using a transhiatal approach.”
c. “It is a combination of restrictive and malabsorption types of bariatric surgery.”
d. “It is a standard operation for pancreatic cancer.”
ANS: C
Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive, and (3) combined restrictive and
malabsorptive. The Roux-en-Y gastric bypass combines both strategies by creating a small gastric pouch and anastomosing the
jejunum to the pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased absorption of digestive
materials. The standard operation for pancreatic cancer is a pancreaticoduodenectomy, also called the Whipple procedure.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 695 | p. 696
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. The nurse is caring for a patient after an esophagectomy. The nurse knows the patient is at risk for an anastomotic leak. Which
finding would indicate this occurrence?
a. Crackles in the lung bases
b. Subcutaneous emphysema
c. Incisional bleeding
d. Absent of bowel sounds
ANS: B
The clinical signs and symptoms include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a patient who
had an esophagectomy, a leak of the esophageal anastomosis may manifest as subcutaneous emphysema in the chest and neck.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 698
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
16. The nurse is caring for a patient after an esophagectomy. In the immediate postoperative period, which nursing intervention is the
highest priority?
a. Preventing atelectasis
b. Managing pain
c. Promoting ambulation
d. Preventing infection
ANS: B
It is imperative to appropriately manage the patient’s pain after gastrointestinal (GI) surgery. Adequate analgesia is necessary to
promote the mobility of the patient and decrease pulmonary complications. Initial pain management may be accomplished by
intravenous opioid (morphine, hydromorphone) administration by means of a patient-controlled analgesia (PCA) pump or through
continuous epidural infusion of an opioid and local anesthetic (bupivacaine).
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 698 | Box 29-18
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
17. An older patient reports taking cimetidine for several years. The nurse knows that this medication can cause central nervous system
side effects. Which side effect would the nurse monitor the patient for?
a. Tremors
b. Dizziness
c. Confusion
d. Hallucinations
ANS: C
Side effects of histamine antagonists include central nervous system (CNS) toxicity (confusion or delirium) and thrombocytopenia.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 702 | Table 29-3
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
18. A patient was admitted with acute liver failure. The patient is lethargic, confused, and has marked asterixis. What stage of hepatic
encephalopathy is the patient exhibiting?
a. Stage 1
b. Stage 2
c. Stage 3
d. Stage 4
ANS: B
The patient is in Stage 2 hepatic encephalopathy as evidenced by lethargy, moderate confusion, marked asterixis, and abnormal
electroencephalography (EEG).
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 694 | Box 29-15
OBJ: Nursing Process Step: Assessment TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
19. A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The patient has been started on a
vasopressin drip. Which side effect is the nurse monitoring for?
a. Constipation
b. Diarrhea
c. Chest pain
d. Bleeding
ANS: C
A major side effect of the medication is systemic vasoconstriction, which can result in cardiac ischemia, chest pain, hypertension,
acute heart failure, dysrhythmias, phlebitis, bowel ischemia, and cerebrovascular accident. These side effects can be offset with
concurrent administration of nitroglycerin. Other complications include bradycardia and fluid retention.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 701
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. How would the nurse administer sucralfate through a gastric tube?
a. Crushed and mixed with 10 mL of water
b. Dissolved in 10 mL of water to form a slurry
c. Mixed in 15 mL of water to form a solution
d. Administered as a whole pill with a 35-mL water flush
ANS: B
Sucralfate should not be crushed but may be dissolved in 10 mL of water to form a slurry. It is also available as a suspension.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 700
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
21. A patient has been admitted with severe abdominal pain. When examining the patient, the nurse notes hypoactive bowel sounds,
abdominal guarding, distention, and a discoloration around the umbilicus. The nurse suspects the patient may have which
condition?
a. Peptic ulcer disease
b. Esophageal varices
c. Acute liver failure
d. Acute pancreatitis
ANS: D
The results of physical assessment of a patient with pancreatitis usually reveal hypoactive bowel sounds and abdominal tenderness,
guarding, distention, and tympany. Findings that may indicate pancreatic hemorrhage include Grey Turner sign (gray-blue
discoloration of the flanks) and Cullen sign (discoloration of the umbilical region); however, they are rare and usually seen several
days into the illness.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 688
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. Which disorders or conditions are potential causes of acute liver failure? (Select all that apply, one, some, or all.)
a. Ischemia
b. Hepatitis A, B, C, D, E, non-A, non-B, non-C
c. Acetaminophen toxicity
d. Wilson disease
e. Reye syndrome
f. Diabetes
ANS: A, B, C, D, E
Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 693 | Box 29-14
OBJ: Nursing Process Step: Intervention TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
2. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which laboratory values to be elevated? (Select all
that apply, one, some, or all.)
a. Calcium
b. Serum amylase
c. Serum glucose
d. Potassium
e. White blood cells
f. Serum triglycerides
ANS: B, C, E, F
Calcium and potassium decrease with acute pancreatitis.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 688 | Table 29-2
OBJ: Nursing Process Step: Diagnosis
TOP: Gastrointestinal
MSC: NCLEX: Physiologic Integrity
3. A patient has been admitted with pancreatitis. Which clinical manifestations would the nurse expect to observe in support of this
diagnosis? (Select all that apply, one, some, or all.)
a. Epigastric and abdominal pain
b. Nausea and vomiting
c. Diaphoresis
d. Jaundice
e. Hyperactive bowel sounds
f. Fever
ANS: A, B, D, F
Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever, abdominal distention, abdominal guarding,
abdominal tympany, hypoactive or absent bowel sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal
mass, Grey-Turner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis involved with pancreatitis and
percussion will reveal a tympanic abdomen; bowel sounds will be decreased or absent.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Assessment
Gastrointestinal Disorders and Therapeutic Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 687 | Box 29-7
5
4. A patient has been admitted with acute liver failure. Which interventions would the nurse expect as part of the interprofessional
collaborative management plan? (Select all that apply, one, some, or all.)
a. Benzodiazepines for agitation
b. Pulse oximetry and serial arterial blood gas measurements
c. Insulin drip for hyperglycemia and hyperkalemia
d. Monitoring electrolyte blood levels
e. Assessing for signs of cerebral edema
ANS: B, D, E
The patient may experience a variety of other complications, including cerebral edema, cardiac dysrhythmias, acute respiratory
failure, sepsis, and acute kidney injury. Cerebral edema and increased intracranial pressure develop as a result of breakdown of the
blood–brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in acute liver failure and may
exacerbate low cerebral perfusion pressure. Hypoxemia, acidosis, electrolyte imbalances, and cerebral edema can precipitate the
development of cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress syndrome, intrapulmonary
shunting, ventilation-perfusion mismatch, sepsis, and aspiration may be attributed to the universal arterial hypoxemia.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Planning
Gastrointestinal Disorders and Therapeutic Management
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 693 | p. 694
6
Chapter 30: Endocrine Anatomy and Physiology
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What mechanism does the endocrine system help maintain equilibrium?
a. Control of smooth muscle
b. Control of skeletal muscle
c. Hormones
d. Neuronal control
ANS: C
The endocrine system controls and communicates by distributing potent hormones throughout the body.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 705 | Figure 30-1
2. A patient is receiving insulin due to the development of steroid-induced hyperglycemia. In addition to lowering blood glucose
levels, what other physiologic effect may occur when insulin is administered?
a. Breakdown of proteins
b. Hypercalcemia
c. Hypokalemia
d. Cellular dehydration
ANS: C
Insulin is a potent anabolic hormone that produces hypoglycemia and augments the transport of potassium into the cells. With
potassium driven into the cells, serum potassium may decrease, resulting in hypokalemia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 706
3. A nurse is caring for a patient who is having difficulty maintaining a normal blood sugar level. In the healthy body, how is a
normal blood glucose level maintained?
a. Insulin secretion
b. Cellular metabolism
c. Insulin-to-glucagon ratio
d. Insulin-to-thyroxine ratio
ANS: C
A normal blood glucose level is maintained by the insulin-to-glucagon ratio. When the blood glucose level is high, insulin is
released and glucagon is inhibited. When blood glucose levels are low, glucagon rather than insulin is released.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 708
4. Decreased insulin and increased glucagon result in what physiologic process?
a. Increased glycogenolysis
b. Decreased fat mobilization
c. Decreased ketosis
d. Increased glycogen storage
ANS: A
Decreased insulin and increased glucagon result in increased glycogenolysis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 708 | Box 30-2
5. Which statement best describes the effects of somatostatin?
a. It stimulates the release of antidiuretic hormone and oxytocin.
b. It suppresses the release of pancreatic polypeptide.
c. It inhibits the release of insulin and glucagon.
d. It inhibits the release of thyroid-stimulating hormone and thyroid hormone.
ANS: C
Somatostatin decreases glucagon secretion, and in high quantities, it decreases insulin release. Hyperglycemia stimulates the
activity of the delta cells. It is theorized that the release of insulin enables somatostatin to control beta-cell activ ity. Somatostatin
may be involved in the regulation of the postprandial influx of glucose into cells.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 707 | p. 708 | Table 30-1
1
6. Which anatomic structure has influence over all areas of body functioning?
a. Hypothalamus
b. Pancreas
c. Thyroid
d. Pituitary
ANS: A
The hypothalamus gland is known as the “master gland” because of the influence it has over all areas of body functioning. The
hypothalamus controls pituitary gland action and response by secreting substances called release-inhibiting factors.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 710
7. A patient has been admitted post thyroidectomy. The nurse knows that adequate thyroid function is dependent on which factor?
a. Basal metabolic rate
b. Dietary intake of iodine
c. Colloid osmotic pressure
d. Sodium levels in the blood
ANS: B
Functioning of the thyroid gland depends on many factors that respond to a delicate hormonal interplay; the hypothalamus, anterior
pituitary, dietary intake of iodine, and circulating protein bodies in the blood all affect thyroid gland function.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 711
8. A patient with thyrotoxicosis has been admitted. What effect of increased T 3 and T4 levels might the nurse expect to see in this
patient?
a. Increased oxygen consumption
b. Decreased basal metabolic rate
c. Decreased cardiac output
d. Increased calcium levels
ANS: A
Both thyroid hormones impact the rate at which oxygen is used in the body and thus affect all metabolic processes in the body.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 712
9. A patient is admitted with a traumatic head injury. The patient starts to exhibit signs of a decrease in antidiuretic hormone (ADH).
What is the function of ADH?
a. Control blood pressure
b. Regulate fluid balance
c. Normalize potassium levels
d. Maintain homeostasis
ANS: B
Antidiuretic hormone has been identified as the single most important hormone responsible for regulating fluid balance within the
body.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 710
10. A patient is admitted with a traumatic head injury. The patient starts to exhibit signs of a decrease in antidiuretic hormone (ADH).
Which symptom would alert the nurse to this problem?
a. Rapidly escalating hypertension
b. Massive diuresis
c. Pulmonary edema
d. Hyperkalemia
ANS: B
A low sodium level is associated with a low serum osmolality (hypoosmolar state). When sodium levels rise, plasma osmolality
increases (hyperosmolar state). Antidiuretic hormone is then released to stimulate water resorption at the nephron to maintain
sodium balance. This process decreases water loss from the body and subsequently concentrates and reduces urine volume. Fluid
conserved in this manner is returned to the circulating plasma, where it dilutes the concentration (osmolality) of plasma.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 710 | p. 711 | Figure 30-4
2
11. What hormone do the alpha cells of the pancreas secrete?
a. Glucagon
b. Insulin
c. Somatostatin
d. Pancreatic polypeptide hormone
ANS: A
Alpha cells secrete glucagon; beta cells secrete insulin; delta cells secrete somatostatin, and pancreatic polypeptide c ells secrete
pancreatic polypeptide hormone.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 705
12. A patient is receiving total parenteral nutrition (TPN). During rounds the dietitian states “the patient is getting too much glucose.”
In which one area is excess glucose stored as glycogen?
a. Pancreas
b. Hepatic cells
c. Gallbladder
d. Stomach
ANS: B
Excess glucose in the form of glycogen is stored in the hepatic and muscle cells for use as fuel at a later time.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 706 | p. 707 | Box 30-1
13. Glucagon release is stimulated by which physiologic factor?
a. Increases in circulating insulin that is secreted
b. Decreases in blood amino acids
c. Stimulation of the sympathetic nervous system
d. High blood glucose levels
ANS: C
Glucagon release from the pancreas is stimulated by low blood glucose levels, starvation, exercise, or stimulation of the
sympathetic nervous system.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 708
14. The patient has been admitted from a skilled nursing facility with urinary sepsis and has severe muscle wasting. What is the process
by which fat and protein are converted to glucose for fuel?
a. Glycogenolysis
b. Gluconeogenesis
c. Digestion
d. Biotransformation
ANS: B
For long-term energy needs, glucagon stimulates glucose release through the more complex process of gluconeogenesis. In
gluconeogenesis, fat and protein nutrients are rapidly broken down into end products that are then changed into glucose.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 707 | p. 708 | Box 30-1
15. Which part of the brain controls the release of hormones in pituitary gland?
a. Cerebellum
b. Occipital lobe
c. Temporal lobe
d. Hypothalamus
ANS: D
The pituitary gland communicates with the hypothalamus by means of a vascular network.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 710
3
16. A patient has been admitted with a brain tumor and starts to exhibit signs of an increase in antidiuretic hormone (ADH). What
should the nurse anticipate in the sodium levels?
a. Increase
b. Decrease
c. Rapid increase than decrease
d. Depends on potassium level
ANS: B
Antidiuretic hormone (ADH) also contributes to control of the sodium level in the extracellular fluid by control of plasma
osmolality. The sodium ion concentration in the plasma largely determines plasma osmolality. Osmoreceptors, located in the
hypothalamus, are sensitive to changes in the circulating plasma osmolality. Because ADH causes the patient to retain free water,
the patient will have a dilutional hyponatremia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 710 | p. 711 | Figure 30-4
17. A patient has been admitted after a craniotomy and starts to exhibit changes in the level of antidiuretic hormone (ADH). What
organ does ADH primarily affect?
a. Liver
b. Pancreas
c. Stomach
d. Kidneys
ANS: D
Antidiuretic hormone has two functions: (1) By means of the V1 receptors, it constricts smooth muscles within the arterial wall,
and (2) through V2 receptors, it regulates fluid balance by altering the permeability of the kidney tubule to water.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 710
18. A patient is brought to the hospital with a major stab wound. After excessive blood loss, the nurse should anticipate what change in
the patient’s serum osmolality?
a. Increase
b. Decrease
c. Rapid decrease than increase
d. Equal to his or her sodium level
ANS: A
With hemorrhage the serum osmolality increases, which stimulates the release of antidiuretic hormone.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 711 | Figure 30-4
19. A patient with thyrotoxicosis has been admitted. The nurse knows that when levels of T 3 and T4 are elevated, the pituitary gland
inhibits what hormone?
a. Thyroglobulin
b. Thyroid-releasing hormone (TRH)
c. Thyroid-stimulating hormone (TSH)
d. Calcitonin
ANS: C
In response to decreased circulating levels of T 3 and T4, the hypothalamus releases thyroid-releasing hormone (TRH). TRH
activates thyroid-stimulating hormone (TSH) in the anterior pituitary, and TSH stimulates the thyroid gland to manufacture and
release the thyroid hormones T3 and T4 in the presence of iodine.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 712
20. What hormone does the adrenal cortex secrete to maintain homeostasis?
a. Androgens
b. Aldosterone
c. Adrenocorticotrophic hormone (ACTH)
d. Corticosteroid
ANS: B
The adrenal cortex secretes cortisol. It regulates fluid homeostasis by means of aldosterone, and it secretes androgens.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 712
4
21. When the brain perceives a stressful or threatening situation, the hypothalamus releases ________________________, which
causes the anterior pituitary to release______________.
a. cortisol; androgens
b. corticotropin-releasing hormone; adrenocorticotrophic hormone (ACTH)
c. ACTH; glucocorticoid hormone
d. ACTH; epinephrine
ANS: B
When the brain perceives a stressful or threatening situation, the hypothalamus releases corticotropin-releasing hormone, which
acts on the anterior pituitary to release adrenocorticotrophic hormone, which circulates in the bloodstream to reach the adrenal
cortex and stimulate glucocorticoid hormone release.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 714
22. A patient is admitted with multiple trauma. Which hormone would the nurse expect to be increased in response to physiologic
stress?
a. Mineralocorticoid
b. Corticosteroid
c. Glucocorticoid
d. Cortisol
ANS: D
Cortisol is released in response to physiologic stress caused by infection, trauma, and the fasting state.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 714
23. A patient is admitted post arrest from sudden cardiac death. According to the code record the patient received a total of 6 mg of
epinephrine. The nurse knows that epinephrine and norepinephrine are also secreted by which organ?
a. Adrenal cortex
b. Adrenal medulla
c. Anterior pituitary
d. Posterior pituitary
ANS: B
The adrenal medulla (inner region) secretes two important catecholamines: epinephrine, also known as adrenaline, and
norepinephrine, also known as noradrenaline.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 714
MULTIPLE RESPONSE
1. A patient is being treated for hypothyroidism. The nurse knows that this disorder can affect a variety of physiologic processes.
What are the major functions of the thyroid hormones? (Select all that apply, one, some, or all.)
a. Increase the rate of glucose used by the cells
b. Decrease fat metabolism
c. Increase the body’s demand for vitamins
d. Decrease cardiac output
e. Stimulate bone resorption
f. Increase serum cholesterol levels
ANS: A, C, E
Major functions of thyroid hormones include interacting with growth hormone, maturation of the skeletal system, development of
the central nervous system, stimulating carbohydrate metabolism, increasing the rate of glucose absorption from the gastrointestinal
tract, increasing the rate of glucose use by the cells, accelerating the rate of fat metabolism, increasing cholesterol degradation in
the liver, decreasing serum cholesterol levels, increasing protein anabolism and catabolism, mobilizing protein and releasing amino
acids into circulation, increasing energy from protein nutrients through gluconeogenesis, increasing the body’s demand for
vitamins, increasing oxygen consumption and use, increasing basal metabolic rate, marked chronotropic and inotropic effects on
the heart, increasing cardiac output, stimulating the contractility and excitability of the myocardium, increasing blood volume,
expanding respiratory rate and depth necessary for normal hypoxic and hypercapnic drive, promoting sympathetic overactivity,
boosting erythropoiesis, increasing metabolism and clearance of various hormones and pharmacologic agents, and stimulating bone
resorption.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 714 | Box 30-3
5
2. The nurse is caring for a patient with diabetes insipidus, which is the result of a decrease in antidiuretic hormone (ADH). Which
statements regarding the stimulation or inhibition of ADH are accurate? (Select all that apply, one, some, or all.)
a. Infection stimulates the release of ADH.
b. Cold stimulates the release of ADH.
c. Emesis stimulates the release of ADH.
d. Opioids inhibit the release of ADH.
e. Hemorrhage inhibits the release of ADH.
f. Pain inhibits the release of ADH.
ANS: C, D
Emesis, hemorrhage, and pain stimulate the release of antidiuretic hormone (ADH). Cold and opioids inhibit the release of ADH.
Infection does not directly affect the release of ADH.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 712 | Table 30-5
OBJ: Nursing Process Step: N/A
TOP: Endocrine Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 31: Endocrine Clinical Assessment and Diagnostic Procedures
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. Which laboratory results would the nurse note
confirming this diagnosis?
a. Hemoglobin A1C of 3%
b. Absence of ketones in the urine
c. Presence of ketones in the blood
d. Fasting glucose of 105 mg/dL
ANS: C
Ketone bodies are a byproduct of rapid fat breakdown. Ketone blood levels rise in acute illness, fasting, and with sustained
elevation of blood glucose in type 1 diabetes in the absence of insulin. The patient would also have ketones in the urine, a
hemoglobin A1C greater than 6%, and a fasting glucose greater than 125 mg/dL.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 718
2. The nurse is caring for a patient who has been newly diagnosed with type 1 diabetes. The nurse notes that the patient is extremely
dehydrated. To make this assessment, what did the nurse evaluate?
a. Skin turgor
b. Nail bed color
c. Capillary refill
d. Skin temperature
ANS: A
A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane moisture. Moist, shiny buccal
membranes indicate satisfactory fluid balance. Skin turgor that is resilient and returns to its original position in less than 3 seconds
after being pinched or lifted indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable for
testing tissue turgor because it is less affected by aging and thus more easily assessed for changes related to fluid balance.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 718
3. A patient is admitted with diabetic ketoacidosis. The nurse requests the practitioner order a glycosylated hemoglobin (HbA1C).
What information does this test provide to the health care team?
a. It is an indicator of the patient’s average blood glucose level over the previous 3
to 4 months.
b. It compares blood glucose levels with serum hemoglobin over the previous 3 to 4
weeks.
c. It is an indicator of the patient’s highest blood ketone level over the past month.
d. It associates the serum and urine glucose levels and is an indicator of kidney
involvement.
ANS: A
The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C) provides information about the
average amount of glucose that has been present in the patient’s bloodstream over the previous 3 to 4 months. During the 120-day
life span of red blood cells (erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a process
known as glycosylation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 717
4. The nurse is caring for a patient with a traumatic brain injury. The nurse suspects the patient is developing diabetes insipidus.
Which test or procedure would confirm this diagnosis?
a. Skull radiographs
b. Serum glucose level
c. Water deprivation test
d. Antidiuretic hormone (ADH) stimulation test
ANS: D
Serum antidiuretic hormone (ADH) levels are compared with the blood and urine osmolality to differentiate syndrome of
inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus (DI). Increased ADH levels in the bloodstream
compared with a low serum osmolality and elevated urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum
ADH in a patient with high serum osmolality, hypernatremia, and reduced urine concentration signal central DI.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 719
1
5. A patient has been admitted who is suspected of having thyrotoxicosis. Which symptom would support this diagnosis?
a. Lethargy despite adequate sleep
b. Bradycardia not related to medications
c. Constipation despite laxatives
d. Weight loss despite increased appetite
ANS: D
Signs and symptoms of thyrotoxicosis include tremors, insomnia, increased appetite, diarrhea, muscle weakness or wasting, and a
change in menstruation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 720 | Box 31-2
6. A patient has been admitted who is suspected of having thyrotoxicosis. Which laboratory findings would confirm this diagnosis?
a. Very low thyroid-stimulating hormone (TSH)
b. Decreased T3 uptake ratio
c. Increased serum osmolality
d. Decreased urine osmolality
ANS: A
Hyperthyroidism (thyrotoxicosis) is indicated by very low thyroid-stimulating hormone level, high serum T 4, and an increased
T3:T4 ratio.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 731
7. A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. Which signs and symptoms obtained as
part of the patient’s history might indicate the presence of hyperglycemia?
a. Recent episodes of tachycardia and missed heart beats
b. Decreased urine output accompanied by peripheral edema
c. Periods of hyperactivity with weight gain
d. Increased thirst and increased urinary output
ANS: D
The patient or family member may relay information about recent, unexplained changes in weight, thirst, hunger, and urination
patterns.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 717
8. A patient is admitted with severe hyperglycemia due to new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor
on the patient’s exhaled breath. What causes this phenomenon?
a. Metabolic alkalosis
b. Ketoacidosis
c. Glycosylation
d. Dehydration
ANS: B
Ketoacidosis results in the patient’s breathing becoming deep and rapid (Kussmaul respirations) and the patient’s breath having a
fruity odor. Metabolic alkalosis and dehydration do not cause this phenomenon. Glycosylation is when the hemoglobin within each
cell binds to the available blood glucose.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 716
9. A patient is reporting a headache, fatigue, abdominal pain, and blurred vision. The nurse knows that these signs may indicate the
patient has what problem?
a. Hypothyroidism
b. Pituitary tumor
c. Cushing syndrome
d. Hyperglycemia
ANS: D
Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient may complain of blurred
vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and abdominal pain.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 716 | Box 31-1
2
10. A patient has been admitted with abdominal pain. The nurse notes that the patient’s fasting blood glucose is 120 mg/dL. Which
statement regarding this finding is accurate?
a. This is a normal finding in critically ill patients.
b. This finding is indicative of prediabetes, but another test should be done to
confirm.
c. This finding is lower than what the nurse would expect in a patient receiving
intravenous fluids.
d. This finding is indicative of diabetic ketoacidosis.
ANS: B
A normal fasting plasma glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between 110 and 126 mg/dL identifies a
person who is prediabetic. An FPG level of greater than 126 mg/dL (7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the
test is repeated on another day to make sure the result is accurate.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 717 | Table 31-1
11. A nurse is teaching a patient with diabetes mellitus. The patient asks the nurse what is an acceptable HbA 1C level for him. What
should the nurse tell the patient?
a. An acceptable level is less than 5.4%.
b. An acceptable level is less than 6.5%.
c. An acceptable level is determined by your practitioner.
d. It is dependent on your age.
ANS: A
A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with diabetes below 6.5%.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 717
12. The nurse is caring for a patient with a traumatic brain injury. Yesterday the patient weighed 62 kg and today the patient weighs 60
kg. How much fluid loss does this change in weight reflect?
a. 1 L
b. 2 L
c. 4 L
d. 10 L
ANS: B
Daily weight changes coincide with fluid retention and fluid loss. 1 L of fluid lost or retained is equal to approximately 2.2 lb, or 1
kg, of weight gained or lost. This patient lost 2 kg of weight, which is equivalent to 2 L of fluid.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 718
13. A patient is admitted with hyponatremia. The practitioner suspects the patient may have syndrome of inappropriate secretion of
antidiuretic hormone (SIADH) and orders a serum ADH level for the next morning. Which medications must be stopped or
withheld at least 8 hours prior to the test?
a. Insulin and furosemide
b. Morphine and carbamazepine
c. Digoxin and potassium
d. Heparin and lopressor
ANS: B
To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH) are withheld for a minimum
of 8 hours. Common medications that affect ADH levels include morphine sulfate, lithium carbonate, chlorothiazide,
carbamazepine, oxytocin, nicotine, alcohol, and selective serotonin reuptake inhibitors.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 718
14. A patient is admitted with hypernatremia secondary to neurogenic diabetes insipidus. The nurse notes that the patient’s serum
osmolality is 350 mOsm/kg. What does this finding indicate?
a. The patient is overhydrated.
b. The patient’s serum osmolality is normal.
c. The patient is dehydrated.
d. The patient is hypothyroid.
ANS: C
Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O. Increased serum osmolality stimulates the
release of antidiuretic hormone, which in turn reduces the amount of water lost through the kidney.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 719
3
15. A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). Which test would help the practitioner differentiate
between central and nephrogenic DI?
a. Water deprivation test
b. Serum osmolality
c. Serum antidiuretic hormone level
d. Antidiuretic hormone (ADH) test
ANS: D
The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI) (central) and nephrogenic
(kidney) DI. In severe central DI, in which the pituitary is affected, the urine osmolality shows a significant increase (becomes
more concentrated), which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test results in
which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney dysfunction because the kidneys are no
longer responsive to antidiuretic hormone.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 719
16. A patient is admitted with hypernatremia secondary to diabetes insipidus (DI). The practitioner suspects the patient has neurogenic
DI. Which finding would confirm that diagnosis?
a. A slight increase in urine osmolality
b. A decrease in urine output
c. A decrease in serum osmolality
d. No change in urine osmolality
ANS: D
In cases of severe central diabetes insipidus (DI), the urine osmolality shows a significant increase (becomes more concentrated).
Test results in which urine osmolality remains unchanged indicate nephrogenic DI.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 719
17. A patient has been admitted with a brain mass. The practitioner suspects it might be a pituitary tumor and orders a computed
tomography (CT) scan. What area of brain should be scanned to confirm this diagnosis?
a. Frontal lobe
b. Base of the skull
c. Temporal lobe
d. Anterior fossa
ANS: B
Computed tomography (CT) of the base of the skull identifies pituitary tumors, blood clots, cysts, nodules, or other soft tissue
masses.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 719
18. A patient reports losing weight even though she eats “everything in sight.” She also reports tremors and diarrhea. The nurse
suspects the patient may have what problem?
a. Hypothyroidism
b. Diabetes mellitus
c. Hyperthyroidism
d. Pituitary tumor
ANS: C
Weight loss, increased appetite, tremors, insomnia, and diarrhea are symptoms of hyperthyroidism.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 720 | Box 31-2
19. A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have
a thyroid disorder. The nurse auscultates a bruit over the thyroid. What does this finding indicate?
a. Normal function
b. Enlargement of the thyroid
c. Hypoplasia of the thyroid
d. Tumor of the thyroid
ANS: B
Auscultation of the thyroid is accomplished by use of the bell portion of the stethoscope to identify a bruit or blowing noise from
the circulation through the thyroid gland. The presence of a bruit indicates enlargement of the thyroid as evidenced by increased
blood flow through the glandular tissue.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 720
4
20. A patient is being evaluated for thyroid dysfunction. The patient’s medications include aspirin, digoxin, chlorothiazide, and insulin.
The nurse knows that the laboratory work may be affected by which of these medications?
a. Aspirin
b. Digoxin
c. Insulin
d. Chlorothiazide
ANS: A
Several drugs increase the serum level of T4 by displacing protein-bound T4. Drugs that displace T4, including heparin (both
unfractionated and low-molecular-weight heparins), cause an increase in serum T 4 levels. Salicylates (aspirin) and furosemide
(Lasix) also raise T4 serum levels by the same mechanism.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 721 | Table 31-5
21. A patient has been admitted with uncontrolled atrial fibrillation and muscle wasting. The practitioner suspects the patient may have
a thyroid disorder. The nurse anticipates the practitioner will initially order which diagnostic procedure to visualize the thyroid?
a. Magnetic resonance imaging (MRI)
b. Ultrasound
c. Biopsy
d. Computed tomography (CT)
ANS: B
Diagnostic tests often begin with ultrasonography to visualize a thyroid nodule or tumor.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 721
22. A patient is being evaluated for thyroid dysfunction. The laboratory findings include a decreased serum free thyroxine (T4) level
and an elevated thyroid-stimulating hormone (TSH) level. These findings confirm which diagnosis?
a. Cushing syndrome
b. Addison disease
c. Thyrotoxicosis
d. Hypothyroidism
ANS: D
Hypothyroidism is indicated by a high thyroid-stimulating hormone (TSH) and low serum T4 levels. Thyrotoxicosis is
hyperthyroidism and is indicated by very low TSH, high serum T4, and increased T3:T4 ratio. Addison disease is a rare disorder of
the adrenal cortex that involves hyposecretion of glucocorticoids (cortisol), sometimes occurring with hyposecretion of
mineralocorticoids (aldosterone). Cushing syndrome is caused by the excess release of the glucocorticoid hormone cortisol.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 720 | p. 721
23. A patient has been admitted with multiple trauma due to a motor vehicle accident several weeks ago. Given the prolonged critical
illness, the nurse knows the patient may no longer secrete adequate amounts of what hormone?
a. Aldosterone
b. Adrenocorticotropic hormone (ACTH)
c. Cortisol
d. Antidiuretic hormone (ADH)
ANS: C
Cortisol is secreted in response to physiologic stress as a result of infection, trauma, and hypoglycemia. Early in critical illness, a
rise in cortisol levels can be documented. However, over time the adrenal gland may not be able to secrete adequate amounts of
stress hormones, especially when critical illness is prolonged. Aldosterone is secreted in response to intravascular hypovolemia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 721
24. A nurse is initiating a patient teaching plan for a patient with hypothyroidism. The patient is currently taking salicylates, lithium,
and sulfonamides. It is important that the nurse tell the patient that these medications influence thyroid levels. How are thyroid
levels affected by these medications?
a. They increase T3.
b. They increasing T4.
c. They decrease T3.
d. They decrease T4.
ANS: C
Salicylates, lithium, and sulfonamides can cause a decrease in T3 levels.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 720 | Table 31-4
5
25. A patient is diagnosed with a pheochromocytoma. What signs or symptoms might the nurse expect to see in this patient?
a. Hypertension and tachycardia
b. Weight gain and acne
c. Diarrhea and facial swelling
d. Blurred vision and poor skin turgor
ANS: A
Signs and symptoms of pheochromocytoma include hypertension and tachycardia. Weight gain and acne are signs of Cushing
syndrome. Diarrhea and facial swelling are signs of hyperthyroidism. Blurred vision and poor skin turgor are signs of
hyperglycemia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 723
26. A patient is admitted with critical hypotension, hyperkalemia, hyponatremia, and hypoglycemia. The nurse knows that these
symptoms are highly suggestive of which disorder?
a. Myxedema
b. Diabetes insipidus
c. Addisonian crisis
d. Cushing syndrome
ANS: C
An Addisonian crisis is a life-threatening condition in which the adrenal gland is almost nonfunctional, usually because of
destruction of adrenal tissue. The patient presents acutely with critical hypotension, an elevated serum potassium level
(hyperkalemia), a low serum sodium level (hyponatremia), and hypoglycemia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 723
27. A patient who was admitted with asthma has been on steroids for a long time. The nurse knows that this patient is at risk of
developing secondary Cushing syndrome. What would be the cause of this condition?
a. Pharmacologic glucocorticoids
b. Pharmacologic mineralocorticoids
c. Cortisol
d. Aldosterone
ANS: A
Symptoms identical to those of primary Cushing syndrome occur in patients with the secondary form who chronically take
pharmacologic doses of glucocorticoids, for example, transplant recipients who take steroids to prevent solid organ rejection,
patients with chronic obstructive pulmonary disease, or those with chronic inflammatory conditions. Cortisol and aldosterone are
hormones released by the adrenal gland.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 722
MULTIPLE RESPONSE
1. A patient is admitted with Cushing syndrome. Which findings would the nurse expect to note as confirming this diagnosis? (Select
all that apply, one, some, or all.)
a. Hirsutism
b. Rounded face
c. Hypotension
d. Decreased libido
e. Scleroderma
f. Fatigue and weakness
ANS: A, B, D, F
Signs and symptoms of Cushing syndrome include hypertension, thin skin that bruises easily, and poor wound healing.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 722 | Box 31-3
2. The nurse is managing a patient with hyperglycemia. Which findings would the nurse expect to note to support this diagnosis?
(Select all that apply, one, some, or all.)
a. Anorexia
b. Abdominal pain
c. Tachycardia
d. Dehydration
e. Change in level of consciousness
f. Kussmaul respirations
ANS: A, B, C, D, E
More than likely the patient with hyperglycemia will be fluid volume depleted and tachycardic.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 716 | p. 717 | Box 31-1
Nursing Process Step: Assessment
Endocrine Clinical Assessment and Diagnostic Procedures
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
3. A patient with thyrotoxicosis is admitted. Which laboratory tests would the nurse expect to be ordered for this patient? (Select all
that apply, one, some, or all.)
a. Total serum triiodothyronine (TT3)
b. Total serum thyroxine (TT4)
c. Free urine thyroid stimulating hormone
d. Total urine thyroxine
e. Thyroglobulin (Tg)
f. Free thyroxine (T4)
ANS: A, B, E, F
Thyroid tests include total serum thyroxine, free thyroxine, total serum triiodothyronine, free triiodothyronine, thyroid-stimulating
hormone (thyrotropin), and thyroglobulin.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Applying
REF: p. 720 | Table 31-2
Nursing Process Step: Assessment
Endocrine Clinical Assessment and Diagnostic Procedures
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
Chapter 32: Endocrine Disorders and Therapeutic Management
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is caring for a critically ill patient with type 1 diabetes. The nurse understands that the patient is at risk for developing
diabetic ketoacidosis (DKA) secondary to what etiology?
a. Excess insulin administration
b. Inadequate food intake
c. Physiologic and psychologic stress
d. Increased release of antidiuretic hormone (ADH)
ANS: C
Major neurologic and endocrine changes occur when an individual is confronted with physiologic stress caused by any critical
illness, sepsis, trauma, major surgery, or underlying cardiovascular disease.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 725
2. The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which findings would the nurse expect to observe
in this patient?
a. Hyperglycemia with low serum osmolality
b. Severe hyperglycemia with minimal or absent ketosis
c. Little or no ketosis in serum with rapidly escalating ketonuria
d. Hyperglycemia and ketosis
ANS: B
The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in serum hyperosmolality and osmotic
diuresis. The disorder occurs mainly in patients with type 2 diabetes.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 743
3. The nurse has admitted a patient with hyperglycemic hyperosmolar state (HHS). Which medical intervention would the nurse
expect to see ordered for this patient?
a. Rapid rehydration with intravenous fluids
b. Insertion of a pulmonary artery catheter
c. Administration of high-dose intravenous insulin
d. Hourly monitoring of urine glucose and ketone levels
ANS: A
The goals of medical management are rapid rehydration, insulin replacement, and correction of electrolyte abnormalities,
specifically potassium replacement. The underlying stimulus of the hyperglycemic hyperosmolar state (HHS) must be discovered
and treated. The same basic principles used to treat patients with diabetic ketoacidosis are used for patients with HHS.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 745
4. A patient has been admitted after surgery for removal of a brain tumor. The nurse suspects the patient may be developing diabetes
insipidus (DI). Which findings would confirm the nurse’s suspicion?
a. Hyperglycemia and hyperosmolarity
b. Hyperglycemia and peripheral edema
c. Intense thirst and passage of excessively large quantities of dilute urine
d. Peripheral edema and pulmonary crackles
ANS: C
The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of diuretics, a fluid challenge, or
hyperglycemia. Characteristics of DI are intense thirst and the passage of excessively large quantities of very dilute urine.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 747
5. The nurse is caring for a patient with a head injury who has developed diabetes insipidus (DI). What medication would the nurse
expect to be prescribed for the patient?
a. Vasopressin
b. Insulin
c. Glucagon
d. Propylthiouracil
ANS: A
Patients with central diabetes insipidus (DI) who are unable to synthesize antidiuretic hormone (ADH) require replacement ADH
(vasopressin) or an ADH analog. The most commonly prescribed drug is the synthetic analog of ADH, desmopressin (DDAVP).
DDAVP can be given intravenously, subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or
subcutaneously every 12 hours.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 750
1
6. Which pathophysiologic mechanism occurs in the syndrome of inappropriate antidiuretic hormone (SIADH)?
a. Massive diuresis, leading to hemoconcentration
b. Dilutional hyponatremia, reducing sodium concentration to critically low levels
c. Hypokalemia from massive diuresis
d. Serum osmolality greater than 350 mOsm/kg
ANS: B
Patients with the syndrome of inappropriate antidiuretic hormone (SIADH) have an excess of antidiuretic hormone secreted into the
bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at
the kidney tubule, leading to dilutional hyponatremia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 751 | p. 754
7. Which nursing intervention should be initiated on all patients with the syndrome of inappropriate antidiuretic hormone (SIADH)?
a. Placing the patient on an air mattress
b. Forcing fluids
c. Initiating seizure precautions
d. Applying soft restraints
ANS: C
The patient with the syndrome of inappropriate antidiuretic hormone (SIADH) has an excess of ADH secreted into the
bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at
the kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an inability to concentrate, mental
confusion, apprehension, seizures, a decreased level of consciousness, coma, and death.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 754
8. A patient is admitted after surgery with a history of hyperthyroidism. The nurse suspects the patient may be developing thyroid
storm. Which finding would confirm this suspicion?
a. Tachycardia
b. Hypotension
c. Decreased appetite
d. Hypothermia
ANS: A
Thyroid storm, also called thyroid crisis, is a rare and life-threatening exacerbation of hyperthyroidism. The pathophysiology
underlying the transition from hyperthyroidism to thyroid storm is not fully understood because thyroid hormone levels are not
necessarily different from patients with hyperthyroidism. Atrial fibrillation is the most common dysrhythmia in patients with
hyperthyroidism, and tachydysrhythmias should be anticipated in thyroid storm, especially in patients with underlying heart
disease.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 756 | Box 32-22
9. The nursing management plan for a patient with thyrotoxicosis would include which intervention?
a. Providing diversional stimuli
b. Restricting fluids
c. Maintaining a quiet, restful environment
d. Administering thyroid supplements at the same time each day
ANS: C
Patients in thyroid storm are agitated, anxious, and unable to rest, and they benefit from an environment that is calm. Gradually, the
effects of the antithyroid medications, iodides, and ß-adrenergic blocking drugs will decrease the neurologic symptoms related to
the catecholamine sensitivity. Frequent reassurance and clear, simple explanations of the patient’s condition help decrease the fear
brought on by the onset thyroid storm.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 758 | Box 32-23
10. The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory
values validate the diagnosis of diabetic ketoacidosis (DKA). Which symptom is most suggestive of DKA?
a. Irritability
b. Excessive thirst
c. Rapid weight gain
d. Peripheral edema
ANS: B
Diabetic ketoacidosis (DKA) has a predictable clinical presentation. It is usually preceded by patient complaints of malaise,
headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Nausea, vomiting,
extreme fatigue, dehydration, and weight loss follow. Central nervous system depression, with changes in the level of
consciousness, can lead quickly to coma.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 738
2
11. The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory
values validate the diagnosis of diabetic ketoacidosis (DKA). Which statement best describes the rationale for administrating
potassium supplements with the patient’s insulin therapy?
a. Potassium replaces losses incurred with diuresis.
b. The patient has been in a long-term malnourished state.
c. Intravenous (IV) potassium renders the infused solution isotonic.
d. Insulin drives the potassium back into the cells.
ANS: D
Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell and metabolic acidosis is
reversed. Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls
below normal. Frequent verification of the serum potassium concentration is required for patients with diabetic ketoacidosis (DKA)
who are receiving fluid resuscitation and insulin therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 740
12. The nurse is caring for a patient with type 1 diabetes who was admitted with complaints of increased lethargy. Serum laboratory
values validate the diagnosis of diabetic ketoacidosis (DKA). Which medical intervention would the nurse expect to be ordered for
this patient?
a. Extensive hydration
b. Oral hypoglycemic agents
c. Large doses of intravenous (IV) insulin
d. Limiting food and fluids
ANS: A
Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered intravenously to patients who are
severely dehydrated or have poor peripheral perfusion to ensure effective absorption. Patients with diabetic ketoacidosis (DKA) are
kept on NPO (nothing by mouth) status until the hyperglycemia is under control. Critical care nurses are responsible for monitoring
the rate of plasma glucose decline in response to insulin.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 740
13. Which pathophysiologic mechanism occurs in the patient with type 2 diabetes?
a. Lack of insulin production
b. Imbalance between insulin production and use
c. Overproduction of glucose
d. Increased uptake of glucose in the cells
ANS: B
Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin resistance.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 732
14. A patient weighs 140 kg and is 60 inches tall. The patient’s blood sugar is being controlled by glipizide. Which topic would be
important for the nurse to include in the patient’s discharge education plan?
a. Signs of hyperglycemia
b. Proper injection technique
c. Weight loss
d. Increased caloric intake
ANS: C
This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to facilitate weight loss in patients
with type 2 diabetes.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 732
15. A patient is admitted with extreme fatigue, vomiting, and headache. This patient has type 1 diabetes that has been well controlled
with an insulin pump. The patient states, “I know it could not be my diabetes because my pump gives me 24-hour control.” Which
reply would be the nurse’s best response?
a. “You know a lot about your pump, and you are correct.”
b. “You’re right. This is probably a virus.”
c. “We’ll get an abdominal CT and see if your pancreas is inflamed.”
d. “We’ll check your serum blood glucose and ketones.”
ANS: D
Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to evaluate for diabetic ketoacidosis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 750
3
16. A patient with a history of type 2 diabetes was admitted after aneurysm repair. The patient’s serum glucose levels have been
elevated for the past 2 days, and the patient is concerned about becoming dependent on insulin. Which statement is the nurse’s best
response to the patient’s concerns?
a. “This surgery may have damaged your pancreas. We will have to do more
evaluation.”
b. “Perhaps your diabetes was more serious from the beginning.”
c. “You will need to discuss this with your physician.”
d. “The stress on your body has temporarily increased your blood sugar levels.”
ANS: D
Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and increasing hepatic
gluconeogenesis.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 745
17. A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the dehydration associated with DKA results from
which pathophysiologic mechanism?
a. Increased serum osmolality and urea
b. Decreased serum osmolality and hyperglycemia
c. Ketones and potassium shifts
d. Acute renal failure
ANS: A
Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular dehydration occurs as the
hyperosmolar extracellular fluid draws the more dilute intracellular and interstitial fluid into the vascular space in an attempt to
return the plasma osmolality to normal.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
18. A patient is admitted with diabetic ketoacidosis (DKA). The nurse knows that the lack of insulin results in which process?
a. Decreased glucagon release
b. Decreased glycogenolysis
c. Decreased ketone production
d. Increased gluconeogenesis
ANS: D
The release of glucagon from the liver is stimulated when insulin is ineffective in providing the cells with glucose for energy.
Glucagon increases the amount of glucose in the bloodstream by breaking down stored glucose (glycogenolysis). In insulin
deficiency states, fat is rapidly converted into glucose (gluconeogenesis). Ketoacidosis occurs when free fatty acids are metabolized
into ketones: Acetoacetate, â-hydroxybutyrate, and acetone are the three ketone bodies that are produced.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
19. A patient is admitted with diabetic ketoacidosis (DKA) and is experiencing polyuria. Which electrolyte disturbances would the
nurse expect to see at this phase of DKA?
a. Decreased calcium and increased phosphorus levels
b. Decreased potassium and sodium levels
c. Increased sodium and decreased phosphorus levels
d. Decreased calcium and potassium levels
ANS: B
Polyuria results in large volumes of water, along with sodium, potassium, and phosphorus, being excreted in the urine, causing a
fluid volume deficit.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
20. A patient is admitted with diabetic ketoacidosis (DKA). The patient presents with dry, cracked lips and is begging for something to
drink. What reply would be the nurse’s best response?
a. “We can’t give you anything to drink until we get your blood sugar under
control.”
b. “You can have one cup of coffee without sugar.”
c. “You can drink anything you want as long as it’s sugar free.”
d. “You can drink as much water has you can handle.”
ANS: A
Patients with diabetic ketoacidosis (DKA) are kept on NPO status (nothing by mouth) until the hyperglycemia is under control.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 740
4
21. A patient is admitted with diabetic ketoacidosis (DKA). The patient’s arterial blood gas indicates the patient has an uncompensated
metabolic acidosis. The patient has rapid, regular respirations. Which medical intervention would the nurse expect to initiate to
correct the acidosis?
a. Initiate oxygen therapy via a face mask.
b. Administer sodium bicarbonate.
c. Administer insulin and fluids intravenously.
d. Prepare for intubation.
ANS: C
Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. In the presence of insulin,
glucose enters the cells, and the body ceases to convert fats into glucose.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 740
22. A patient is admitted with severe hyperglycemia. The patient is very lethargic and has a “fruity” odor to his breath. The nurse
knows the odor on the patient’s breath is indicative of which situation?
a. Alcohol intoxication
b. Lack of sodium bicarbonate
c. Hypokalemia
d. Presence of acetone
ANS: D
Acid ketones dissociate and yield hydrogen ions (H +) that accumulate and precipitate a decrease in serum pH. The level of serum
bicarbonate also decreases, consistent with a diagnosis of metabolic acidosis. Breathing becomes deep and rapid (Kussmaul
respirations) to release carbonic acid in the form of carbon dioxide. Acetone is exhaled, giving the breath its characteristic “fruity”
odor.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
23. A patient in diabetic ketoacidosis (DKA) is comatose with a temperature of 102.2° F. The nurse suspects the patient may have
which secondary disorder?
a. Head injury
b. Hypothalamus infarction
c. Infection
d. Heat stroke
ANS: C
A patient in diabetic ketoacidosis can experience a variety of complications, including fluid volume overload, hypoglycemia,
hypokalemia or hyperkalemia, hyponatremia, cerebral edema, and infection.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 741
24. A patient presents with ketoacidosis and a blood glucose level of 125 mg/dL. Diabetic ketoacidosis has been ruled out. The nurse
knows that ketoacidosis can occur in which condition?
a. Acute pancreatitis
b. Drug overdose
c. Hyperglycemic hyperosmolar state
d. Hyperaldosteronism
ANS: A
Ketoacidosis also occurs with acute pancreatitis, starvation, and alcoholic ketoacidosis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 735
25. As a patient with diabetic ketoacidosis (DKA) receives insulin and fluids, the nurse knows careful assessment must be given to
which electrolyte?
a. Potassium
b. Sodium
c. Phosphorus
d. Calcium
ANS: A
Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum potassium falls below
normal. Frequent verification of the serum potassium concentration is required for the patient with diabetic ketoacidosis receiving
fluid resuscitation and insulin therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 740
5
26. A patient has been admitted with diabetic ketoacidosis (DKA). The nurse knows that the top priority in the initial treatment of
DKA is which intervention?
a. Lowering the blood sugar as quickly as possible
b. Administering intravenous fluids
c. Administering sodium bicarbonate
d. Determining the precipitating cause
ANS: B
A patient with diabetic ketoacidosis (DKA) is dehydrated and may have lost 5% to 10% of his or her body weight in fluids. A fluid
deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to rehydrate both the intracellular and
the extracellular compartments and prevent circulatory collapse.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
27. The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis (DKA), the intravenous (IV) line should be
changed to a solution containing glucose when what happens?
a. Patient becomes more alert.
b. IV insulin has been infusing for 4 hours.
c. Blood glucose drops to 200 mg/dL.
d. Blood glucose drops to 100 mg/dL.
ANS: C
When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a 50/50 mix of hypotonic saline and 5%
dextrose. Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose level falls.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 740
28. When a patient with diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects a drop in the serum levels of
which electrolytes?
a. Sodium and potassium
b. Potassium and phosphate
c. Bicarbonate and calcium
d. Sodium and phosphate
ANS: B
Frequent verification of the serum potassium concentration is required for patients with DKA receiving fluid resuscitation and
insulin therapy. The serum phosphate level is sometimes low (hypophosphatemia) in DKA. Insulin treatment may make this more
obvious as phosphate is returned to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate
replacement is recommended.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 740
29. A patient has been admitted with diabetic ketoacidosis, and treatment has been initiated. Which findings would lead the nurse to
suspect the patient is dehydrated?
a. Poor skin turgor and flat neck veins
b. Dyspnea and crackles
c. Presence of Chvostek and Trousseau signs
d. Extra heart sounds and 3+ edema
ANS: A
Poor skin turgor and flat neck veins are indicative of dehydration. Dyspnea, crackles, extra heart sounds, and 3+ edema are signs of
fluid overload. Chvostek and Trousseau signs are indicative of hypocalcemia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 738
30. A patient with diabetic ketoacidosis (DKA) has an insulin drip infusing, and the nurse has just administered subcutaneous insulin.
The nurse is alert for signs of hypoglycemia, which would include what findings?
a. Kussmaul respirations and flushed skin
b. Irritability and paresthesia
c. Abdominal cramps and nausea
d. Hypotension and itching
ANS: B
Irritability and paresthesia are seen in hypoglycemia.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 742 | Box 32-8
6
31. A patient was admitted with diabetic ketoacidosis (DKA) an hour ago and is on an insulin drip. Suddenly, the nurse notices
frequent premature ventricular contractions (PVCs) on the electrocardiogram. The nurse notifies the practitioner. The nurse would
anticipate an order for which intervention?
a. A lidocaine bolus
b. Stopping the insulin drip
c. Synchronizing cardioversion
d. Obtaining serum electrolytes
ANS: D
Hypokalemia can occur within the first hours of rehydration and insulin treatment. Continuous cardiac monitoring is required,
because low serum potassium (hypokalemia) can cause ventricular dysrhythmias.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 741
32. A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of hyperglycemic hyperosmolar
syndrome (HHS) is given. Which findings support this diagnosis?
a. Decreased serum glucose and increased serum ketones
b. Increased urine ketones and decreased serum osmolality
c. Increased serum osmolality and increased serum potassium
d. Increased serum osmolality and increased serum glucose
ANS: D
Laboratory findings are used to establish the definitive diagnosis of hyperglycemic hyperosmolar syndrome (HHS). Plasma glucose
levels are strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 743
33. An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum ketones. Immediate attention
must be given to which intervention?
a. Evaluating clotting factors
b. Fluid administration
c. Insulin administration
d. Sodium replacement
ANS: B
The physical examination may reveal a profound fluid deficit. Signs of severe dehydration include longitudinal wrinkles in the
tongue, decreased salivation, and decreased central venous pressure, with increases in heart rate and rapid respirations (Kussmaul
air hunger does not occur). In older patients, assessment of clinical signs of dehydration is challenging.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 745
34. A patient with hyperglycemic hyperosmolar state (HHS) has a serum glucose level of 400 mg/dL and a serum sodium level of 138
mEq/L. What is the intravenous fluid of choice?
a. D5W
b. 0.45% NS
c. 0.9% NS
d. D5/NS
ANS: A
The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose more than 7 to 10 L of fluid.
Physiologic saline solution (0.9%) is infused at 1 L/h, especially for patients in hypovolemic shock if there is no cardiovascular
contraindication. Several liters of volume replacement may be required to achieve a blood pressure and central venous pressure
within normal range. Infusion volumes are adjusted according to the patient’s hydration state and sodium level.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 745
35. A patient has been admitted with hyperosmolar hyperglycemic state (HHS). The nurse knows that intravenous insulin is usually
administered at what dosage?
a. 0.1 U/kg/h
b. 1.0 U/kg/h
c. 2.0 U/kg/h
d. 5.0 U/kg/h
ANS: A
Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 U/h for a person weighing 70 kg) should lower the
plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If the measured glucose does not decrease by this amount, the
insulin infusion rate may be doubled until the blood glucose is declining at a rate of 50 to 70 mg/dL/h.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 745
7
36. A patient is admitted with a long history of mental illness. The patient’s spouse states the patient has been drinking up to 10 gallons
of water each day for the past 2 days and refuses to eat. The patient is severely dehydrated and soaked with urine. The nurse
suspects the patient has which problem?
a. Central diabetes insipidus (DI)
b. Nephrogenic DI
c. Dipsogenic DI
d. Iatrogenic DI
ANS: C
Psychogenic diabetes insipidus (DI) is a rare form of the disease that occurs with compulsive drinking of more than 5 L of water a
day. Long-standing psychogenic DI closely mimics nephrogenic DI because the kidney tubules become less responsive to
antidiuretic hormone as a result of prolonged conditioning to hypotonic urine.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 748
37. A patient is presenting with signs of diabetes insipidus (DI). Which findings would confirm this diagnosis?
a. Hyperosmolality and hypernatremia
b. Hyperosmolality and hyponatremia
c. Hypoosmolality and hypernatremia
d. Hypoosmolality and hyponatremia
ANS: A
In central diabetes insipidus (DI), there is an inability to secrete an adequate amount of antidiuretic hormone (arginine vasopressin)
in response to osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine. Hypernatremia is usually associated with
serum hyperosmolality.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 748
38. The nurse understands that the onset of seizures in the patient with diabetes insipidus (DI) is indicative of which situation?
a. Increased potassium levels
b. Hyperosmolality
c. Severe dehydration
d. Toxic ammonia levels
ANS: C
This excessive intake of water reduces the serum osmolality to a more normal level and prevents dehydration. In the person with a
decreased level of consciousness, the polyuria leads to severe hypernatremia, dehydration, decreased cerebral perfusion, seizures,
loss of consciousness, and death.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 745
39. The nurse is developing a discharge education plan for a patient with syndrome of inappropriate secretion of antidiuretic hormone
(SIADH). Which topic should be included in the plan?
a. Measuring intake and output
b. Encouraging fluids
c. A low-sodium diet
d. Hypothermia management
ANS: A
Patient and family education about syndrome of inappropriate secretion of antidiuretic hormone (SIADH), its effect on water
balance, and the reasons for fluid restrictions using the teach back method should include how to measure intake and output.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 755
40. A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a serum sodium level of 120
mEq/L, a serum osmolality level of 220 mOsm/kg, and urine-specific gravity of 1.035. The nurse suspects the patient may be
developing what problem?
a. Diabetes ketoacidosis (DKA)
b. Diabetes insipidus (DI)
c. Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
d. Hyperaldosteronism
ANS: C
A decreased urine output, hyponatremia, hypoosmolality, and high urine-specific gravity are classic signs of syndrome of
inappropriate secretion of antidiuretic hormone (SIADH). Oat cell carcinoma is a precipitating factor for SIADH.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 750 | Table 32-7
8
41. Which medication can place a patient at risk for developing syndrome of inappropriate secretion of antidiuretic hormone (SIADH)?
a. Adenosine
b. Diltiazem
c. Heparin sodium
d. Acetaminophen
ANS: D
Acetaminophen increases the release of antidiuretic hormone.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 752 | Box 32-18
42. A patient is admitted with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse understands that the
hyponatremia associated with this disorder is the result of which mechanism?
a. Increased cortisol release
b. Excessive water reabsorption
c. Excessive sodium excretion
d. Decreased glucagon release
ANS: B
The patient with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) has an excess of ADH secreted into the
bloodstream, more than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at
the kidney tubule, leading to dilutional hyponatremia.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 751
43. A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse would expect
the first line treatment to include which intervention?
a. Fluid restriction
b. Hypotonic intravenous fluid administration
c. Administration of D5W
d. Administration of vasopressin
ANS: A
Reduction in fluid intake is one component of the treatment plan for syndrome of inappropriate secretion of antidiuretic hormone
(SIADH).
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 754
44. A patient has been diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse is
administering hypertonic saline. The nurse knows that the serum sodium should not be raised more than how many milliequivalents
per day?
a. 5 mEq/day
b. 10 mEq/day
c. 20 mEq/day
d. 25 mEq/day
ANS: B
Serum sodium levels must be evaluated at least every 4 hours during the acute phase of sodium replacement. The serum sodium
should not be raised more than 10 mEq/L in 24 hours.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Evaluation
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 754
45. Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an increased risk of developing
which disorder?
a. Type 1 diabetes
b. Thyrotoxicosis
c. Diabetes insipidus
d. Myxedema coma
ANS: C
Any patient who has head trauma or resection of a pituitary tumor has an increased risk of developing diabetes insipidus.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 747
9
46. Patients discharged with antithyroid medications should be alerted to which potential side effect?
a. Hyperthermia
b. Agranulocytosis
c. Tachypnea
d. Diaphoresis
ANS: B
Patients discharged with antithyroid medications are alerted to the potential side effect of agranulocytosis. Symptoms of
agranulocytosis include sudden cough, fever, rash, and inflammation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 759
47. In caring for a patient with a thyrotoxicosis, the nurse would expect to observe which neurologic symptom?
a. Lethargy
b. Depression
c. Seizures
d. Agitation
ANS: D
Agitation and the inability to rest are often found in a patient with thyrotoxic crisis.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 756 | Box 32-22
48. A patient has thyroid storm. The nurse is providing medication instruction for home. The patient asks, “If I have a fever, should I
take Tylenol or aspirin?” Which response would be the most appropriate?
a. “Either one is fine because they do not affect the antithyroid medication.”
b. “Take Tylenol rather than aspirin because aspirin increases the amount of free
thyroid hormone in circulation.”
c. “Take aspirin rather than Tylenol because Tylenol increases the amount of free
thyroid hormone in circulation.”
d. “They both prevent the antithyroid medication from working correctly. I would
recommend an NSAID.”
ANS: B
For management or elevated temperature, patients are instructed to use acetaminophen rather than salicylates because salicylates
increase the amount of free thyroid hormone in circulation.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Health Promotion and Maintenance
REF: p. 757
49. Which finding is expected in the patient with hypothyroidism?
a. Increased T4
b. Anemia
c. Decreased thyroid stimulating hormone
d. Hyperglycemia
ANS: B
Anemia is a common problem that is present in 25% to 50% of patients with hypothyroidism. Symptoms of fatigue and depression
are associated. Erythropoiesis (red blood cell production) is impaired and inadequate. Coagulation abnormalities may coexist.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 760
50. The nurse is caring for a patient with myxedema coma. The patient’s temperature is 93° F. Which intervention would the nurse
include in the plan of care for this patient?
a. Give aggressive therapy that includes warm peritoneal lavage.
b. Allow the patient to maintain this body temperature to decrease oxygen demands.
c. Use warming blankets to slowly warm the patient.
d. Wait until the patient shivers to start warming.
ANS: C
Hypothermia will gradually improve as the patient is treated with thyroid hormone. Several warm blankets comfortably wrapped
around the patient (with mild hypothermia) may be sufficient to help raise the body temperature to normal. Active warming devices
are also used. Continuous assessments are important to avoid too-rapid heating and vasodilation.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Intervention TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 761
10
51. The nurse is caring for a patient with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Which findings
would confirm this diagnosis?
a. Decreased ADH level and hyperkalemia
b. Decreased ADH level and hypernatremia
c. Increased ADH level and serum ketones
d. Increased ADH level and low serum osmolality
ANS: D
Secretion of antidiuretic hormone (SIADH) occurs when there are increased levels of ADH in the blood compared with a low
serum osmolality.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 751
52. Decreased urine osmolality is a sign of which disorder?
a. Hyperglycemia
b. Diabetes insipidus
c. Thyroid crisis
d. Syndrome of inappropriate secretion of antidiuretic hormone
ANS: B
Decreased urine osmolality is a sign of diabetes insipidus.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 748
MULTIPLE RESPONSE
1. The neuroendocrine stress response produces which findings? (Select all that apply, one, some, or all.)
a. Elevated blood pressure
b. Decreased gastric motility
c. Tachycardia
d. Heightened pain awareness
e. Increased glucose
ANS: A, B, C, E
The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes an increased heart rate and blood
pressure. Blood is shunted from nonessential organs such as the stomach, glucose is made available to the brain cells, and pain
awareness is decreased.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
REF: p. 725
2. A patient was admitted with diabetic ketoacidosis (DKA). Glucose is 349 mg/dL, K+ is 3.7 mEq/L, and pH is 7.10. Which of the
following interventions would you expect? (Select all that apply, one, some, or all.)
a. NS 1.5 L IV fluid bolus
b. Insulin infusion at 5 units/h
c. Sodium bicarbonate 50 mmol IV push
d. Vasopressin 10 units IM every 3 hours
e. Potassium 20 mEq/L of IV fluid
ANS: A, B, E
Dehydration is a common presenting issue in diabetic ketoacidosis (DKA), so the administration of fluids and insulin will help
correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH is less than 6.9. As dehydration is
reversed, potassium moves back into the cells, and hypokalemia can result, so administration of replacement potassium is
necessary.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Planning
TOP: Endocrine
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 738 | p. 740
11
Chapter 33: Trauma
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. An unresponsive trauma patient has been admitted to the emergency department. Which statement regarding opening the airway is
accurate?
a. Airway assessment must incorporate cervical spine immobilization.
b. Hyperextension of the neck is the only acceptable technique.
c. Flexion of the neck protects the patient from further injury.
d. Airway patency takes priority over cervical spine immobilization.
ANS: A
Airway assessment must incorporate cervical spine immobilization. The patient’s head should not be rotated, hyperflexed, or
hyperextended to establish and maintain an airway. The cervical spine must be immobilized in all trauma patients until a cervical
spinal cord injury has been definitively ruled out.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 766
2. A patient with severe traumatic brain injury has been admitted to the critical care unit. What is one intervention to minimize
secondary brain injury?
a. Hyperventilate the patient to keep PCO2 less than 30.
b. Restrict fluids to keep central venous pressure less than 6 cm H 2O.
c. Maintain the patient’s body temperature more than 37.5° C.
d. Administer fluids to keep the systolic blood pressure greater than 90 mm Hg.
ANS: D
Secondary injury can be caused by ischemia, hypercapnia, hypotension, cerebral edema, sustained hypertension, calcium toxicity,
or metabolic derangements. Hypoxia or hypotension, the best-known culprits for secondary injury, typically are the result of
extracranial trauma. Extreme vasodilation of the cerebral vasculature occurs in an attempt to supply oxygen to the cerebral tissue.
This increase in blood volume increases intracranial volume and raises intracranial pressure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 770
3. A patient has sustained an epidural hematoma after a 10-foot fall from a roof. The nurse understands that an epidural hematoma is a
condition that has which characteristic?
a. Usually arterial in nature
b. Worse mortality rate than subdural hematomas
c. Associated with a permanent loss of consciousness
d. Signs and symptoms include bilateral pupil dilation
ANS: A
Epidural hematoma (EDH) is a collection of blood between the inner table of the skull and the outermost layer of the dura. EDHs
are most often associated with skull fractures and middle meningeal artery lacerations (two thirds of patients). A blow to the head
that causes a linear skull fracture on the lateral surface of the head may tear the middle meningeal artery. As the artery bleeds, it
pulls the dura away from the skull, creating a pouch that expands into the intracranial space.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 772
4. A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor vehicle crash. The patient’s plan of care would
involve which nursing action?
a. Perform neurologic assessments once a shift.
b. Obtain a computed tomography (CT) scan every day.
c. Monitor blood pressure and temperature every hour.
d. Initiate warming measures to keep temperature greater than 37.5° C.
ANS: C
Severe diffuse axonal injury (DAI) usually manifests as a prolonged, deep coma with periods of hypertension, hyperthermia, and
excessive sweating. Treatment of DAI includes support of vital functions. The outcome after severe DAI is poor because of the
extensive dysfunction of cerebral pathways. Neurologic assessment is performed every hour. DAI may not be visible on computed
tomography (CT) scan. Warming measures are generally not needed, but cooling measure may be needed.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 774
1
5. A patient is admitted with a C5 to C6 subluxation fracture. He is able to move his legs better than he can move his arms. The nurse
suspects the patient may have which type of injury?
a. Posterior cord syndrome
b. Brown-Séquard syndrome
c. Diffuse axonal injury
d. Central cord syndrome
ANS: D
Central cord syndrome is associated with cervical hyperextension/flexion injury and hematoma formation in the center of the
cervical cord. This injury produces a motor and sensory deficit more pronounced in the upper extremities than in the lower
extremities. Posterior cord syndrome is associated with cervical hyperextension injury with damage to the posterior column. This
results in the loss of position sense, pressure, and vibration below the level of injury. Brown-Séquard syndrome is associated with
damage to only one side of the cord. This produces loss of voluntary motor movement on the same side as the injury, with loss of
pain, temperature, and sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe prolonged
posttraumatic coma that is not caused by a mass lesion, although DAI with mass lesions has been reported.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 777 | p. 778
6. A patient is admitted with a C5 to C6 subluxation fracture. He is able to move his legs better than he can move his arms. Nursing
care for the patient includes which intervention?
a. Keep the room cool, dark, and quiet.
b. Maintain mean arterial pressure (MAP) at 85 to 95 mm Hg.
c. Elevate the head of the bed 45 degrees.
d. Resuscitate low blood pressure by only using intravenous fluid.
ANS: B
Management of acute cervical spinal cord injury (SCI) involves close hemodynamic monitoring. Current guidelines for the
management of acute cervical SCI cite that hypotension (systolic blood pressure less than 90 mm Hg) should be avoided or
corrected as soon as possible after acute SCI. It is also considered an option to maintain the mean arterial pressure (MAP) at 85 to
90 mm Hg for the first 5 to 7 days after acute SCI to improve spinal cord perfusion. The room should be kept warm to avoid
hypothermia. Elevating the head of the bed will often cause hypotension and is contraindicated until additional spinal cord injuries
have been ruled out. Because of the profound vasodilation found with neurogenic shock, patients should be resuscitated with both
intravenous fluids and vasopressors to restore intravascular volume as well as vascular tone.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 782
7. A patient with a Le Fort III facial fracture has been admitted to the critical care unit. Which statements is true regarding this type of
facial fracture?
a. It is frequently associated with cerebrospinal fluid leaks.
b. It is not as severe as Le Forte I and II injuries.
c. The patient’s airway is not usually compromised.
d. It is associated with a low risk for hemorrhagic shock.
ANS: A
Le Fort III fractures are associated with craniofacial disruption. Cerebrospinal fluid frequently leaks with Le Fort II and III
fractures because there is frequently communication between the cranial base and the cribriform plate. Patients are at risk of airway
occlusion from the tongue, hemorrhage, broken teeth, emesis, or bone fragments. Significant blood loss can occur with these
injuries because of the extensive soft tissue and vascular damage that results.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 784
8. A patient has been admitted with a flail chest. What findings would the nurse expect to note supporting this diagnosis?
a. Tracheal deviation toward the unaffected side
b. Jugular venous distention
c. Paradoxical respiratory movement
d. Respiratory alkalosis
ANS: C
Tracheal deviation and jugular venous distention are findings associated with tension pneumothorax. Respiratory acidosis is usually
present because of the ineffective breathing pattern. In a flail chest, a free-floating segment of the chest wall moves independently
from the rest of the thorax and results in paradoxical chest wall movement during the respiratory cycle. During inspiration, the
intact portion of the chest wall expands while the injured part is sucked in. During expiration, the chest wall moves in, and the flail
segment moves out.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 786
2
9. A patient has been admitted with a flail chest and pulmonary contusion. Which finding will cause a nurse to suspect that the
patient’s condition is deteriorating?
a. Increased bruising on the chest wall
b. Increased need for pain medication
c. The development of respiratory alkalosis
d. Increased work of breathing
ANS: D
A contusion manifests initially as a hemorrhage followed by alveolar and interstitial edema. Patients with severe contusions may
continue to show decompensation, such as respiratory acidosis and increased work of breathing, despite aggressive nursing
management. Increased bruising and the need for pain medication are not signs of deterioration.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 786
10. A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia,
hypotension, jugular venous distention, tracheal deviation to the left, and decreased breath sounds on the right side. The nurse
suspects these findings are indicative of which disorder?
a. Tension pneumothorax
b. Cardiac tamponade
c. Simple pneumothorax
d. Ruptured diaphragm
ANS: A
Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia, hypotension, and sudden chest pain extending to
the shoulders. Patients with cardiac tamponade will not have unilateral decreased breath sounds. Neither a simple pneumothorax
nor a ruptured diaphragm will result in hypotension, jugular venous distention, or tracheal deviation unless it goes untreated.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 787
11. A patient is admitted with a blunt cardiac injury (BCI) with no evidence of rupture. The nursing management plan should include
which intervention?
a. Administer nitroglycerine for chest pain as needed.
b. Monitor the patient for new onset dysrhythmias.
c. Monitor serial biomarkers for evidence of further damage.
d. Do not administer antidysrhythmic medications, as they are ineffective.
ANS: B
The patient should be monitored for new onset of dysrhythmias. The patient may complain of chest pain that is similar to anginal
pain, but it is not typically relieved with nitroglycerin. Chest pain is usually caused by associated injuries. Use of biomarkers, such
as troponin, offers very little diagnostic help for blunt cardiac injury (BCI). Medical management is aimed at preventing and
treating complications. This approach includes hemodynamic monitoring in a critical care unit and possible administration of
antidysrhythmic medications.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 789
12. A patient is admitted with acute abdominal trauma. The patient has a positive Focused Assessment with Sonography for Trauma
(FAST scan) and is hemodynamically unstable. What procedure should the nurse anticipate next?
a. Emergency surgery
b. Diagnostic peritoneal lavage (DPL)
c. Computed tomography scan
d. Intraabdominal pressure monitoring
ANS: A
Hemodynamically unstable patients with a positive Focused Assessment with Sonography for Trauma (FAST) scan generally
undergo emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is undertaken less frequently in many
trauma centers. Computed tomography (CT) scanning is the mainstay of diagnostic evaluation in the hemodynamically stable
patient with abdominal trauma; however, when the patient is hemodynamically unstable, the patient is taken to surgery.
Intraabdominal pressure monitoring is done in the presence of intraabdominal hypertension.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 790
3
13. A patient is admitted to the intensive care unit (ICU) for observation of his grade II splenic laceration. Which signs and symptoms
suggest that the patient has had a delayed rupture of his splenic capsule and is now in hemorrhagic shock?
a. Blood pressure (BP), 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40
mL/h; skin that is pink, warm, and dry, with capillary refill of 3 seconds
b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/h; pale, cool,
clammy skin; confused
c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/h; pale, cool,
dry skin; alert and oriented
d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/h; flushed,
warm, diaphoretic skin; agitated and confused
ANS: B
The first set of vital signs is normal. Patients who are in hemorrhagic shock are significantly tachycardic with a narrowed pulse
pressure and oliguric, and their skin is pale, cool, and clammy. They also have a low hematocrit and are confused.
Hemodynamically stable patients may be monitored in the critical care unit by means of serial hematocrit values and vital signs.
Progressive deterioration may indicate the need for operative management.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 768
14. A patient was thrown 30 feet from an open-top Jeep and straddled a row of mailboxes before landing on the ground. The patient has
an open pelvic fracture. What characteristics of this injury are important for the nurse to understand?
a. Aggressive fluid and blood replacement will probably be needed.
b. The patient will probably be able to walk as soon as the patient is stable.
c. The patient will probably not need surgery to stabilize her fracture.
d. There is little likelihood of damage to the genitourinary or gastrointestinal tracts.
ANS: A
The mortality rate for these injuries is high because, unlike closed pelvic fractures that bleed into the peritoneum, open pelvic
fractures result in external exsanguinations.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 794
15. A patient with multisystem trauma has been in the intensive care unit (ICU) for 6 days. The patient is still intubated and
mechanically ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The patient’s
vital signs include blood pressure (BP), 92/66 mm Hg; heart rate (HR), 118 beats/min; temperature (T), 38.7° C; and central venous
pressure (CVP), 5 mm Hg. What is the most likely cause of this hemodynamic picture?
a. Septic shock
b. Hemorrhagic shock
c. Cardiogenic shock
d. Neurogenic shock
ANS: A
The patient with multiple injuries is at risk for overwhelming infections and sepsis. The source of sepsis in the trauma patient can
be invasive therapeutic and diagnostic catheters or wound contamination with exogenous or endogenous bacteria. The source of the
septic nidus must be promptly evaluated. Gram stain and cultures of blood, urine, sputum, invasive catheters, and wounds are
obtained.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 796
16. Older trauma patients have a higher mortality than younger trauma patients. The nurse understands that this fact is probably related
to what physiologic change?
a. Deterioration of cerebral and motor skills
b. Poor vision and hearing
c. Diminished pain perception
d. Limited physiologic reserve
ANS: D
Older adults have limited ability to increase their heart rate in response to blood loss, obscuring one of the earliest signs of
hypovolemia—tachycardia. Loss of physiologic reserve and the presence of preexisting medical conditions are likely to produce
further conflicting hemodynamic data. An older patient’s lack of physiologic reserve makes it imperative that early nutritional
support is initiated.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 797 | Box 31-14
4
17. The nurse is working on an organization-wide falls prevention project. The nurse understands that the majority of falls accounting
for traumatic injury occur in what population?
a. Construction workers
b. Adolescents
c. Older adults
d. Young adults
ANS: C
Older persons experience most of the falls that result in injuries, and these falls are likely to occur from level surfaces or steps.
Because many of the falls may be caused by an underlying medical condition (e.g., syncope, myocardial infarction, dysrhythmias),
management of an older patient who has fallen must include an evaluation of events and conditions immediately preceding the fall.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 796
18. A patient with multisystem trauma has been in the critical care unit for 2 days. The patient is still intubated and mechanically
ventilated and has a chest tube, urinary drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands that
immobility places the patient at risk for developing which complication?
a. Pneumonia
b. Infection
c. Venous thromboembolism
d. Fat embolism syndrome
ANS: C
Trauma patients are at risk for infection because of contaminated wounds, invasive therapeutic and diagnostic catheters, intubation
and mechanical ventilation, host susceptibility, and the critical care environment. Nursing management must include interventions
to decrease and eliminate the trauma patient’s risk of infection.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 794
19. A nurse and a new graduate nurse are discussing the secondary survey of the trauma patient. The nurse asks the new graduate to
identify the most important aspect of a secondary survey. Which response would indicate the new graduate nurse understood the
information?
a. Check circulatory status.
b. Check electrolyte profile.
c. Insert a urinary catheter.
d. Obtain patient history.
ANS: D
During the secondary survey, a head-to-toe approach is used to thoroughly examine each body region. The history is one of the
most important aspects of the secondary survey. Additional interventions during the resuscitation phase involve placement of
urinary and gastric catheters. During resuscitation from traumatic hemorrhagic shock, normalization of standard clinical parameters
such as blood pressure, heart rate, and urine output is not adequate. Circulatory status is part of the primary survey.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 768
20. A nurse and a nursing student are discussing management of the trauma patient. The nurse asks the student what the AVPU method
is used for during the primary survey. Which response would indicate the new graduate nurse understood the information?
a. Used to assess respiratory status
b. Used to assess circulatory status
c. Used to assess pain status
d. Used to assess level of consciousness
ANS: D
The AVPU method can be used to quickly describe the patient’s level of consciousness: A: alert, V: responds to verbal stimuli, P:
responds to painful stimuli, and U: unresponsive.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 767
21. A patient was admitted after a motor vehicle crash (MVC). The nurse knows that this type of injury is the greatest cause of what
type of trauma?
a. Spinal shock
b. Blunt thoracic trauma
c. Maxillofacial injuries
d. Penetrating thoracic injuries
ANS: B
Blunt trauma to the chest most often is caused by motor vehicle crashes (MVCs) or falls. Spinal shock is a condition that can occur
shortly after traumatic injury to the spinal cord. Maxillofacial injury results from blunt or penetrating trauma. Blunt trauma may
occur from motor vehicle, industrial, or athletic injuries; violent blows to the head; or falls. The penetrating object involved
determines the damage sustained from penetrating thoracic trauma. Low-velocity weapons (e.g., 22-caliber gun, knife) usually
damage only what is in the weapon’s direct path.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 785
5
22. A trauma patient’s condition has deteriorated. The nurse notes changes in patient’s condition, including trachea shift, absence of
breath sounds on the left side, and hypotension. The nurse suspects that the patient has developed what complication?
a. Cardiac tamponade
b. Hemothorax
c. Open pneumothorax
d. Ruptured diaphragm
ANS: B
Assessment findings for patients with a hemothorax include hypovolemic shock. Breath sounds may be diminished or absent over
the affected lung. With hemothorax, the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can be
diagnosed on the basis of clinical manifestations of hypotension associated with the absence of breath sounds or dullness to
percussion on one side of the chest.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 787
23. A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted a chest tube on the left side, and 1800 mL of
blood was evacuated from the chest. The nurse expects that the patient will be taken to surgery for what procedure?
a. Thoracotomy
b. Pericardiocentesis
c. Splenectomy
d. Pneumonectomy
ANS: A
Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/h
for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 788
24. During assessment of a new trauma patient, the nurse observes perianal ecchymosis. The nurse suspects the patient has what
problem?
a. Pelvic fracture
b. Bladder trauma
c. Rectal laceration
d. Spleen laceration
ANS: A
Signs of pelvic fracture include swelling, tenderness, and/or bruising to the pubis, iliac bones, hips, or sacrum. Perianal ecchymosis
(scrotum or vulva), indicating extravasation of urine or blood, may be present.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 793
25. The nurse understands that certain trauma patients are at risk for developing fat embolism syndrome. Which group of patients is a
high risk for this complication?
a. Patients with liver trauma
b. Patients with burns
c. Patients with orthopedic trauma
d. Patients with spleen trauma
ANS: C
Fat embolism syndrome can occur as a complication of orthopedic trauma.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 795
MULTIPLE RESPONSE
1. Major trauma patients are at high risk of developing deep venous thrombosis and pulmonary embolism. The nurse understands that
trauma patients are at risk due to which factors? (Select all that apply, one, some, or all.)
a. Blood stasis
b. Hypernatremia
c. Injury to the intimal surface of the vessel
d. Hyperosmolarity
e. Hypercoagulopathy
f. Immobility
ANS: A, C, E, F
The factors that form the basis of venous thromboembolism (VTE) pathophysiology are blood stasis, injury to the intimal surface of
the vessel, and hypercoagulopathy. Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and
immobility. Hypernatremia and hyperosmolarity are associated with acute kidney injury.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 794
6
2. A patient has been admitted with muscle trauma and crush injuries. The nurse understands that this patient is at high risk for the
development of acute kidney injury secondary to rhabdomyolysis. Which findings would suggest the patient is developing this
complication? (Select all that apply, one, some, or all.)
a. Dark tea–colored urine
b. Decreased urine output
c. Hypoxemia
d. Diminished pulses
e. Increased serum creatine kinase level
ANS: A, B, E
Circulating myoglobin can lead to the development of kidney failure by three mechanisms: decreased renal perfusion, cast
formation with tubular obstruction, and direct toxic effects of myoglobin in the kidney tubules. Dark tea-colored urine suggests
myoglobinuria. The most rapid screening test is a serum creatine kinase level. Urine output and serial creatine kinase levels should
be monitored. Hypoxemia and diminished pulses are not associated with rhabdomyolysis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 795
3. The nurse is caring for a patient with extensive trauma to the lower extremities. The nurse understands that patient is at risk for
compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply,
one, some, or all.)
a. Paresthesia
b. Decreased pulses
c. Pain in the affected extremity
d. Swelling in the affected extremity
e. Decreases capillary refill
ANS: A, C, D
Clinical manifestations of compartment syndrome include obvious swelling and tightness of an extremity, paresis, and pain of the
affected extremity. Diminished pulses and decreased capillary refill do not reliably identify compartment syndrome because they
may be intact until after irreversible changes have occurred. Elevated intracompartmental pressures confirm the diagnosis.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 794
4. The nurse is caring for a patient with blunt abdominal trauma. The nurse understands that patient is at risk for abdominal
compartment syndrome. Which findings would the nurse expect to note as evidence of this complication? (Select all that apply,
one, some, or all.)
a. Decreased cardiac output
b. Increased peak pulmonary pressures
c. Decreased urine output
d. Hypoxemia
e. Bradycardia
ANS: A, B, C, D
Clinical manifestations of abdominal compartment syndrome include decreased cardiac output, decreased tidal volumes, increased
peak pulmonary pressures, decreased urine output, and hypoxemia.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiologic Integrity
REF: p. 791
5. Patients immobilized because of spinal trauma are at a high risk for contractures. The nursing management plan for these patients
should include which preventive measures? (Select all that apply, one, some, or all.)
a. Consultation by physical therapist (PT) and occupational therapist (OT) early in
the treatment of the patient.
b. Turning and repositioning the patient every 2 hours as ordered by the physician.
c. Range of motion exercises 1 month after the spine has been stabilized.
d. Removal of splints every 4 hours and at bedtime.
e. Hand splints for patients with paraplegia.
f. Hand and foot splints for patients with quadriplegia.
ANS: A, B, F
Physical therapy and occupational therapy personnel should be consulted early in the patient’s course. Range-of-motion exercises
are initiated as soon as the spine has been stabilized. Footdrop splints should be applied on admission to prevent contractures and
prevent skin breakdown of the heels. Hand splints should be applied for patients with quadriplegia. Hand and foot splints should be
removed every 2 hours.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 784
7
Chapter 34: Shock, Sepsis, and Multiple-Organ Dysfunction Syndrome
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A nurse is discussing the concept of shock with a new graduate nurse. Which statement indicates the new graduate nurse
understood the information?
a. “Shock is a physiologic state resulting in hypotension and tachycardia.”
b. “Shock is an acute, widespread process of inadequate tissue perfusion.”
c. “Shock is a degenerative condition leading to organ failure and death.”
d. “Shock is a condition occurring with hypovolemia that results in hypotension.”
ANS: B
Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations.
It is a complex pathophysiologic process that often results in multiple-organ dysfunction syndrome and death. All types of shock
eventually result in ineffective tissue perfusion and the development of acute circulatory failure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 801
2. The nurse is caring for a patient in hypovolemic shock secondary to cirrhosis of the liver. The nurse understands that this type of
shock results from shifting of fluid into the abdominal cavity. What is the resulting hypovolemia called?
a. Absolute hypovolemia
b. Distributive hypovolemia
c. Relative hypovolemia
d. Compensatory hypovolemia
ANS: A
Absolute hypovolemia occurs when there is a loss of fluid from the intravascular space. This can result from an external loss of
fluid from the body or from internal shifting of fluid from the intravascular space to the extravascular space. Fluid shifts can result
from a loss of intravascular integrity, increased capillary membrane permeability, or decreased colloidal osmotic pressure. Relative
hypovolemia occurs when vasodilation produces an increase in vascular capacitance relative to circulating volume.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 805
3. A patient has been admitted with hypovolemic shock due to traumatic blood loss. Which nursing measure can best facilitate the
administration of large volumes of fluid?
a. Inserting a large-diameter peripheral intravenous catheter
b. Positioning the patient in the Trendelenburg position
c. Encouraging the patient to drink at least 240 mL of fluid each hour
d. Administering intravenous fluids under pressure with a pressure bag
ANS: A
Measures to facilitate the administration of volume replacement include insertion of large-bore peripheral intravenous catheters;
rapid administration of prescribed fluids; and positioning the patient with the legs elevated, trunk flat, and head and shoulders
above the chest.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 807
4. The nurse is caring for a patient in cardiogenic shock. The nurse recognizes that the patient’s signs and symptoms are the result of
what problem?
a. Inability of the heart to pump blood forward
b. Loss of circulating volume and subsequent decreased venous return
c. Disruption of the conduction system when reentry phenomenon occurs
d. Suppression of the sympathetic nervous system
ANS: A
Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It can occur with dysfunction of the right
or the left ventricle or both. The lack of adequate pumping function leads to decreased tissue perfusion and circulatory failure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 807
1
5. The nurse is caring for a patient in cardiogenic shock. Which hemodynamic parameters would the nurse expect to note to support
this diagnosis?
a. Increased right atrial pressure
b. Decreased pulmonary artery wedge pressure
c. Increased cardiac output
d. Decreased cardiac index
ANS: D
Assessment of the hemodynamic parameter of patients in cardiogenic shock reveals a decreased cardiac output and a cardiac index
less than 2.2 L/min/m2.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 810
6. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the patient is
probably having an immunoglobulin E (IgE)-mediated response as a result of what physiologic mechanism?
a. Direct activation of mast cells and basophils
b. Nonimmunologic stimulation of biochemical mediators
c. Repeat exposure to an antigen in the presence of preformed IgE antibodies
d. Activation of the systemic inflammatory response
ANS: C
Immunoglobulin E (IgE) is an antibody that is formed as part of the immune response. The first time an antigen enters the body, an
antibody IgE, specific for the antigen, is formed. The antigen-specific IgE antibody is then stored by attachment to mast cells and
basophils. This initial contact with the antigen is known as a primary immune response. The next time the antigen enters the body,
the preformed IgE antibody reacts with it, and a secondary immune response occurs.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 811
7. A patient has been admitted with anaphylactic shock due to an unknown allergen. The nurse understands that the decrease in the
patient’s cardiac output is the result of which mechanism?
a. Peripheral vasodilation
b. Increased venous return
c. Increased alveolar ventilation
d. Decreased myocardial contractility
ANS: A
Peripheral vasodilation results in decreased venous return. This decreases intravascular volume and the development of relative
hypovolemia. Decreased venous return results in decreased stroke volume and a fall in cardiac output.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 811 | p. 813 | Box 34-10
8. A patient with a known penicillin allergy develops anaphylactic shock after a dose of ampicillin was given in error. Which
medication would the nurse administer first?
a. Methylprednisolone
b. Gentamicin
c. Atropine
d. Epinephrine
ANS: D
Epinephrine is given in anaphylactic shock to promote bronchodilation and vasoconstriction and inhibit further release of
biochemical mediators.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 814
9. A patient has been admitted with a neurologic disorder. With which disorder should the nurse be the most vigilant for the
development of neurogenic shock?
a. Ischemic stroke
b. Spinal cord injury
c. Guillain-Barré syndrome
d. Brain tumor
ANS: B
The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be referred to as spinal shock. The latter
condition refers to loss of neurologic activity below the level of SCI, but it does not necessarily involve ineffective tissue perfusion.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 815
2
10. A patient has been admitted with septic shock due to urinary sepsis. The practitioner inserts a pulmonary artery (PA) catheter.
Which hemodynamic value would the nurse expect to note to support this diagnosis?
a. Cardiac output (CO) of 8 L/min
b. Right atrial pressure (RAP) of 17 mm Hg
c. Pulmonary artery occlusion pressure (PAOP) of 23 mm Hg
d. Systemic vascular resistance (SVR) of 1100 dynes/seconds/cm-5
ANS: A
Increased cardiac output and decreased systemic vascular resistance are classic signs of septic shock.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 821 | Box 34-17
11. A nurse is caring for a patient in septic shock due to urinary sepsis. Which pathophysiologic mechanism results in septic shock?
a. Bacterial toxins lead to vasodilation.
b. White blood cells are released to fight invading bacteria.
c. Microorganisms invade organs such as the kidneys and heart.
d. Decreased red blood cell production and fluid loss.
ANS: A
The syndrome encompassing severe sepsis and septic shock is a complex systemic response that is initiated when a microorganism
enters the body and stimulates the inflammatory or immune system. Shed protein fragments and the release of toxins and other
substances from the microorganism activate the plasma enzyme cascades (complement, kinin and kallikrein, coagulation, and
fibrinolytic factors), as well as platelets, neutrophils, monocytes, and macrophages.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 817
12. A patient has been admitted with septic shock related to tissue necrosis. The nurse knows the initial goal for medical management
for this patient is which intervention?
a. Limiting fluids to minimize the possibility of heart failure
b. Finding and eradicating the cause of infection
c. Discontinuing invasive monitoring as a possible cause of sepsis
d. Administering vasodilator substances to increase blood flow to vital organs
ANS: B
Effective treatment of severe sepsis and septic shock depends on timely recognition. The diagnosis of severe sepsis is based on the
identification of three conditions: known or suspected infection, two or more of the clinical indications of the systemic
inflammatory response, and evidence of at least one organ dysfunction. Clinical indications of systemic inflammatory response and
sepsis were included in the original American College of Chest Physicians/Society of Critical Care Medicine consensus definitions.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 822
13. A patient has been admitted with hypovolemic shock due to blood loss. Which finding would the nurse expect to note to support
this diagnosis?
a. Distended neck veins
b. Decreased level of consciousness
c. Bounding radial and pedal pulses
d. Widening pulse pressure
ANS: B
Signs of hypovolemia include flattened neck veins, a decreased level of consciousness, weak and thready peripheral pulses, and a
narrowed pulse pressure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 805
14. A patient is being admitted from the emergency department (ED) with cardiogenic shock secondary to unstable angina
unresponsive to medications. The patient was intubated and ventilated in the ED. Which intervention should the nurse prepare to
initiate when the practitioner arrives in the unit?
a. Administration of sodium bicarbonate
b. Rapid infusion of crystalloids
c. Insertion of an intraaortic balloon pump (IABP)
d. Insertion of dialysis catheters for continuous renal replacement therapy (CRRT)
ANS: C
Mechanical circulatory assist devices are used if adequate tissue perfusion cannot be immediately restored. Options include an
intraaortic balloon pump (IABP), a percutaneous ventricular assist device (VAD), or an extracorporeal membrane oxygenator. The
IABP is used to decrease myocardial workload by improving myocardial supply and decreasing myocardial demand. It achieves
this goal by improving coronary artery perfusion and reducing left ventricular afterload. Sodium bicarbonate, fluids, and dialysis
are not indicated in this situation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Shock
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 810
3
15. A patient is being admitted with cardiogenic shock secondary to acute heart failure. In addition to a diuretic, which medication
would the nurse anticipate the practitioner ordering for the patient?
a. Epinephrine
b. Nitroprusside
c. Dobutamine
d. Nitroglycerine
ANS: A
Inotropic agents are used to increase contractility and maintain adequate blood pressure and tissue perfusion. Dobutamine is the
inotrope of choice. A vasopressor, preferably norepinephrine (not Epinephrine), may be necessary to maintain blood pressure when
hypotension is severe. Diuretics may be used for preload reduction. Vasodilating agents (Nitroglycerine and Nitroprusside) are
used for preload and afterload reduction only in specific situations in conjunction with an inotrope or when the patient is no longer
in shock.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 810
16. The nurse is caring for a patient who what just admitted with septic shock. The nurse knows that certain interventions should be
completed within 3 hours of time of presentation. Which intervention would be a priority for the nurse to implement upon receipt of
a practitioner’s order?
a. Administer fresh frozen plasma
b. Obtain a serum lactate level
c. Administer epinephrine
d. Measure central venous pressure
ANS: B
According to the Surviving Sepsis Campaign Bundles, the following interventions should be completed within 3 hours of time of
presentation.
1. Measure lactate level.
2 Obtain blood cultures prior to administration of antibiotics.
3. Administer broad spectrum antibiotics.
4. Administer 30 mL/kg crystalloid for hypotension or lactate ≥4 mmol/L.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 821 | Box 34-17
17. The nurse is caring for a patient with systemic inflammatory response syndrome (SIRS) due to pneumonia. What is SIRS due to
infection called?
a. Infectivity
b. Anaphylaxis
c. Sepsis
d. Acute respiratory distress syndrome (ARDS)
ANS: C
When systemic inflammatory response syndrome (SIRS) is the result of infection, it is referred to as sepsis.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 824
18. A nursing instructor is discussing the difference between primary and secondary multiple-organ dysfunction syndrome (MODS)
with a nursing student. Which statement indicates the student understood the information?
a. “Primary MODS is the result of inflammation in organs not involved in the initial
insult.”
b. “Primary MODS is the result of a direct organ injury.”
c. “Primary MODS is due to a disorganization of the inflammatory immune system
response.”
d. “Primary MODS is due to disruption of the coagulation system.”
ANS: B
Organ dysfunction may be the direct consequence of an initial insult (primary multiple-organ dysfunction syndrome [MODS]) or
can manifest latently and involve organs not directly affected in the initial insult (secondary MODS). Patients can experience both
primary and secondary MODS. Primary MODS results from a well-defined insult in which organ dysfunction occurs early and is
directly attributed to the insult itself.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 823
OBJ: Nursing Process Step: Diagnosis
TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
19. The nurse is caring for a patient with sepsis due to necrotic tissue. The nurse knows that necrotic tissue can stimulate the
inflammatory immune response. Which biochemical mediator is secreted in response to endotoxin or tissue injury?
a. Arachidonic acid metabolite
b. Platelet-activating factor
c. Tumor necrosis factor
d. Interleukin
ANS: C
Tumor necrosis factor-á (TNF-á, also known as cachectin) is a polypeptide that is released from macrophages and lymphocytes in
response to endotoxin, tissue injury, viral agents, and interleukins. When present in excessive amounts, TNF-á causes widespread
destruction in most organ systems and is responsible for the pathophysiologic changes in systemic inflammatory response
syndrome (SIRS) and septic shock, including fever, hypotension, decreased organ perfusion, and increased capillary permeability.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 830
OBJ: Nursing Process Step: Diagnosis
TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
20. A patient has developed septic shock. The nurse knows that the patient is at risk for gastrointestinal dysfunction. What happens to
the gastrointestinal tract in the patient with septic shock?
a. Anorexia leads to loss of gastric enzymes
b. Lack of food ingestion leads to intestinal hypomotility
c. Hypoperfusion results in loss of gut barrier function
d. Low cardiac output causes decreased hydrochloric acid secretion
ANS: C
With microcirculatory failure to the gastrointestinal tract, the gut’s barrier function may be lost, which leads to bacterial
translocation, sustained inflammation, endogenous endotoxemia, and multiple-organ dysfunction syndrome (MODS).
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 830
OBJ: Nursing Process Step: Diagnosis
TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
21. A patient has developed septic shock. The nurse knows that the clinical manifestations of ischemic hepatitis show up 1 to 2 days
after the insult. Which finding would the nurse expect to note to support this diagnosis?
a. Elevated serum creatinine
b. Decreased bilirubin
c. Jaundice
d. Decreased serum transaminase
ANS: C
Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult. Jaundice and transient elevations in serum
transaminase and bilirubin levels occur. Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production of
bilirubin from hemoglobin catabolism.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 832
OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
22. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. The nurse knows
that DIC is known to occur in patients with retained placental fragments. What is the pathophysiologic consequence of DIC?
a. Hypersensitivity response to an antigen
b. Excessive thrombosis and fibrinolysis
c. Profound vasodilatation
d. Loss of intravascular volume
ANS: B
Disseminated intravascular coagulation (DIC) results simultaneously in microvascular clotting and hemorrhage in organ systems,
leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor derangement leads to further inflammation
and further thrombosis. Microvascular damage leads to further organ injury. Cell injury and damage to the endothelium activate the
intrinsic or extrinsic coagulation pathways.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: p. 833
OBJ: Nursing Process Step: Diagnosis
TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
23. A patient is admitted after she develops disseminated intravascular coagulation (DIC) after a vaginal delivery. Which laboratory
value would the nurse expect to note to support this diagnosis?
a. Decreased fibrinogen degradation products
b. Decreased D-dimer concentrations
c. Decreased platelet counts
d. Increased serum glucose levels
ANS: C
Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation products are clinical indicators of
disseminated intravascular coagulation (DIC). DIC does not affect serum glucose levels.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 833
OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
24. The nurse is caring for a patient in shock with an elevated lactate level. Which order should the nurse question in the management
of this patient?
a. Start an insulin drip for blood sugar greater than 180 mg/dL.
b. Administer sodium bicarbonate to keep arterial pH greater than 7.20.
c. Start a norepinephrine drip to keep mean arterial blood pressure greater than 65
mm Hg.
d. Administer crystalloid fluids.
ANS: B
Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis. Glucose control to a target level of 140 to
180 mg/dL is recommended for all critically ill patients. Vasoconstrictor agents are used to increase afterload by increasing the
systemic vascular resistance and improving the patient’s blood pressure level. Crystalloids are balanced electrolyte solutions that
may be hypotonic, isotonic, or hypertonic. Examples of crystalloid solutions used in shock situations are normal saline and lactated
Ringer solution.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 804
OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
25. An elderly patient is admitted with pneumonia. This morning the patient is febrile, tachycardic, tachypneic, and confused. The
nurse suspects the patient may be developing what problem?
a. Sepsis
b. Delirium
c. Adult respiratory distress syndrome
d. Acute kidney injury
ANS: A
Increased heart rate, change in sensorium, increased temperature, and increased respiratory rate are all signs of sepsis in the
presence of an existing infection.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: p. 821
OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
26. The nurse is caring for a patient with multiple-organ dysfunction syndrome (MODS). The nurse understands that earlier nutritional
support is critical for the patient to prevent profound weight loss. Why does this occur in patient MODS?
a. Patient experiences hypometabolism.
b. Patient experiences hypermetabolism.
c. Patient experiences anorexia.
d. Patient has gut dysfunction.
ANS: B
Hypermetabolism in systemic inflammatory response syndrome (SIRS) or multiple-organ dysfunction syndrome (MODS) results in
profound weight loss, cachexia, and loss of organ function. The goal of nutritional support is the preservation of organ structure and
function. Although nutritional support may not definitely alter the course of organ dysfunction, it prevents generalized nutritional
deficiencies and preserves gut integrity. Enteral nutrition may exert a physiologic effect that downregulates the systemic immune
response and reduces oxidate stress.
PTS: 1
DIF: Cognitive Level: Knowledge
REF: p. 834
OBJ: Nursing Process Step: Assessment TOP: SIRS/MODS
MSC: NCLEX: Physiologic Integrity
27. A patient is admitted with a brain and spinal cord injury secondary to a motor vehicle crash. The nurse is monitoring the patient for
signs of neurogenic shock. Clinical findings in neurogenic shock are related to which pathophysiologic process?
a. Loss of sympathetic nervous system innervation
b. Parasympathetic nervous system stimulation
c. Injury to the hypothalamus
d. Focal injury to cerebral hemispheres
ANS: A
Neurogenic shock can be caused by anything that disrupts the sympathetic nervous system (SNS). The problem can occur as the
result of interrupted impulse transmission or blockage of sympathetic outflow from the vasomotor center in the brain. The most
common cause is spinal cord injury (SCI).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Shock
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 815
6
MULTIPLE RESPONSE
1. A patient is being admitted with septic shock. The nurse appreciates that the key to treatment is finding the cause of the infection.
Which cultures would the nurse obtain before initiating antibiotic therapy? (Select all that apply, one, some, or all.)
a. Blood cultures
b. Wound cultures
c. Urine cultures
d. Sputum cultures
e. Complete blood count (CBC) with differential
ANS: A, B, C, D
A key measure in the treatment of septic shock is finding and eradicating the cause of the infection. At least two blood cultures plus
urine, sputum, and wound cultures should be obtained to find the location of the infection before antibiotic therapy is initiated.
Antibiotic therapy should be started within 1 hour of recognition of severe sepsis without delay for cultures.
PTS: 1
DIF: Cognitive Level: Knowledge
OBJ: Nursing Process Step: Assessment TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 822
2. A patient in cardiogenic shock is being treated in the critical care unit. Which findings would the nurse expect to note in the patient
to support this diagnosis? (Select all that apply, one, some, or all.)
a. Warm, dry skin
b. Heart rate greater than 100 beats/min
c. Weak, thready pulse
d. Increased right atrial pressure
e. Decreased pulmonary artery occlusion pressure
ANS: B, C, D
Clinical manifestations of cardiogenic shock include heart rate greater than 100 beats/min; cool, pale, moist skin; weak, thready
pulse; and increased right atrial pressure and pulmonary artery occlusion pressure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
TOP: Shock
MSC: NCLEX: Physiologic Integrity
REF: p. 809 | Box 34-7
3. The nurse is caring for a patient in septic shock due secondary to pneumonia. The nurse knows that evidence-based guidelines for
the treatment of septic shock include which interventions? (Select all that apply, one, some, or all.)
a. Administer norepinephrine to maintain mean arterial pressure of 65 mm Hg.
b. Administer low-dose dopamine to maintain urine output greater than 30 mL/h.
c. Start enteral nutrition within the first 48 hours after diagnosis of septic shock.
d. Administer 30 mL/kg crystalloid for hypotension or lactate greater than or equal
to 4 mmol/L.
e. Perform an adrenocorticotropic hormone (ACTH) stimulation test to identify
patients who need hydrocortisone.
ANS: A, C, D
There is no evidence to support the use of low-dose dopamine to maintain urine output. An adrenocorticotropic hormone (ACTH)
stimulation test should not be used to identify patients who need hydrocortisone.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
TOP: Shock
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 804 | p. 821 | Box 34-17
7
Chapter 35: Burns
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is a leading cause of death in the hospitalized burn patient?
a. Smoke inhalation
b. Infection
c. Burn shock
d. Renal failure
ANS: B
Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been
going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection
in burn patients.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 852
TOP: Burns
2. A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center.
Which factor is most important when determining whether or not to refer a patient to a burn center?
a. The size and depth of burn injury and the burning agent
b. The age and present medical history of the patient
c. The depth of the burn injury and the presence of soot in the sputum
d. The medical history of the patient and the size and depth of the burn injury
ANS: D
Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient’s
age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the
above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and
appropriate referral to a burn center.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 841 | p. 842 | Box 35-1
TOP: Burns
3. Using the “rule of nines,” calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and
full-thickness burns to half of his left arm, his entire left leg, and his perineum.
a. 28%
b. 23.5%
c. 45.5%
d. 16%
ANS: B
The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 842 | Figure 35-3
TOP: Burns
4. A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation
and the patient states they are very painful. What kind of burn would the nurse document in the patient’s record?
a. Superficial, first-degree burn
b. Partial-thickness, second-degree burn
c. Deep dermal partial-thickness, second-degree burn
d. Full-thickness, third-degree burn
ANS: B
A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and
weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are
injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts
off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this
depth will heal in 7 to 21 days.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 843
TOP: Burns
1
5. Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He
also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and
rising peak airway pressures. The nurse suspects the patient’s change in condition is due to which problem?
a. Uncontrolled pain
b. Hypovolemia
c. Worsening hypoxemia
d. Decreased pulmonary compliance
ANS: D
Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance.
Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 846
TOP: Burns
6. Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the “rule of nines,” calculate the
estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum,
and entire right leg.
a. 2775 mL
b. 5550 mL
c. 8325 mL
d. 11,100 mL
ANS: B
In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg =
37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL × 37 × 75 = 11,100
mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.
DIF: Cognitive Level: Evaluating
REF: p. 847 | Table 35-1
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
7. What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body
surface area (TBSA) burn?
a. The heat from the burn leads to immediate vascular wall destruction and
extravasation of intravascular fluid.
b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn
wound edema.
c. Plasma colloid osmotic pressure is decreased because of protein leakage into the
extravascular space.
d. Capillary permeability decreases in burned and unburned tissue, leading to
hypovolemia.
ANS: C
Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after
injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space.
Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 847 | Table 35-1
TOP: Burns
8. A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously
but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide
and probably has carbon monoxide (CO) poisoning. What action should the nurse take next?
a. Ask the practitioner to order a STAT chest radiograph.
b. Apply a pulse oximeter to one of his unburned fingers.
c. Call the local hyperbaric chamber to check on its availability.
d. Administer 100% high-flow oxygen via a nonrebreathing mask.
ANS: D
The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting
nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at
40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three
times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in care of burn patients.
DIF: Cognitive Level: Evaluating
REF: p. 849
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
9. The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to
prevent cross-contamination and decrease the risk of infection in the burn-injured patient?
a. Gloves are the only personal protective equipment worn when changing dressings
that are in direct contact of body fluids.
b. Family members only have to wear a gown when visiting a patient because masks
will increase anxiety in the patient.
c. Changing gloves and handwashing should be done when moving from area to
area on the same patient.
d. Sharing of equipment between patients in the same room does not show evidence
of cross-contamination.
ANS: C
Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing
technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same
patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands
must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever
contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient.
Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps,
and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers
between patients.
DIF: Cognitive Level: Understanding
REF: p. 852
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
10. The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage?
a. Zone of coagulation
b. Peripheral zone
c. Zone of stasis
d. Zone of hyperemia
ANS: A
The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is
usually the site of greatest heat transfer, leading to irreversible skin death.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 841
TOP: Burns
11. The nurse and a new graduate nurse are caring for a patient with extensive burns and are discussing skin grafts. Which statement
indicates the new graduate understood the information?
a. “Autografts are procured from both live and deceased donors.”
b. “Autografts can be placed at the bedside or in the operating room.”
c. “Autografts can transmit disease and be rejected.”
d. “Autografts provide permanent coverage and are the least expensive.”
ANS: D
An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient’s
burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least
expensive. Homografts can transmit disease and be rejected.
DIF: Cognitive Level: Understanding
REF: p. 857
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
12. A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin
usually dissolves in 5 to 7 days because of what reason?
a. Infection
b. Lack of blood supply
c. Lack of lymphatic drainage
d. Contamination
ANS: B
After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually
is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in
various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary
coverage of full- and partial-thickness wounds, burn wounds, and donor sites.
DIF: Cognitive Level: Understanding
REF: p. 858
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
13. A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies
during the early phase of recovery?
a. Large doses of opioids given intramuscularly
b. Intravenous opioids used in combination with oral antidepressants
c. Large doses of opioids given subcutaneously
d. Small doses of intravenous opioids titrated to effect
ANS: D
Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background
pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and
gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be
administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.
DIF: Cognitive Level: Understanding
REF: p. 859
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
14. Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent
or correct contractures. Priority nursing interventions concerning this therapy include which action?
a. Daily assessment for proper fit and effectiveness
b. Removal of splints during showers and dressing changes
c. Allowing for frequent breaks from splint use
d. Passive and active range of motion may be used instead of splints
ANS: A
Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked
daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times,
except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per
shift to allow burn care and range-of-motion exercises.
DIF: Cognitive Level: Applying
REF: p. 850
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
15. Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria?
a. Pure silver
b. Bacitracin
c. Mafenide acetate cream
d. Silver sulfadiazine
ANS: D
Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many
gram-negative and -positive bacteria associated with burn wound infection. Mafenide acetate cream penetrates through burn eschar
and is bacteriostatic against many gram-negative and -positive organisms. Its use is limited because the application is
uncomfortable for the patient because it creates a burning sensation, and it is rapidly absorbed, requiring dressing changes two or
three times daily. It is used routinely for coverage of small wounds. Bacitracin ointment is a topical agent applied to superficial
burns and facial burns. Bacitracin is effective against gram-positive organisms but not against gram-negative organisms or fungal
organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties. The
wound moisture activates the silver and releases it into the wound. An advantage of silver dressings is that the dressing does not
need to be changed daily because of the sustained release of silver. Silver dressings should be used judiciously and limited to 4 to 6
weeks despite the current absence of negative systemic or local consequences.
DIF: Cognitive Level: Applying
REF: p. 855 | Table 35-2
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
16. A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure
but no blister formation. What kind of burn would the nurse document in the patient’s record?
a. Superficial partial-thickness burn
b. Moderate partial-thickness burn
c. Deep dermal partial-thickness burn
d. Full-thickness burn
ANS: C
Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A
deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs
because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 842 | p. 862
TOP: Burns
4
17. A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What
is the nurse’s first priority?
a. Clean the wounds and remove blisters.
b. Assess the airway and provide 100% oxygen.
c. Place a urinary drainage catheter and assess for myoglobin.
d. Place a central intravenous access and provide antibiotics.
ANS: B
The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation
injury are initially administered 100% oxygen.
DIF: Cognitive Level: Applying
REF: p. 846
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
18. A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total
body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20%
full-thickness burns to the right arm, right upper leg, and areas on the face. The patient’s weight is estimated at 85 kg. What is the
initial plan for fluid replacement?
a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of
LR over the next 16 hours
b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic
NS over the next 16 hours
c. 11,900 mL of dextran evenly divided over the first 24 hours
d. 11,475 mL of LR evenly divided over the first 24 hours
ANS: A
Per the Parkland formula, you would administer 5950 mL of Lactated Ringer (LR) solution for the first 8 hours and 5950 mL of LR
over the next 16 hours (4 mL × 85 kg × 45% = 15,300 mL in first 24 hours).
DIF: Cognitive Level: Analyzing
REF: p. 847 | Table 35-1
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
19. A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention
for this patient during the resuscitation phase?
a. Intravenous opiates and assessment of pulses in both arms
b. Oral antiinflammatory drugs and preparation for insertion of an arterial line
c. Measurement of sedimentation rate and systemic antibiotics
d. Application of splints and initiation of total parenteral nutrition
ANS: A
Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions.
Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular
compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation.
DIF: Cognitive Level: Applying
REF: p. 859
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
20. A patient is admitted to the burn unit with extensive burns after a house fire. The patient’s vital signs and physical exam include a
heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the
fluid resuscitation plan?
a. Continue as planned; everything looks good.
b. IV rate should be decreased and colloids started.
c. IV rate should be increased and fluid status closely watched.
d. Fluids should be switched to packed red blood cells.
ANS: C
Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/h; a pulse rate lower than 120 beats/min;
blood pressure in normal to high ranges; a central venous pressure less than 12 cm H 2O or a pulmonary artery occlusion pressure
less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 851 | p. 852
TOP: Burns
5
21. A patient is admitted to the burn unit with extensive burns after a house fire. The patient’s vital signs and physical exam include a
heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient’s symptoms are
most likely attributable to what cause?
a. Blood loss associated with burns and pain
b. Hemodynamic stability related to adequate fluid resuscitation.
c. Overresuscitation related to overestimation of the burn area involved
d. Underresuscitation because of probable wound conversion
ANS: D
The rate of fluid administration is adjusted according to the individual’s response, which is determined by monitoring urine output,
heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient’s intake and output is imperative to ensure
that he or she is appropriately resuscitated. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ
perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Overresuscitation may lead to
moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal
portions of the extremities; or to edema-inhibiting perfusion of the zone of stasis, resulting in wound conversion.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 847
TOP: Burns
22. A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm,
right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What
procedure should the nurse anticipate next?
a. Escharotomy
b. Silver sulfadiazine application
c. Splint application
d. Xenograft application
ANS: A
An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed
at the bedside with a sterile field and scalpel.
DIF: Cognitive Level: Applying
REF: p. 848
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
23. A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high
degree of suspicion for what complication associated with this type of burn injury?
a. Rhabdomyolysis
b. Stress ulcers
c. Pneumothorax
d. Venous thromboembolism
ANS: C
The electrical burn process can result in a profound alteration in acid–base balance and rhabdomyolysis, resulting in
myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle
destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic
renal failure.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 850
TOP: Burns
24. The nursing management plan for a patient with full-thickness burns includes which intervention?
a. Daily replacement of autografts
b. Daily wound care with premedication
c. Weekly wound care until all eschar is debrided
d. Surgical skin grafting within 8 hours of admission
ANS: B
Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection.
Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients
should receive adequate premedication with analgesics and sedatives.
DIF: Cognitive Level: Understanding
REF: p. 855 | Table 35-2
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
25. What are the goals of the rehabilitation phase of burn management?
a. Recuperation and healing physically and emotionally
b. Hydrotherapy and splinting
c. Reverse wound isolation and surgical grafting
d. Bed rest and splinting
ANS: A
The rehabilitation phase is one of recuperation and healing physically and emotionally.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 859
TOP: Burns
6
26. A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing,
which is characterized by rapid synthesis of collagen. What phase is the patient in?
a. Wound phase
b. Inflammatory phase
c. Proliferative phase
d. Maturation phase
ANS: C
The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the
fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory
phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed
vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of
healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops
tensile strength as collagen deposits form scar tissue.
DIF: Cognitive Level: Applying
REF: p. 854
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
27. A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware
that this injury predisposes the patient to the development of what complication?
Tension pneumothorax
Adult respiratory distress syndrome (ARDS)
Asthma
Lung cancer
a.
b.
c.
d.
ANS: B
Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS).
Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or
extracorporeal membrane oxygenation.
DIF: Cognitive Level: Applying
REF: p. 848
OBJ: Nursing Process Step: Intervention TOP: Burns
MSC: NCLEX: Physiologic Integrity
28. Roughly 80% of burns in children are classified as what type of burn?
a. Radiation
b. Chemical
c. Electrical
d. Thermal
ANS: D
The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns
in children are caused by scalds (i.e., contact with hot objects or liquids).
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 844
TOP: Burns
29. Identify in the correct order the five layers of the skin from the surface inward.
1. Stratum granulosum
2. Stratum corneum
3. Stratum germinativum
4. Stratum lucidum
5. Stratum spinosum
a. 2, 4, 1, 5, 3
b. 2, 4, 5, 1, 3
c. 4, 2, 5, 1, 3
d. 4, 5, 1, 3, 2
ANS: A
From the surface inward, its five layers are the (2) stratum corneum, (4) stratum lucidum, (1) stratum granulosum, (5) stratum
spinosum, and (3) stratum germinativum.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 840 | p. 841 | Figure 35-1
TOP: Burns
7
MULTIPLE RESPONSE
1. According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that
apply, one, some, or all.)
a. Arms
b. Perineum
c. Chest
d. Genitalia
e. Face
ANS: B, D, E
According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and
perineum are best treated in a burn center.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 845
TOP: Burns
8
Chapter 36: Organ Donation and Transplantation
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What happens to patients that meet criteria for imminent death?
a. They are placed on life support and referred to the organ procurement
b.
c.
d.
organizations.
They are referred to the organ procurement organizations at the time of their
death.
They are referred to the organ procurement organizations in a timely manner.
They are referred to a practitioner to make the decision if they are candidates for
organ donation.
ANS: C
The Centers for Medicare and Medicaid Services guidelines, the Joint Commission standards, and hospital policies require that
patients meeting criteria for imminent death and cardiac death be referred to an organ procurement organization in a timely manner.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 864
TOP: Transplantation
2. Which statement would indicate that a patient who has received an organ transplant understands the teaching about
immunosuppressive medications?
a. “My drug dosages will be lower because the medications enhance each other.”
b. “I will be less prone to side effects because I will be taking more than one drug.”
c. “Lower doses of these medications put me at greater risk for infection.”
d. “Taking more than one medication will put me at risk for developing allergies.”
ANS: A
These “triple-drug” regimens are designed to prevent rejection while reducing the toxicity of the individual medications.
DIF: Cognitive Level: Analyzing
REF: p. 875
OBJ: Nursing Process Step: Intervention TOP: Transplantation
MSC: NCLEX: Health Promotion and Maintenance
3. A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The
electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. How would this organ donor be
classified?
a. Brain-dead donor
b. Donation after cardiac death
c. Living related donor
d. Living unrelated donor
ANS: A
A brain-dead donor is a donor declared dead by neurologic criteria for brain death. Donation after cardiac death is when the donor
is declared dead by circulatory criteria for death. A living related donor is a family member related by blood who donates a kidney,
portion of the liver, pancreas, intestine, or lung to another family member. A living unrelated donor (directed or nondirected) is a
living individual not related to a patient requiring a transplant who donates a kidney, portion of the liver, pancreas, intestine, or
lung to that patient. The donor may be anonymous or altruistic.
DIF: Cognitive Level: Understanding
REF: p. 865 | Table 36-1 | p. 867 | Table 36-3
OBJ: Nursing Process Step: Intervention TOP: Transplantation
MSC: NCLEX: Physiologic Integrity
4. A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The
electroencephalogram is negative for brain waves. The family has agreed to organ donation. How would the nurse check for the
absence of cerebral motor reflexes?
a. Performing a sternal rub
b. Applying needle pricks to fingers and toes
c. Clapping hands near the ears
d. Applying pressure to the nail beds or supraorbital ridge
ANS: D
These motor responses can be stimulated by the application of pressure to the nail beds or supraorbital ridge.
DIF: Cognitive Level: Applying
REF: p. 868
OBJ: Nursing Process Step: Intervention TOP: Transplantation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. The nurse is caring for a patient after a heart transplant. Which finding would the nurse anticipate after cardiac transplantation?
a. Two P waves on the electrocardiogram (ECG)
b. High cardiac output
c. Anginal pain
d. Resting heart rate of 60 to 70 beats/min
ANS: A
An electrocardiogram (ECG) abnormality unique to a transplanted heart is the presence of a second P wave generated by the native
sinoatrial (SA) node left in the atrial cuff. Because this impulse does not cross the suture line, it is capable of conducting only
through the remnant of the native recipient atria. However, this is not seen in hearts transplanted using the bicaval technique
because the native right atrium and therefore the SA node is removed.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 879
TOP: Transplantation
6. Who determines the medical suitability of the patient for organ donation?
a. The organ procurement organization (OPO) coordinator
b. The patient’s family
c. The admitting health care provider
d. The transplant team
ANS: A
Determining medical suitability is solely the responsibility of the organ procurement organization (OPO). Speaking to the family
about donation is also the responsibility of the OPO unless designated requestors at the hospital have been trained to do so.
DIF: Cognitive Level: Understanding
REF: p. 866
OBJ: Nursing Process Step: Intervention TOP: Transplantation
MSC: NCLEX: Physiologic Integrity
7. Rejection that occurs within hours after the transplantation and results in immediate graft failure is referred to as what type of
rejection?
a. Acute
b. Intermediate
c. Chronic
d. Hyperacute
ANS: D
Hyperacute rejection is a humoral-mediated response, which occurs within hours after transplantation and results in immediate
graft failure. Acute rejection tends to occur weeks to months after transplantation but can occur at any time. Chronic rejection
occurs at varying times after transplantation and progresses for years until it leads to ultimate failure of the transplanted organ.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
REF: p. 873
TOP: Transplantation
8. The nurse is caring for a patient after a lung transplant. Which intervention would be a priority for the nurse?
a. Wean the patient from the ventilator.
b. Maintain hypotensive levels.
c. Start corticosteroid therapy.
d. Initiate pulmonary function studies.
ANS: A
Ventilation settings are determined partially by the underlying disease process and patient progression. Regular suctioning of
secretions is crucial to maintain airway clearance. Extubation is performed after satisfactory gas exchange and lung mechanics are
accomplished, and most patients are extubated within 24 to 48 hours. Evaluation for graft dysfunction, reperfusion injury, gas
trapping, and phrenic nerve injury is ongoing. Early mobilization after extubation is essential for improved pulmonary toilet and
helps prevent reintubation.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
REF: p. 883
TOP: Transplantation
9. The nurse is caring for a patient after a liver transplant. Which finding would be of most concern to the nurse?
a. Increased serum glucose
b. Low aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
c. Elevated prothrombin time
d. Decreased blood urea nitrogen and creatinine
ANS: C
A patient with suspected primary nonfunction of a liver graft demonstrates (1) hemodynamic instability, (2) progressive
deterioration of kidney function, (3) coagulopathies and abnormal serum liver function laboratory test results, (4) hypoglycemia,
(5) continued ventilatory dependence, and (6) an inability to awaken from anesthesia.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 893
TOP: Transplantation
2
10. A patient with liver failure manifested by portal hypertension and ascites is hospitalized and waiting for a liver transplant. Which
order should the nurse question?
a. Low-sodium diet
b. Low-protein diet
c. ABO typing
d. Human leukocyte antigen tissue typing
ANS: D
Liver failure is managed with a low-protein diet to decrease the risk of hepatic encephalopathy. A low-sodium diet is ordered to
help manage the ascites. Blood type and body size are used to match a liver donor, not human leukocyte antigen tissue testing.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
REF: p. 870
TOP: Transplantation
11. A nurse is preparing a patient for a liver transplant. The patient asks which stage of the procedure is the longest and most difficult.
What would the nurse tell the patient?
a. Stage 1—recipient hepatectomy
b. Stage 2—vascular anastomoses
c. Stage 3—biliary anastomosis
d. Stage 4—induction therapy
ANS: A
Liver transplant surgery can be divided into three stages: (1) recipient hepatectomy (the longest and most difficult part of the
surgery), (2) vascular anastomoses with donor liver, and (3) biliary anastomosis. Induction therapy, which refers to the first in any
series of therapeutic measures taken to treat a disease, would be administered after the transplant and is not part of the procedure.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
REF: p. 890 | p. 891
TOP: Transplantation
12. A patient has had a kidney transplant. The nurse knows that monitoring of which parameter would have the highest priority?
a. Fluid volume
b. Electrolytes
c. Complete blood count
d. Temperature
ANS: A
Adequate hydration is an absolute necessity for continued graft function in the immediate postoperative period. Hypovolemia can
lead to compromised blood flow to the kidney, acute tubular necrosis, and possible graft failure. The new kidney will produce large
amounts of urine, and replacement fluids, usually maintained at a ratio of 1:1 mL, must be sustained.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 896 | p. 897
TOP: Transplantation
13. After a pancreatic transplant with bladder exocrine drainage, the nurse would anticipate which order?
a. Continuous bladder irrigation
b. Intermittent insulin injections
c. Removal of the nasogastric tube as soon as the patient is alert
d. Daily hematocrit and hemoglobin levels
ANS: A
An increased potential for urinary catheter occlusion exists for pancreas recipients who have undergone a urinary diversion
procedure. The exocrine pancreatic enzymes make the urine more viscous, and they irritate the anastomosis site on the bladder,
causing an increased risk of bleeding. Continuous bladder irrigation may be necessary to keep the catheter patent.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 899
TOP: Transplantation
14. The nurse is caring for a patient with a pancreas transplant. Which statement made by the patient indicates the need for further
teaching?
a. “I no longer need to monitor my blood glucose levels.”
b. “I will need to have periodic pancreas biopsies.”
c. “I may feel the urge to urinate frequently.”
d. “I will give urine samples to monitor for rejection.”
ANS: A
Patients with functional pancreas grafts continue to need glucose monitoring at home but often forget to continue this practice after
they no longer require insulin. Continued monitoring with frequent clinic visits is required for several months after pancreas
transplantation.
DIF: Cognitive Level: Applying
REF: p. 900
OBJ: Nursing Process Step: Evaluation
TOP: Transplantation
MSC: NCLEX: Health Promotion and Maintenance
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
15. Which statement made by a patient who has received an organ transplant indicates that the teaching was effective?
a. “I will finally be able to eat a regular diet.”
b. “I will establish a routine for checking any skin changes.”
c. “I will check my blood pressure regularly to make sure it’s not too high.”
d. “After my drug regimen is established, I won’t have to worry about rejection.”
ANS: B
Immunosuppressed patients are at greater risk for developing skin cancer. After transplantation, such a patient needs to monitor for
hypotension and eat a diet that is low in sodium, fat, and cholesterol.
DIF: Cognitive Level: Applying
REF: p. 885
OBJ: Nursing Process Step: Evaluation
TOP: Transplantation
MSC: NCLEX: Health Promotion and Maintenance
16. A nurse is caring for a patient who is receiving sirolimus. The nurse knows to monitor the patient for what side effect?
a. Bleeding
b. Diarrhea
c. Rigors
d. Hypotension
ANS: A
Other primary side effects of this medication include hyperlipidemia and myelosuppression. Most of the myelosuppressive effect is
directed at platelets, and severe thrombocytopenia can result, making it necessary to discontinue the medication.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 875 | p. 876 | Table 36-6
TOP: Transplantation
17. A patient who has received a transplant is being taught about cyclosporine. Which statement made by the patient would indicate the
teaching was effective?
a. “I know this drug prevents my immune system from working.”
b. “If I find the capsules are hard to swallow, I’ll take the liquid.”
c. “I will need to watch for bruising.”
d. “I will need to monitor my blood pressure.”
ANS: D
This drug can cause hypertension. Capsules and liquid form are not interchangeable. The immune system still has some ability to
work. Cyclosporine does not affect the bone marrow.
DIF: Cognitive Level: Applying
REF: p. 875 | p. 876 | Table 36-6
OBJ: Nursing Process Step: Evaluation
TOP: Transplantation
MSC: NCLEX: Health Promotion and Maintenance
18. A patient who has received a transplant is being taught about azathioprine. Which statement made by the patient would indicate the
teaching was effective?
a. “I will notify my health care provider if my gums start to bleed.”
b. “I will make sure to increase the amount of fiber in my diet.”
c. “I realize I may have an increase in hair growth.”
d. “I know the flulike symptoms will go away as I get used to the drug.”
ANS: A
A common adverse effect is the suppression of other rapidly proliferating cells, resulting in leukopenia, thrombocytopenia, and
anemia. The dose of the drug is adjusted to keep the white blood cell (WBC) count between 3000 and 5000 cells/mm3, thus
protecting the patient from an increased risk of infection.
DIF: Cognitive Level: Applying
REF: p. 875 | p. 876 | Table 36-6
OBJ: Nursing Process Step: Evaluation
TOP: Transplantation
MSC: NCLEX: Health Promotion and Maintenance
19. Which nursing problem would be best for a patient who has received a kidney transplant?
a. Deficient fluid volume
b. Excess fluid volume
c. Urinary retention
d. Decreased cardiac output
ANS: A
Hypovolemia can lead to compromised blood flow to the kidney, acute kidney injury, and possible graft failure. The new kidney
will be producing large amounts of urine, and fluid replacement, usually maintained in a 1:1 ratio, must be sustained.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 897
TOP: Transplantation
4
20. A patient is admitted after a lung transplant. The nurse knows the patient is at risk for developing pneumonia. What assessment
feature would be a priority for the nurse to monitor?
a. Oxygen saturation
b. Chest tube output
c. Intake and output
d. Blood pressure
ANS: A
These patients are at risk for developing pneumonia. Aggressive postoperative pulmonary toilet is essential to promote airway
clearance because surgical denervation of the lungs diminishes the cough reflex after surgery. Thus it is important to monitor
oxygen saturation levels.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 886 | p. 887
TOP: Transplantation
21. A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The
electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. When the nurse turns the
patient’s head quickly from side to side, the patient’s eyes do not move. The nurse knows this is the result of the loss of what
reflex?
a. Oculovestibular
b. Corneal
c. Oculocephalic
d. Pupillary
ANS: C
Oculocephalic reflex: Ocular movements are lost with brain death. The oculocephalic reflex, also described as doll’s eyes, involves
fast turning of the head to both sides. In brain death, this should not generate any eye movements. Oculovestibular reflex: Because
the oculovestibular reflex is tested using iced water or normal saline, it is sometimes called cold calorics. The head of the bed is
elevated 30 degrees, and approximately 50 mL of ice water or normal saline is injected into the ear; no movement of the eye toward
the side of the stimulus should be present. It is recommended that the patient be observed for up to 1 minute after each ear
irrigation, and 5 minutes should be allowed before testing the opposite ear. Corneal and jaw reflexes: Facial sensory and motor
responses are elicited by testing for corneal and jaw reflexes. Stroking a cotton-tipped swab gently across the cornea tests the
corneal reflexes. Pupillary reflexes: Pupillary signs are evaluated by absence of the light reflex, which is consistent with brain
death. Most often the pupils are round, oval, or irregularly shaped, although dilated pupils may remain even after brain death has
occurred.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 868
TOP: Transplantation
22. The nurse is teaching a patient about antiviral medications. The patient asks “What is the most common viral infection in transplant
recipients?” what should the nurse tell the patient?
a. Influenza
b. Respiratory syncytial virus
c. Cytomegalovirus (CMV)
d. Parainfluenza
ANS: C
Cytomegalovirus (CMV) is the most common viral infection in transplant recipients. CMV may occur within the first few months
after transplantation and may occur later on. Other common viruses after transplant include respiratory syncytial virus, influenza,
adenovirus, human metapneumovirus, and parainfluenza. These are not treated prophylactically but as they occur.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 885
TOP: Transplantation
23. A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The
electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. Which organs would not be
considered for transplant?
a. Heart
b. Lung
c. Liver
d. Kidney
ANS: C
Brain death is an absolute contraindication for a liver transplant.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 888 | Box 36-10
TOP: Transplantation
5
24. The Model for End-Stage Liver Disease (MELD) formula is used to calculate risk of 3-month mortality in patients 12 years old or
older. What criteria is part of the MELD formula?
a. Whether the patient has undergone hemodialysis at least twice in the past 2 weeks
b. The number of organs in which metastasis has occurred following hepatocellular
carcinoma
c. The presence or absence of intractable pruritus
d. The number of hours the patient is expected to live without a transplant
ANS: A
The Model for End-Stage Liver Disease (MELD) formula is used in all U.S. transplant centers to calculate the risk of 3-month
mortality in patients 12 years old or older. The MELD objective criteria include serum total bilirubin, serum creatinine,
prothrombin time, international normalized ratio, and whether the patient has undergone hemodialysis at least twice in the past 2
weeks. Patients who have hepatocellular carcinoma that meet specific tumor criteria are automatically given a MELD score of 22
because the risk of metastasis outside the liver within 3 months is high. Once metastasis occurs, the patient is no longer deemed a
transplant candidate. Intractable pruritus and number of hours to live are not part of the MELD formula.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 889
TOP: Transplantation
MULTIPLE RESPONSE
1. Which federal laws regulate the medical and surgical therapy involved with organ transplantation? (Select all that apply, one, some,
or all.)
a. Omnibus Budget Reconciliation Act
b. Uniform Anatomical Gift Act
c. Hospital Conditions of Participation-Organ Donations
d. Medical Examiner Laws
e. Uniform Determination of Death Act
ANS: A, C
The Uniform Anatomical Gift Act, Uniform Determination of Death Act, and Medical Examiner Laws Restricting Ability of
Medical Examiner or Coroner to deny organ donation are all state laws.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 866 | Table 36-2
TOP: Transplantation
2. Not every patient with end-stage liver disease is a candidate for receiving a transplant. Which conditions are contraindications to a
kidney transplant? (Select all that apply, one, some, or all.)
a. Malignancy during the past 5 years
b. Active infectious process
c. Advanced cardiopulmonary disease
d. Recreational drug use
e. Nonadherence to current medical regimen
ANS: B, C, D, E
Contraindications to kidney transplantation include malignancy during the past 3 years, active infectious process, advanced
cardiopulmonary disease, high risk for surgery, nonadherence to current medical regimen, recreational drug use, and other serious
contributing disease processes.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 895 | Box 36-16
TOP: Organ Donation and Transplantation
3. Many barriers exist to increasing the number of organ donors to meet today’s growing need. Which barriers are related to hospital
factors? (Select all that apply, one, some, or all.)
a. Limited resources
b. Lack of interest
c. Failure to approve protocols
d. Nurses’ attitudes
e. Delay in termination of life support
ANS: B, C, D, E
A recent study of hospital donation practices and their impact on organ donation outcomes revealed gaps in knowledge of organ
donation; brain death; referral criteria; and at times, a poor relationship between the hospital and the organ procurement
organization. It is important that nurses are knowledgeable about the organ donation process. Nurses must assess their own beliefs
that pertain to organ donation because the attitude of the nurse and care given to the family can impact the outcome of the donation.
DIF: Cognitive Level: Analyzing
REF: p. 865
TOP: Organ Donation and Transplantation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
OBJ: Nursing Process Step: N/A
6
4. The organ procurement organization coordinator writes orders to initiate standard donor care. Which interventions are parts of
standard donor care? (Select all that apply, one, some, or all.)
a. Continue administration of osmotic agents and diuretics.
b. Maintain head of bed at 30 to 40 degrees elevation.
c. Continue routine pulmonary suctioning and side-to-side body positioning.
d. Warm blanket to maintain body temperature above 36.5° C.
e. Maintain mean arterial pressure less than 70 mm Hg.
ANS: B, C, D
Standard donor care includes: maintain head of bed at 30 to 40 degrees elevation, continue routine pulmonary suctioning and
side-to-side body positioning, and warm blanket to maintain body temperature above 36.5° C. Osmotic agents and diuretics should
be discontinued. Mean arterial pressure should be maintained above 70 mm Hg.
DIF: Cognitive Level: Applying
REF: p. 870 | Box 36-3
OBJ: Nursing Process Step: Intervention TOP: Organ Donation and Transplantation
MSC: NCLEX: Physiologic Integrity
5. Potential recipients are matched with donors based on what factors? (Select all that apply, one, some, or all.)
a. Blood type
b. Human leukocyte antigen
c. Race
d. Socioeconomic status
e. Severity of illness
f. Location of recipient
g. Waiting time on the list
ANS: A, B, E, F, G
Potential recipients are matched with the donor based on blood type, height, weight, human leukocyte antigen, distance from the
donor, waiting time on the list, and severity of illness. The national system in place for organ allocation is fair and equitable for
those requiring a transplant. The list does not reference race, gender, or socioeconomic status.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 870
TOP: Transplantation
6. The nurse is caring for a patient who has had a recent heart transplant. Which signs and symptoms would alert the nurse that the
patient is rejecting the transplant? (Select all that apply, one, some, or all.)
a. Shortness of breath
b. Tolerance of exercise
c. Disturbance in mood
d. Decreased weight
e. Pulmonary crackles
f. Onset of hypertension
g. Sudden onset of edema
ANS: A, C, E, G
Signs and symptoms of heart transplant rejections include intolerance to exercise, increased weight, and onset of hypotension.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 880 | Box 36-6
TOP: Transplantation
7
Chapter 37: Hematologic and Oncologic Emergencies
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. How is the intrinsic coagulation pathway activated?
a. Local blood vessels constrict at the injury site.
b. Damaged subendothelium comes into contact with circulating blood.
c. Tissue factor is released by injured vascular cells.
d. Serotonin and histamine are released.
ANS: B
The extrinsic pathway begins when vascular injury causes the release of tissue factor. The intrinsic pathway begins when damaged
subendothelium comes into contact with circulating blood. The two pathways converge when fibrinogen and prothrombin are
converted to their active forms and a clot is established.
DIF: Cognitive Level: Understanding
REF: p. 903
TOP: Hematologic Disorders and Oncologic Emergencies
MSC: NCLEX: Physiologic Integrity
OBJ: Nursing Process Step: N/A
2. Which element does NOT play a role in thrombin inhibition?
a. Thromboxane A2
b. Antithrombin III
c. Protein S
d. Protein C
ANS: A
The prostaglandin thromboxane A2 contributes to vasoconstriction and promotes further platelet degranulation. Excessive thrombin
formation results in rapid consumption of coagulation factors and depletion of regulatory substances—protein C, protein S, and
antithrombin.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 903
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
3. What is the most common cause of disseminated intravascular coagulation (DIC)?
a. Sepsis caused by gram-positive organisms
b. Sepsis caused by gram-negative organisms
c. Sickle cell anemia
d. Burns
ANS: B
Although all of these answers can cause disseminated intravascular coagulation (DIC), sepsis, particularly that caused by
gram-negative organisms, can be identified as the culprit in as many as 20% of cases, making it the most common cause of DIC.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Remembering
REF: p. 906 | Box 37-1
Nursing Process Step: Diagnosis
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
4. A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites
and ecchymosis beneath the blood pressure cuff. The patient’s platelet count is normal, and international normalized ratio (INR) is
elevated. What laboratory value would be valuable in definitively diagnosing the patient’s condition?
a. Fibrin split products
b. D-Dimer level
c. Bleeding time
d. White blood cell count
ANS: B
D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of coagulopathy.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 907
Nursing Process Step: Diagnosis
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. A patient was admitted with gram-negative sepsis a few days ago. Today the nurse notes continual oozing from intravenous sites
and ecchymosis beneath the blood pressure cuff. The patient’s platelet count is normal, and international normalized ratio (INR) is
elevated. Which treatment goal is the highest priority?
a. Maintain adequate organ perfusion.
b. Suppress antibody response that is destroying platelets.
c. Treat life-threatening metabolic disturbances.
d. Begin hypothermic therapy to prevent cerebral hemorrhage.
ANS: A
The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware of the conditions that
commonly contribute to the development of DIC and treating them vigorously and without delay provide the best defenses against
this devastating condition. After DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are
paramount to achieving a favorable outcome.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 908
Nursing Process Step: Planning
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
6. Which ethnic descent is the most prevalent for Sickle cell anemia?
a. West African
b. Middle Eastern
c. Pacific Islander
d. Asian
ANS: A
This genetic trait is primarily found in people of West African descent. The disease has also been linked to persons of sole
European or Middle Eastern ancestry; however, this is extremely rare. The disease is not prevalent in persons of Asian or Pacific
Islander descent.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Remembering
REF: p. 913
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
7. What is the primary mechanism in the development of idiopathic thrombocytopenic purpura (ITP)?
a. Destruction of platelets by lymphocytic antibodies
b. Destruction of malignant cells through radiation or chemotherapy
c. Formation of heparin antibodies
d. Damage to the endothelium
ANS: A
In idiopathic thrombocytopenic purpura (ITP), lymphocytes produce antibodies that begin to destroy existing platelets.
DIF: Cognitive Level: Understanding
REF: p. 909
TOP: Hematologic Disorders and Oncologic Emergencies
MSC: NCLEX: Physiologic Integrity
OBJ: Nursing Process Step: N/A
8. A patient is admitted with symptoms of a low-grade fever, joint pain, tachycardia, hepatomegaly, photophobia, and an inability to
follow commands. The patient is becoming more agitated and complaining of pain. The nurse suspects that the patient has which
disorder?
a. Idiopathic thrombocytopenic purpura
b. Heparin-induced thrombocytopenia
c. Sickle cell anemia
d. Disseminated intravascular coagulation
ANS: C
A variety of clinical manifestations are associated with sickle cell anemia. The patient may present with a low-grade fever, bone or
joint pain, pinpoint pupils, inability to follow commands, photophobia, tachycardia, tachypnea, decreased respiratory excursion,
hepatomegaly, nonpalpable spleen, and pretibial ulcers.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 914 | p. 915 | Figure 37-6
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
9. The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP). Which platelet count would the nurse expect to
note to confirm this diagnosis?
a. 28,000/mm3
b. 35,000/mm3
c. 72,000/mm3
d. 110,000/mm3
ANS: A
A platelet count below 30,000/mm3 is indicative of idiopathic thrombocytopenic purpura (ITP).
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 910
Nursing Process Step: Diagnosis
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP). The nursing management plan for this patient
would include which intervention?
a. Instituting a heparin infusion of 1000 U/h
b. Instructing the patient to blow his or her nose carefully
c. Removing heparin from hemodynamic pressure monitoring systems
d. Administering isotonic saline intravenously
ANS: B
Recognizing potential hazards and providing a safe care environment is of utmost concern. For example, padding bed rails can
protect the patient from bruising. Substituting sponge-tipped oral care devices for firm-bristled toothbrushes can help minimize
mucosal trauma and bleeding, and the patient is instructed on how to blow his or her nose gently to avoid instigating epistaxis.
When shaving patients, the use of an electric razor is preferred to reduce the risk of laceration associated with a blade.
Venipuncture and intramuscular injections are avoided.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 910
Nursing Process Step: Intervention
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
11. The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse understands that this disorder has
which characteristic?
a. Formation of thrombi
b. Spontaneous epistaxis
c. Elevated prothrombin times
d. Massive peripheral ecchymoses
ANS: A
Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for thrombosis than bleeding. Vessel
occlusion can result in the need for limb amputation, stroke, acute myocardial infarction, and even death. The resultant formation of
fibrin platelet-rich thrombi is the primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and
gives rise to its more descriptive name: white clot syndrome.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 911
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
12. The nurse is caring for a patient with type 2 heparin-induced thrombocytopenia (HIT). The nurse knows that pulmonary embolism
is a serious complication of HIT. Which findings would alert the nurse to the presence of this complication?
a. Blanching of fingers and toes and loss of peripheral pulses
b. Chest pain, pallor, and confusion
c. Headache, impaired speech, and loss of motor function
d. Dyspnea, pleuritic pain, and rales
ANS: D
The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb indicate peripheral vascular
thrombi. Neurologic signs and symptoms such as confusion, headache, and impaired speech can signal the onset of cerebral artery
occlusion and stroke. Acute myocardial infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure.
Thrombi in the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 911 | p. 912 | Table 37-5
Nursing Process Step: Diagnosis
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
13. The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing
heparin-induced thrombocytopenia (HIT). Which intervention would be included into the patient’s plan of care to monitor for this
potential complication?
a. Monitor D-dimer levels every 5 to 10 hours from day 2 to day 5.
b. Monitor prothrombin time (PT) every 5 to 14 hours from day 2 to day 12.
c. Monitor platelet count every 2 or 3 days from day 4 to day 14.
d. Monitor international normalized ratio (INR) every 5 days from day 10 to day 30.
ANS: C
Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed every 2 or 3 days from day 4
to day 14. When a decrease in the platelet count is detected, heparin therapy should be discontinued immediately, and the patient
should be tested for the presence of heparin antibodies.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 912
Nursing Process Step: Intervention
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
14. The nurse is caring for a critically ill patient who is receiving heparin and understands that the patient is at risk for developing
heparin-induced thrombocytopenia (HIT). Which previous medical conditions places this patient at risk for developing HIT?
a. Sepsis
b. Deep vein thrombosis
c. Cardiac arrest
d. Pneumonia
ANS: B
Ascertaining a medical history that includes previous heparin therapy, deep vein thrombosis, or cardiovascular surgery that
included the use of cardiopulmonary bypass can alert the nurse to potential problems.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 912
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
15. What is the primary mechanism in the development of tumor lysis syndrome?
a. Destruction of platelets by lymphocytic antibodies
b. Destruction of malignant cells through radiation or chemotherapy
c. Formation of heparin antibodies
d. Damage to the endothelium
ANS: B
The primary mechanism involved in the development of tumor lysis syndrome is the destruction of massive numbers of malignant
cells, either by chemotherapy or radiation. This mass destruction results in the release of large amounts of potassium, phosphorus,
and nucleic acids, leading to severe metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and
hypocalcemia.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 916 | p. 917
Nursing Process Step: N/A
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
16. Which pathophysiologic event contributes to renal failure associated with tumor lysis syndrome?
a. Hypocalcemia
b. Elevated white blood cell count
c. Metabolic acidosis
d. Crystallization of uric acid in the renal tubules
ANS: D
When therapy is initiated, tumor cell destruction releases nucleic acids, which are metabolized into uric acid. Metabolic acidosis
ensues, resulting in crystallization of the uric acid in the distal tubules of the kidneys and leading to obstruction of urine flow.
Glomerular filtration rates drop as the kidneys are unable to clear the increasing amounts of uric acid. Consequently, acute kidney
injury eventually occurs.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 917 | Table 37-7
Nursing Process Step: Diagnosis
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
17. A patient with a history of alcoholism is admitted with esophageal bleeding. Which finding would be an indication for the
administration of blood in this patient?
a. Hemoglobin less than 7 g/dL
b. Hematocrit less than 30%
c. Altered level of conscious
d. D-dimer greater than 250 ng/mL
ANS: A
A transfusion threshold of 7 g/dL or below, with a target hemoglobin (Hb) range of 7 to 9 g/dL, should be the default for all
critically ill patients, unless specific comorbidities or acute illness-related factors modify clinical decision-making. Transfusion
triggers should not exceed 9 g/dL in most critically ill patients. An altered level of conscious and an elevated D-dimer are not
indications for transfusion.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 920 | Box 37-15
Nursing Process Step: Intervention
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
18. Hospital-acquired anemia is an increasing problem in critically ill patients. Which nursing interventions can be most beneficial in
preventing this problem?
a. Administering fluids and inotropic agents to optimize blood pressure
b. Using blood salvage devices
c. Obtaining smaller blood samples through the use of pediatric blood tubes and
point-of-care testing
d. Decreasing afterload through the use of vasodilators
ANS: C
Frequent blood draws in critically ill patients have been associated with the development of anemia. Blood losses correspond to
actual volume of samples and discard when drawing from venous access lines. Critical care nurses can be instrumental in
significantly decreasing blood loss in this arena. The use of pediatric collection tubes and point-of-care testing are techniques that
yield valid diagnostic results but require smaller amounts of blood.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 919
Nursing Process Step: Intervention
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
19. A patient has been admitted with sickle cell anemia and is requiring a blood transfusion. The nurse understands that transfusions
should be used with caution in this patient because of what complication?
a. Fluid overload
b. Iron overload
c. Vasoocclusive crisis
d. Stroke
ANS: B
Transfusion therapy is used with extreme caution due to risks such as iron overload, exposure to hepatitis, HIV and other infectious
agents, alloimmunization, induction of hyperviscosity, and limitations on resources. The indications for having a blood transfusion
or exchange are recurrent painful vasoocclusive crises with long hospital admissions, acute chest syndrome, stroke, priapism, and
leg ulcers.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 914
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
20. The nurse is developing a patient education plan for a patient with sickle cell anemia. Hydroxyurea is the medication used in the
treatment of the disorder. The nurse would inform the patient that the hydroxyurea may be increased by what dosage until the
maximum of 35 mg/kg is reached?
a. 5 mg/kg every 4 weeks
b. 10 mg/kg every 8 weeks
c. 5 mg/kg every 12 weeks
d. 15 mg/kg every 15 weeks
ANS: C
The patient is usually started at a dose of 15 mg/kg by mouth once a day. The dose is increased by 5 mg/kg every 12 weeks until 35
mg/kg is reached as long as the patient’s blood count remains within an acceptable range.
DIF: Cognitive Level: Applying
REF: p. 914
TOP: Hematologic Disorders and Oncologic Emergencies
MSC: NCLEX: Physiologic Integrity
OBJ: Nursing Process Step: N/A
21. A patient has been admitted with tumor lysis syndrome (TLS). Which intervention would be incorporated into the plan of care to
prevent the metabolic imbalances associated with this disorder?
a. Give sodium polystyrene sulfonate for hypokalemia.
b. Keep urine pH below 7.0.
c. Restrict all oral fluids.
d. Restrict foods containing potassium.
ANS: D
Dietary restrictions of potassium and phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid
formation and to increase renal clearance. These can be accomplished through the administration of sodium bicarbonate to increase
the pH of the urine to above 7.0, which increases the solubility of uric acid, preventing subsequent crystallization. Administration
of intravenous fluids may be necessary early in the course of treatment if inadequate hydration exists. If potassium levels rise
dangerously, Kayexalate (sodium polystyrene sulfonate) may be given orally, or if the patient is unable to tolerate oral medications
because of nausea and vomiting, rectal instillation may be used.
DIF: Cognitive Level: Applying
REF: p. 918
TOP: Hematologic Disorders and Oncologic Emergencies
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
OBJ: Nursing Process Step: N/A
5
22. Place these pathophysiologic mechanisms of disseminated intravascular coagulation (DIC) in the order in which they occur.
1. Activation of the fibrinolytic system
2. Breakdown of thrombi; spontaneous hemorrhage
3. Consumption of coagulation factors; failure of regulatory mechanisms
4. Endothelial damage; release of tissue factor
5. Thrombin formation; clots form along epithelial walls
a. 4, 5, 3, 1, 2
b. 4, 1, 3, 2, 5
c. 5, 1, 2, 4, 3
d. 2, 3, 1, 5, 4
ANS: A
Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form, consuming coagulation factors. The
fibrinolytic system is triggered to break down the clots, which leads to spontaneous hemorrhage.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 906 | p. 907 | Figure 37-3
Nursing Process Step: N/A
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. A patient has been admitted with tumor lysis syndrome (TLS). Which laboratory findings would the nurse expect to note to support
this diagnosis? (Select all that apply, one, some, or all.)
a. Increased calcium
b. Decreased potassium
c. Dysrhythmias
d. Elevated blood urea nitrogen (BUN)
e. Elevated creatine
ANS: C, D, E
Common laboratory findings in tumor lysis syndrome (TLS) are as follows: increased potassium, phosphorus, uric acid, blood urea
nitrogen (BUN), and creatine; decreased calcium, creatinine clearance, pH, bicarbonate, and PaCO 2.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 918 | Table 37-8
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
2. A patient has been admitted with immune thrombocytopenia purpura (ITP). Which sign and symptoms would the nurse expect to
note to support this diagnosis? (Select all that apply, one, some, or all.)
a. Gingival bleeding
b. Retinal hemorrhage
c. Fluid retention
d. Muscle cramps
e. Petechial hemorrhages on legs
ANS: A, B, E
Signs and symptoms of immune thrombocytopenia purpura (ITP) include the following. Integumentary: Petechial hemorrhage of
lower extremities, ecchymoses, gingival bleeding, and spontaneous epistaxis. Neurologic: Sudden, severe headache; nausea and
vomiting; seizures; focal neurologic deficits; and decreased level of consciousness. Renal: Hematuria. Gastrointestinal:
Hematemesis, melena, and hematochezia. Other: Heavy menses in women and retinal hemorrhage. Laboratory: Decreased platelet
count, often below 30,000 mm3.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 910 | Table 37-4
Nursing Process Step: Assessment
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
3. The nurse is caring for a patient with heparin-induced thrombocytopenia (HIT). The nurse knows the patient is at high risk for
bleeding and injury. Which interventions would be included in the plan of care? (Select all that apply, one, some, or all.)
a. Avoid intramuscular injections.
b. Use a large-gauge intravenous cannula for venipunctures.
c. Use a soft-bristled toothbrush when providing mouth care.
d. Use a draw sheet when repositioning the patient in bed.
e. Shave the patient with an electric shaver only.
ANS: A, C, D, E
Bleeding precautions include all of these options except using a large-gauge intravenous cannula for venipunctures. If necessary,
only small-gauge needles or cannulas should be used.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 909 | Box 37-3
Nursing Process Step: Intervention
Hematologic Disorders and Oncologic Emergencies
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
Chapter 38: The Obstetric Patient
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient has been admitted with preeclampsia. The nurse understands that this disorder is characterized by what widespread
physiologic changes?
a. Increase in circulating plasma volume
b. Vasospasms in the arterial system
c. Disseminated intravascular coagulation
d. High systemic vascular resistance
ANS: B
Characteristics of preeclampsia include widespread arteriolar vasospasms, resulting in decreased perfusion to virtually all organs,
including the placenta; a decrease in plasma volume; activation of coagulation cascade; and alteration in glomerular capillary
endothelium. These generalized cyclic vasospasms lead to tissue ischemia and eventually end-organ dysfunction.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 929 | Figure 39-1
TOP: Obstetrics
2. What is the second leading cause of maternal death in the United States?
a. Sepsis
b. Hemorrhage
c. Hypertensive disease
d. Disseminated intravascular coagulation
ANS: C
Hypertensive disease is present in up to 5% of pregnant women. It is the second leading cause of death in childbearing women, and
it contributes to high rates of newborn morbidity and mortality.
DIF: Cognitive Level: Remembering
REF: p. 928
OBJ: Nursing Process Step: Diagnosis
TOP: Obstetrics
MSC: NCLEX: Health Promotion and Maintenance
3. A patient has been admitted with severe preeclampsia. The nurse knows that the patient’s treatment plan would include which
intervention?
a. Titrating intravenous fluids to maintain urine output greater than 50 mL/h
b. Administering hydralazine to keep the systolic blood pressure less than 120 mm
Hg
c. Placing the patient on bed rest to decrease the chance of delivery
d. Administering magnesium sulfate to maintain serum levels of 4 to 7 mEq/L
ANS: B
Severe hypertension must be addressed after magnesium infusions. Antihypertensive agents need to be used to keep diastolic blood
pressure between 90 and 100 mm Hg. The main drugs used to achieve this are hydralazine hydrochloride and labetalol. Diuretics
are used only in the setting of pulmonary edema. The placenta plays a central role in the development of the disease, for which the
only known cure is delivery of the fetus and removal of the placenta.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 930
TOP: Obstetrics
4. A patient has been admitted with severe preeclampsia. The nurse understands the patient is at risk for hemolysis, elevated liver
enzymes, and low platelet count (HELLP) syndrome. What clinical manifestations would indicate the patient is developing this
condition?
a. Nausea, vomiting, and epigastric pain
b. Jaundice, pruritus, and flank pain
c. Hypoactive bowel sounds, bleeding at puncture sites, and back pain
d. Fever, jugular vein distention, and chest pain
ANS: A
The clinical manifestations of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, which include nausea,
vomiting, malaise, flulike symptoms, and epigastric pain, may suggest a multitude of other clinical diagnoses. Misdiagnosis is
common and may result in a delay of correct treatment. HELLP syndrome may be confused with acute renal disease,
gastroenteritis, hepatitis, gallbladder disease, pyelonephritis, or thrombotic thrombocytopenic purpura.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 930
TOP: Obstetrics
1
5. What intrinsic factor can influence fetal development?
a. Fungal infections
b. Chromosomal abnormalities
c. Radiation exposure
d. Medication exposure
ANS: B
Intrinsic factors such as chromosomal abnormalities and congenital anomalies account for 25% of all birth defects. Extrinsic factors
such as radiation exposure; bacterial, fungal, and viral infections; medication exposure; and “unknown” causes account for the
remainder.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 939
TOP: Obstetrics
6. A patient is brought to the unit after delivering a very large baby. The patient suddenly becomes extremely agitated and complains
of shortness of breath. An amniotic fluid embolism is suspected. The nurse would immediately prepare for which intervention?
a. Insertion of a pulmonary artery catheter
b. Administration of an ampule of 50% dextrose
c. Administration of magnesium sulfate
d. Intubation and mechanical ventilation
ANS: D
Management consists of maintaining oxygenation and supporting cardiac function. Supportive therapy consists of maintenance of
blood pressure through aggressive volume replacement and inotropic support, intubation and mechanical ventilation, and blood
component therapy for hemorrhage. Other therapies such as low-dose heparin, bronchodilators, and steroids may be used.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 934
TOP: Obstetrics
7. Which statement regarding pregnancy and asthma is accurate?
a. Progesterone causes smooth muscle relaxation, which can worsen asthma
b.
c.
d.
symptoms.
Poorly controlled asthma has been associated with an increased incidence of
spontaneous abortion.
A decrease in peak expiratory flow rate (PEFR) of more than 20% of the patient’s
personal best requires a visit to the emergency room.
It is estimated that approximately two thirds of patients will have worsening of
asthma symptoms.
ANS: B
Poorly controlled asthma during pregnancy has been associated with an increased incidence of spontaneous abortion. The lessening
of asthma symptoms during pregnancy is the result of smooth muscle relaxation caused by progesterone. A decrease in peak
expiratory flow rate (PEFR) of more than 20% of the patient’s personal best requires a call to the physician; a decrease to of greater
than 50% of the patient’s personal best signals the need for a visit to the emergency department and the need for rapid assessment
and intervention. It is estimated that approximately one third of patients will experience no change in asthma symptoms, one third
will see improvement, and one third will have worsening of symptoms.
DIF: Cognitive Level: Understanding
REF: p. 931
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Safe and Effective Care Environment
8. When is the greatest risk for the patient who has had a cesarean section to develop a pulmonary embolism?
a. First time patient gets out of bed
b. Postoperative day 2
c. During the procedure
d. Immediate postpartum period
ANS: D
The greatest risk for developing pulmonary embolism is in the immediate postpartum period, especially if a cesarean section was
performed.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 933
TOP: Obstetrics
9. A patient who is 32 weeks pregnant is admitted with a pneumothorax. What must the practitioner consider when placing a chest
tube?
a. The diaphragm has been displaced 4 cm upward from its original location.
b. The diaphragm has been flattened and displaced 2 cm downward.
c. The lungs have shrunk to accommodate for the increase in abdominal size.
d. The lower lobes are one-half of their original size.
ANS: A
During pregnancy, as the uterus grows, the maternal diaphragm is displaced 4 cm above its normal location. This change in
location must be considered if placement of a chest tube is necessary to avoid injury to the diaphragm. The insertion point during
pregnancy is usually between the third and fourth intercostal spaces.
DIF: Cognitive Level: Applying
REF: p. 938
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
10. According to research, what are the minimal viability parameters for an infant?
a. 20 to 21 weeks’ gestation and fetal weight between 500 and 1000 g.
b. 22 to 23 weeks’ gestation and fetal weight between 1000 and 15,000 g.
c. 23 to 24 weeks’ gestation and fetal weight between 500 and 1000 g.
d. 24 to 25 weeks’ gestation and fetal weight between 500 and 1200 g.
ANS: C
Research has placed minimal viability parameters between 23 and 24 weeks’ gestation and fetal weight between 500 and 1000 g
(0.5 and 1 kg).
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 940
TOP: Obstetrics
11. A patient is admitted who is pregnant and has a congenital cardiac disorder. The patient is experiencing complications that include
dysrhythmias, heart failure, and thromboembolism. The nurse recognizes that these are symptoms of which condition?
a. Atrial septal defect
b. Ventricular septal defect
c. Patent ductus arteriosus
d. Mitral stenosis
ANS: A
The most common complications seen with atrial septal defect (ASD) are dysrhythmias, heart failure, and thromboembolism.
Complications of ventricular septal defect include tachycardia, heart failure, and pulmonary hypertension. Complications of patent
ductus arteriosus include large left-to-right shunts, causing congestive heart failure or pulmonary hypertension. Complications of
mitral stenosis include thromboembolism; heart failure; and arrhythmias, especially atrial fibrillation.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 926
TOP: Obstetrics
12. A patient is admitted who is pregnant and has Marfan syndrome. The nurse knows that this disorder places the patient at risk for
what complication?
a. Stroke
b. Pulmonary embolism
c. Heart failure
d. Aortic dissection
ANS: D
Marfan syndrome is an autosomal dominant disorder of connective tissue in which serious cardiovascular involvement, usually
dissection or rupture of the aorta, may occur.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 927
TOP: Obstetrics
13. The treatment plan for management of an obstetric patient with peripartum cardiomyopathy (PPCM) includes which interventions?
a. Oxygen therapy, pain management, and preload enhancement
b. Walking exercises, diuretics, and anticoagulants
c. Diuretics, digoxin, and anticoagulation
d. Fluid resuscitation, beta-blockers, and vasoconstrictors
ANS: C
Symptoms are identical to those of classic cardiac failure, but treatment depends on the pregnancy status of the patient. Women
who present with peripartum cardiomyopathy (PPCM) during pregnancy require joint cardiac and obstetric care, but as soon as the
baby is born and the patient is hemodynamically stable, standard therapy for heart failure may be applied. This would include
treatment with diuretics, digoxin, beta-blockade, and afterload reduction. Angiotensin-converting enzyme inhibitors, angiotensin
receptor blockers, and renin inhibitors are contraindicated during pregnancy because of fetotoxicity but may be used after the infant
is born. After the bleeding has been stopped after delivery, anticoagulation is commonly used to prevent thromboembolism and the
formation of left ventricular thrombus, which is associated with a worse prognosis.
DIF: Cognitive Level: Applying
REF: p. 927
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
14. A patient who is 30-weeks pregnant is admitted with severe asthma. The nurse understands that sufficient fetal oxygenation
requires what minimum level of maternal oxygenation?
a. PaO2 greater than 100 mm Hg
b. PaO2 greater than 70 mm Hg
c. Oxygen saturation of 100%
d. Oxygen saturation greater than 70%
ANS: C
Sufficient fetal oxygenation requires a maternal arterial oxygen tension (PaO 2) greater than 70 mm Hg, which corresponds to an
oxygen saturation of 95%.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 931
TOP: Obstetrics
3
15. What is the most common cause of obstetric cardiac arrest in pregnancy?
a. Anesthetic complications
b. Idiopathic peripartum cardiomyopathy
c. Pregnancy-induced hypertension
d. Hemorrhage
ANS: D
Obstetric causes for cardiac arrest in pregnancy are hemorrhage (17%), pregnancy-induced hypertension (16%), idiopathic
peripartum cardiomyopathy (8%), and anesthetic complications (2%).
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 928 | Table 38-6
TOP: Obstetrics
16. What is the most common obstetric cause of disseminated intravascular coagulopathy (DIC)?
a. Preeclampsia
b. Abruptio placentae
c. Dead fetus syndrome
d. Amniotic fluid embolism
ANS: B
Although all of these above conditions can cause disseminated intravascular coagulopathy (DIC), abruptio placentae is the most
common obstetric cause of DIC.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 930 | Table 38-8
TOP: Obstetrics
17. A multiparous woman was admitted at 36 weeks’ gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate
was normal. Severe preeclampsia was diagnosed. What is the treatment goal for this patient?
a. Maintaining maternal blood pressure greater than 140/90 mm Hg
b. Delaying delivery of the fetus as long as possible
c. Preventing maternal seizures, which may compromise fetal oxygenation
d. Limiting fluid intake to avoid postpartum edema.
ANS: C
The treatment goals of severe preeclampsia are to prevent seizures, decrease arterial spasms, and effect prompt delivery of the
fetus. MgSO4 is the standard treatment for prevention and control of seizure activity in preeclampsia and eclampsia.
DIF: Cognitive Level: Applying
REF: p. 930
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
18. A multiparous woman was admitted at 36 weeks’ gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate
was normal. Severe preeclampsia was diagnosed. In addition to her clinical signs and symptoms, the patient’s laboratory studies
demonstrate hemolysis of red blood cells, elevated liver enzymes, and a low platelet count. What would be anticipated as an
additional diagnosis?
a. Disseminated intravascular coagulopathy (DIC)
b. Dead fetus syndrome
c. Amniotic fluid embolism
d. HELLP syndrome
ANS: D
Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is an associated syndrome that affects 4% to 12% of
patients with severe preeclampsia or eclampsia. The maternal mortality rate ranges from 3.5% to 24%, and the perinatal mortality
rate ranges from 10% to 60%.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 930
TOP: Obstetrics
19. A multiparous woman was admitted at 36 weeks’ gestation for nausea, vomiting, and severe epigastric pain. The fetal heart rate
was normal. Severe preeclampsia was diagnosed. The patient is placed on a magnesium sulfate drip of 3 g/h. After an hour the
patient has a seizure. The nurse notifies the practitioner. What order would the nurse anticipate?
a. Administer another 2- to 4-g bolus of magnesium sulfate.
b. Increase the magnesium drip at a rate of 1 to 2 g/h.
c. Prepare the patient for immediate delivery of the baby.
d. Prepare for intubation and mechanical ventilatory support.
ANS: A
Control of eclamptic seizures is accomplished through administration of 4 to 6 g of intravenous MgSO4 over 5 to 10 minutes. This
bolus is followed by a continuous infusion of 2 to 3 g/h. If a patient has a recurrent seizure, another 2- to 4-g bolus can be given
over 3 to 5 minutes.
DIF: Cognitive Level: Applying
REF: p. 930
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
20. The mnemonic “tone, tissue, trauma, and thrombosis” refers to potential causes of which disorder?
a. Hypoxia
b. Abruptio placentae
c. Postpartum hemorrhage (PPH)
d. Trauma
ANS: C
Postpartum hemorrhage (PPH) has many potential causes. As a way of remembering the causes of PPH, several sources have
suggested using the “4 T’s” as a mnemonic: tone, tissue, trauma, and thrombosis.
DIF: Cognitive Level: Remembering
REF: p. 939
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
21. What is the leading cause of maternal trauma?
a. Burns
b. Motor vehicle accident
c. Falls
d. Domestic violence
ANS: B
Motor vehicle accidents (MVAs) are the leading cause of maternal blunt trauma and account for 55% to 82% of maternal trauma.
DIF: Cognitive Level: Remembering
REF: p. 934
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
22. The nurse is caring for a patient with preexisting spinal cord injury (SCI) who is 37 weeks pregnant. The SCI occurred at T4.
Which intervention would be added to the plan of care when the patient goes into labor?
a. Instruct the patient to let the nurse know when labor starts.
b. Administer steroids at the onset of labor.
c. Monitor the patient for signs of autonomic dysreflexia.
d. Prepare the patient for a cesarean section.
ANS: C
Patients with injuries above T6 are at risk for developing autonomic dysreflexia reaction (ADR) and may require assisted vaginal
delivery or a cesarean section. Vaginal delivery with a spinal cord injury (SCI) is possible. Uterine sensory nerves enter the spinal
cord at T11 to L1; women with SCI above T10 are, therefore, unable to feel uterine contractions. Steroids may be used for the
initial management of SCI and are not part of the labor process.
DIF: Cognitive Level: Applying
REF: p. 938
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
23. What is the leading cause of cardiac arrest in pregnancy?
a. Sepsis
b. Pregnancy-induced hypertension
c. Hemorrhage
d. Pulmonary embolism
ANS: D
The leading cause of cardiac arrest in pregnancy is pulmonary embolism, followed by hemorrhage, pregnancy-induced
hypertension, and sepsis.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 928 | Table 38-6
TOP: Obstetrics
24. Which statement regarding the use of medications or other therapies for advanced cardiac life support (ACLS) in the pregnant
patient is accurate?
a. No contraindications exist for use of atropine in pregnancy.
b. Epinephrine is contraindicated because it decreases uteroplacental perfusion.
c. Lidocaine is contraindicated because it crosses the placenta and has adverse fetal
effects.
d. Electric therapies are contraindicated because of the potential for electrocution of
the infant.
ANS: A
No contraindications exist for use of atropine in pregnancy. Epinephrine may decrease uteroplacental perfusion because of its
vasoconstrictive nature; however, the benefits outweigh the risks of administration. Lidocaine crosses the placenta but in
therapeutic levels does not have adverse fetal or uteroplacental effects. Electric therapies such as defibrillation, car dioversion, and
pacing are not contraindicated in pregnancy, but all fetal monitoring devices should be removed because a theoretical risk of the
scalp electrode arcing and electrocuting the infant does exist.
DIF: Cognitive Level: Understanding
REF: p. 928
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
MULTIPLE RESPONSE
1. What are some of the unique causes of septic shock in pregnant patients? (Select all that apply, one, some, or all.)
a. Postpartum pyelonephritis
b. Ectopic pregnancy
c. Chorioamnionitis
d. Septic abortion
e. Postpartum hemorrhage
ANS: A, C, D
Unique causes of septic shock in pregnant patients include chorioamnionitis, septic abortion, and postpartum pyelonephritis.
Causes of hemorrhagic shock unique to pregnancy include abruptio placentae, ectopic pregnancy, placenta previa, and postpartum
hemorrhage.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 931
TOP: Obstetrics
2. What conditions or disorders place the obstetric patient at a 25% to 50% risk of maternal mortality? (Select all that apply, one,
some, or all.)
a. Marfan syndrome with valvular involvement
b. Pulmonary hypertension
c. Coarctation of aorta with valvular involvement
d. Marfan syndrome with aortic involvement
e. Mitral stenosis with atrial fibrillation
ANS: B, C, D
Maternal mortality risks are as follows. Group 3: Mortality rate, 25% to 50%. Risks for this group include pulmonary hypertension,
coarctation of the aorta with valvular involvement, and Marfan syndrome with aortic involvement. Group 2: Mortality rate, 5% to
15%. Risks for group 2A include mitral stenosis, New York Heart Association classes III and IV; aortic stenosis; coarctation of
aorta without valvular involvement; tetralogy of Fallot, uncorrected; previous myocardial infarction; and Marfan syndrome with a
normal aorta. Risks for group 2B include mitral stenosis with atrial fibrillation and artificial valve.
DIF: Cognitive Level: Understanding
REF: p. 925 | Box 38-4
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
3. What factors must be considered when making clinical decisions regarding critically ill obstetric patients? (Select all that apply,
one, some, or all.)
a. Maternal-fetal mortality
b. Parental desires
c. Fetal weight
d. Parameters of maternal age
e. Parameters of gestational age
ANS: A, B, C, E
Critical care clinicians may encounter situations in which extrauterine viability, fetal outcomes, and maternal stability are
uncertain. Clinical decisions must be made in light of the maternal–fetal risk–benefit ratio. Personal, cultural, spiritual, and social
beliefs regarding viability may affect the clinical decision-making process. Parental and family beliefs and desires may conflict
with those of the health care team. When confronting the dilemma of viability, the parameters of gestational age, fetal weight,
parental desires, and maternal–fetal mortality must be considered.
DIF: Cognitive Level: Understanding
REF: p. 940
OBJ: Nursing Process Step: Intervention TOP: Obstetrics
MSC: NCLEX: Physiologic Integrity
4. Which physiologic changes are common in pregnant women? (Select all that apply, one, some, or all.)
a. Circulating blood volume decreases by 20% as it is diverted to the placenta.
b. Oxygen consumption increases to accommodate the fetus’s needs.
c. Respiratory tidal volumes decrease because of the elevated diaphragm.
d. Gastric motility decreases because of displacement of gastrointestinal structures
e.
by the enlarged uterus.
The glomerular filtration rate increases as cardiac output rises.
ANS: B, D, E
Blood volumes increase and cardiac output rises to accommodate fetal circulation. The enlargement of the uterus pushes the
abdominal contents upward, impairing gastric function.
DIF:
REF:
OBJ:
MSC:
Cognitive Level: Understanding
p. 924 | Table 38-2 | p. 925 | Table 38-3 | p. 925 | Table 38-4
Nursing Process Step: Assessment TOP: Obstetrics
NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
5. A patient has been admitted with severe preeclampsia. The nurse knows that the patient’s treatment plan would include which
goals? (Select all that apply, one, some, or all.)
a. Prevention of seizures
b. Decreasing arterial spasms
c. Prompt delivery of the fetus
d. Support of hypotension
e. Administration of broad-spectrum antibiotics
ANS: A, B, C
Controlling seizures and decreasing arterial spasm are essential in treating preeclampsia; patients are usually hyperten sive, and
antibiotics are not necessary.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
REF: p. 930
TOP: Obstetrics
6. Which obstetric conditions may precipitate disseminated intravascular coagulation (DIC) in an obstetric patient? (Select all that
apply, one, some, or all.)
a. Abruptio placentae
b. Amniotic fluid embolism
c. Asthma
d. Intracranial hemorrhage
e. Bacterial pneumonia
f. Dead fetus syndrome
ANS: A, B, F
Abruptio placentae, amniotic fluid embolism, and dead fetus syndrome can result in the development of disseminated intravascular
coagulation (DIC).
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 930 | Table 38-8
TOP: Obstetrics
7
Chapter 39: The Pediatric Patient
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. What is the daily fluid requirement for a 60-kg child?
a. 2600 mL/m2 per day
b. 1500 mL/m2 per day
c. 2400 mL/m2 per day
d. 3000 mL/m2 per day
ANS: B
Fluids at 1500 mL/m2 per day can be used for children who weigh more than 10 kg.
DIF: Cognitive Level: Remembering
REF: p. 959 | Table 39-8
OBJ: Nursing Process Step: Assessment TOP: Pediatrics
MSC: NCLEX: Health Promotion and Maintenance
2. What is the circulating blood volume of a neonate?
a. 40 to 60 mL/kg
b. 75 to 80 mL/kg
c. 80 to 85 mL/kg
d. 65 to 70 mL/kg
ANS: C
The circulating blood volume of a neonate is 80 to 85 mL/kg.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: n/a
TOP: Pediatrics
3. The patient is a 1-month-old infant with stable supraventricular tachycardia (SVT) at a rate of 250 beats/min. She weighs 6 kg.
How much adenosine should be given?
a. 0.05 mg rapid IV push
b. 0.1 mg rapid IV push
c. 0.6 mg rapid IV push
d. 0.5 mg rapid IV push
ANS: C
If the child in supraventricular tachycardia (SVT) is unstable and shows signs of decreased cardiac output and poor perfusion,
immediate treatment is indicated. If the child has IV access readily available, then adenosine 0.1 mg/kg should be administered up
to a maximum of 6 mg rapid bolus. This dose can be doubled up to maximum of 12 mg for a second dose.
DIF: Cognitive Level: Applying
REF: p. 953
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
4. What are the normal cerebral perfusion pressure values for a child?
a. 30 to 50 mm Hg
b. 40 to 60 mm Hg
c. Values are unknown
d. 60 to 100 mm Hg
ANS: C
The normal cerebral perfusion pressure (CPP) values in children are unknown. It is thought that CPP should be in the range of 40 to
60 mm Hg, but this figure may vary because perfusion is determined by blood flow and not blood pressure.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 955
TOP: Pediatrics
5. What is the difference between the upper airway of an infant and that of an adult?
a. The infant’s epiglottis is located lower than an adult’s.
b. The infant’s tongue is larger than the adult’s, and it fills the oral cavity.
c. The infant’s larynx is more tubular shaped with its narrowest portion at the
d.
epiglottis.
The infant’s airway is more rigid than an adult’s.
ANS: B
An infant’s epiglottis is large and floppy, and because of its high placement, it can press against the pharyngeal soft palate on
inspiration. An infant’s tongue is also large relative to head size and fills the oral cavity.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 943
TOP: Pediatrics
1
6. To establish a patent airway in an infant or child younger than 2 years of age, the nurse would perform which action?
a. Initiate the head-tilt/chin-lift maneuver.
b. Hyperextend the neck and pull the jaw forward.
c. Place a towel under the upper shoulders with the jaw slightly extended into
d.
“sniffing” position.
Place a folded towel under the head to extend the neck.
ANS: C
Knowledge of childhood anatomy is necessary to establish a patent airway. Infants and toddlers younger than 2 years of age,
because of their large occiputs, need to have a small roll or towel placed under the upper shoulders, with the jaw slightly extended
into a “sniffing” position.
DIF: Cognitive Level: Applying
REF: p. 945 | Figure 39-2
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
7. Which method can be used to establish an endotracheal tube size for a child younger than 2 years of age?
a. Match the endotracheal tube size to the infant’s age.
b. Take the child’s age, add 16, and divide by 4.
c. Measure the length of the child’s little finger and divide by 2.
d. No method is needed, as only one size is available.
ANS: A
For a child younger than 2 years of age, endotracheal tube size is matched to the child’s age. To ensure that the correct intubation
equipment is selected for the different sizes and ages of pediatric patients, many hospitals use length-based, color-coded
resuscitation tapes, such as the Broselow system.
DIF: Cognitive Level: Applying
REF: p. 947 | Box 39-2
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
8. Which process is a pathophysiologic consequence of respiratory syncytial virus (RSV)?
a. Replacement of the epithelium with nonciliated tissue resulting in submucosal
b.
c.
d.
edema and eventual necrosis
Necrosis of the alveoli resulting in collapse and destruction
Inflammation of the diaphragm resulting in alveolar hypoventilation
Bronchoconstriction resulting in airway inflammation and eventual airflow
obstruction
ANS: A
Respiratory syncytial virus involves inflammation of respiratory epithelium, leading to necrosis. The epithelium is replaced with
nonciliated tissue. Submucosal edema forms with lymphocytic infiltrates and other alveolar debris. Obstruction occurs from mucus
secretions and debris not being cleared because of the lack of ciliated epithelium.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 950
TOP: Pediatrics
9. A 5-year-old boy has been admitted with severe asthma. His initial PaCO2 was 30 mm Hg. One hour later his PaCO2 is 45 mm Hg,
and 1 hour after that, his PaCO2 is 56 mm Hg. Which intervention would the nurse anticipate being ordered by the practitioner?
a. High-dose steroids
b. Chest percussion and vibration
c. Fluid resuscitation with normal saline
d. Intubation and mechanical ventilation
ANS: D
Criteria for mechanical ventilation include a PaCO2 more than 55 mm Hg or increasing greater than 5 to 10 mm Hg per hour.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 952 | Table 39-5
TOP: Pediatrics
10. What is the pathophysiologic characteristic of a left-to-right shunt resulting from a congenital heart defect?
a. Decreased pulmonary blood flow
b. Mixed lesions with variable clinical symptoms
c. Increased pulmonary blood flow
d. Obstruction of blood flow to the ventricles
ANS: C
Cardiac defects that allow the blood to flow from a high pressure left side of the child’s heart to the lower pressure right side,
left-to-right shunt, cause an increase in pulmonary blood flow and congestive heart failure. Obstructive defects impede blood flow
out of the ventricles. Whereas obstructions on the left side of the heart result in congestive heart failure (CHF), obstructions on the
right side cause cyanosis. A pediatric patient with mixed lesions presents with variable clinical symptoms that depend on the degree
of mixing of the pulmonary blood, hypoxemia, and CHF.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: n/a
TOP: Pediatrics
2
11. Central cyanosis is associated with which phenomena?
a. Decreased peripheral blood flow
b. Desaturation of arterial blood
c. Reduced hemoglobin of 15 g/dL
d. Permanent cerebral hypoxia
ANS: B
Cyanosis is visible when hemoglobin is reduced by 5 g per 100 mL of blood. Cyanosis associated with desaturation of arterial
blood is called central cyanosis. Peripheral cyanosis is a condition in which cyanosis exists but the child has normal arterial oxygen
saturation.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 952
TOP: Pediatrics
12. What is the initial treatment for hypoxia, acidosis, or hypothermia?
a. Vasopressin
b. Bronchodilators
c. Oxygenation and ventilation
d. Hydration
ANS: C
Bradycardia can result from hypoxia, acidosis, or hypothermia. Bradycardia is defined as a cardiac rate less than 100 beats/min for
an infant and less than 60 beats/min for a child. Treatment initially includes adequate oxygenation and ventilation for the pediatric
patient.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 953
TOP: Pediatrics
13. What is the initial setting on a manual defibrillator for a patient older than 1 year?
a. 100 joules
b. 360 joules
c. 2 joules/kg
d. 4 joules/kg
ANS: C
On a manual defibrillator, the initial dose of electricity is 2 joules/kg. If using an automated external defibrillator, this should only
be used for children older than 1 year. Immediately after the shock, cardiopulmonary resuscitation should be resumed for 2 minutes
(five cycles). The compressions support the heart while it is in a recovery state even if a perfusion rhythm has returned.
DIF: Cognitive Level: Remembering
REF: p. 955
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
14. A 4-year-old child is admitted with fever, chills, headache, vomiting, lethargy, photophobia, and nuchal rigidity. Based on these
clinical manifestations, what diagnosis would the nurse anticipate?
a. Status epilepticus
b. Bacterial meningitis
c. Head trauma
d. Septic shock
ANS: B
The clinical manifestations of bacterial meningitis include fever, chills, headache, vomiting, irritability or lethargy, photophobia,
nuchal rigidity, and positive Kernig or Brudzinski sign. In meningococcemia, petechiae and purpura may be observed on the child.
The late stages of this disease may produce an increased intracranial pressure and cardiovascular collapse.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 957
TOP: Pediatrics
15. A 4-year-old child is admitted with fever, chills, headache, vomiting, lethargy, photophobia, and nuchal rigidity. Nursing
management for this patient would include which intervention?
a. Measuring and documenting head circumference
b. Allowing the patient’s siblings to visit
c. Isolating the patient during initial antibiotic treatment and for 24 hours thereafter
d. Administering anticonvulsant medications every 6 hours
ANS: C
Initial management includes use of isolation precautions, initiation of antibiotic therapy, maintenance of ventilation and hydration,
reduction of increased intracranial pressure, management of systemic shock, control of seizures and temperature, and provision of
family education and support.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 957
TOP: Pediatrics
3
16. A 4-year-old child is admitted to the critical care unit with fever, chills, headache, vomiting, lethargy, photophobia, and nuchal
rigidity. The patient has been unable to eat, and tube feedings are to be initiated. What is the preferred method for determining the
insertion length of the nasogastric tube?
a. Measure from the naris to ear to xiphoid process.
b. Measure from the ear to the umbilicus.
c. Measure from the naris to the xiphoid to ear.
d. Measure from the naris to ear to a point between the xiphoid process and the
umbilicus.
ANS: D
Determining the insertion length of a nasogastric tube in the child is from naris to ear to xiphoid process and then measuring to a
point between the xiphoid and the umbilicus.
DIF: Cognitive Level: Applying
REF: p. 959
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
17. The nurse is caring for a 6-month-old infant who is having frequent episodes of apparent life-threatening events (ALTEs). The
practitioner has ordered a number of treatments for the patient. Which treatment would the nurse question as being inappropriate in
this situation?
a. Prone positioning
b. Moderate sedation
c. Nasal continuous positive airway pressure
d. Recurrent cutaneous stimulation
ANS: B
For frequent episodes of infant apnea, treatments include prone positioning, use of rocker beds, recurrent cutaneous stimulation,
nasal continuous positive airway pressure, or a switch to continuous gavage feedings to help control symptoms of gastroesophageal
reflux disease. Treatment also includes the use of respiratory stimulant drugs, such as theophylline or caffeine. The administration
of sedatives would be contraindicated in this situation as they can depress respirations.
DIF: Cognitive Level: Applying
REF: n/a
OBJ: Nursing Process Step: Intervention TOP: Pediatrics
MSC: NCLEX: Physiologic Integrity
18. A 3-month-old infant presents with vomiting and diarrhea. The infant appears to be drowsy; his pulse rate is 180 beats/min; and he
has had a dry diaper for the past 3 hours. The nurse suspects the patient has developed which condition?
a. Mild dehydration
b. Moderate dehydration
c. Desiccation
d. Severe dehydration
ANS: D
Severe dehydration: The child is drowsy, limp, cold, and sweaty, and the extremities may be cyanotic. The patient has a rapid or
feeble pulse that is sometimes difficult to palpate and has respirations that are deep and a rate that is rapid; these are signs of
hypotensive shock. The fontanel is very sunken; urine is not excreted for several hours, and no tears are evident; and the eyes are
very sunken. Moderate dehydration: The child is thirsty, restless, lethargic, and irritable; has a rapid or weak pulse; has respirations
that may be deep, and the rate may be rapid; has a sunken fontanel; and has normal or low blood pressure. The skin retracts slowly
when pinched, mucous membranes are dry, and urine is dark and the amount reduced. Mild dehydration: The child is restless,
thirsty, and alert; has a normal pulse rate and strength; and has normal blood pressure, respiratory rate, and fontanels. The skin
readily retracts when pinched, mucous membranes are moist, and urine output is normal.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 953
TOP: Pediatrics
19. What is the key to effective pain management in children?
a. Behavioral assessment
b. Pain assessment
c. Physical assessment
d. Activity assessment
ANS: B
Pain assessment is the key to effective pain management. Many of the factors that influence an adult’s pain also influence a child’s
pain. One difference is the influence of parental anxiety and behavior regarding their child’s overall experience of pain.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 960
TOP: Pediatrics
4
20. Which medication is used for weaning a child with an opioid dependency?
a. Morphine
b. Fentanyl
c. Meperidine
d. Methadone
ANS: D
The most commonly used narcotics for children are morphine (0.02 to 0.1 mg/kg given intravenously), fentanyl (0.5 to 1.5 mcg/kg
given intravenously), and hydromorphone (0.005 to 0.2 mg/kg given intravenously). Methadone (0.1 mg/kg) is an extremely
long-acting narcotic, but it is not used as commonly for acute pain control. This drug is used for weaning from iatrogenic narcotic
dependency or for chronic pain control. Meperidine (0.75 mg/kg) is not a drug of choice because it decreases cardiac output and
causes tachycardia.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 961
TOP: Pediatrics
MULTIPLE RESPONSE
1. What elements help a child cope successfully with a critical care crisis? (Select all that apply, one, some, or all.)
a. An outside support system
b. A resilient personality
c. Another child with the same illness
d. A supportive family
e. A fatalistic practitioner
ANS: A, B, D
Three elements help a child cope successfully with a crisis: (1) a resilient personality, (2) a supportive family, and (3) an outside
support system. The critical care health team members serve as the outside support system, applying the family-centered concept as
they reinforce and strengthen the coping efforts of the child and family.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 962
TOP: Pediatrics
2. Which anatomic and physiologic findings are normal in infants younger than 1 year old? (Select all that apply, one, some, or all.)
a. The epiglottis is large and floppy.
b. The basal metabolic rate is lower than that of an adult.
c. The size of the head is smaller compared with the rest of the body.
d. The hormonal and metabolic response to pain is the same as that of an adult.
e. A positive Babinski reflex is a normal finding.
ANS: A, D, E
Many anatomic and physiologic differences exist between an adult and an infant. The epiglottis is large and floppy, the hormonal
and metabolic response to pain is the same as that of an adult, and a positive Babinski reflex is a normal finding. The basal
metabolic rate is higher than that of an adult, and the size of the head is larger compared with the rest of the body.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Understanding
REF: p. 943 | p. 944 | p. 955 | Box 39-1
Nursing Process Step: Assessment
The Pediatric Patient in the Adult Critical Care Unit
NCLEX: Physiologic Integrity
3. Optimal treatment of a pediatric patient with status asthmaticus includes which actions? (Select all that apply, one, some, or all.)
a. Placing the patient in the knee-chest position
b. Extending the neck to promote opening of the airway
c. Providing humidified oxygen
d. Administering β-adrenergic therapy
e. Administering corticosteroids
ANS: C, D, E
Standard treatment for a pediatric patient who has asthma includes receiving oxygen, β-adrenergic therapy, corticosteroids, and
anticholinergic medications as indicated. Intensive care management of a child with status asthmaticus involves humidified oxygen
to maintain an oxygen saturation of more than 95%, combined with pharmacologic therapies.
DIF:
OBJ:
TOP:
MSC:
Cognitive Level: Applying
REF: p. 951
Nursing Process Step: Intervention
The Pediatric Patient in the Adult Critical Care Unit
NCLEX: Physiologic Integrity
4. What are the causes of status epilepticus in children? (Select all that apply, one, some, or all.)
a. High fever
b. Encephalitis
c. Metabolic disorders
d. Meningitis
e. Gradual weaning of anticonvulsant drugs
ANS: A, B, C, D
Causes may include high fever, meningitis, encephalitis, metabolic disorders, and abrupt cessation of anticonvulsant drugs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 957
TOP: Pediatrics
5
5. A 3-year-old patient is admitted with head trauma as the result of a motor vehicle crash. The nurse knows that the complications of
a head injury include which conditions? (Select all that apply, one, some, or all.)
a. Infection
b. Seizures
c. Hemorrhage
d. Cerebral bleeding
e. Brain herniation
ANS: A, B, C, D, E
Complications of head injuries include hemorrhage, infections, cerebral bleeding, cerebral edema, seizures, and brain herniation.
Treatment is based on the clinical signs in the patient.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 958
TOP: Pediatrics
6
Chapter 40: The Older Adult Patient
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. A 78-year-old patient has been admitted after an inferior myocardial infarction (MI). The nurse knows that age-related changes in
the cardiovascular system coupled with the MI place the patient at risk for what problem?
a. Hypertension
b. Heart failure
c. Ventricular fibrillation
d. Bradycardia
ANS: B
Age-related myocardial infarction (MI) is one of the most common causes of heart failure. Age-associated changes in arterial
structure and function cause large vessels to become less distensible, leading to prolonged systolic contraction, lengthened diastolic
relaxation, increased myocardial oxygen demand, and diminished organ perfusion. Additionally, atherosclerotic coronary arteries
may limit blood flow to the myocardium, creating a higher risk of developing myocardial ischemia or infarction.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 967
TOP: Gerontology
2. An 82-year-old patient was admitted for pneumonia. The nurse knows that there are a number of age-related pulmonary changes
that may affect this patient. What change would the nurse expect to find?
a. Increased tidal volumes
b. Weakening of intercostal muscles and the diaphragm
c. Improved cough reflex
d. Decreased sensation of the glottis
ANS: B
Respiratory muscle function is affected by skeletal muscle and peripheral muscle strength. During aging, skeletal muscle
progressively atrophies, and its energy metabolism decreases, which may partially explain the declining strength of the respiratory
muscles.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 971
TOP: Gerontology
3. A 68-year-old patient was admitted after an inferior myocardial infarction (MI). Dopamine 3 mcg/kg/min has been ordered for this
patient. What nursing implications should be considered when administering this medication to an older patient?
a. No changes are noted in older patients with this drug.
b. Drug effect is enhanced by increased receptor site action.
c. Increased breakdown by liver hepatocytes occurs, increasing dosage
requirements.
d. Drug metabolism and detoxification are slowed, increasing the risks of drug
toxicity.
ANS: D
Reduced drug-metabolizing capacity is caused by a decline in activity of the drug-metabolizing enzyme system, microsomal
ethanol oxidizing system, and decrease in total liver blood flow. Medications that depend on the cytochrome P450 group of liver
enzymes are most affected because age-associated changes cause as much as a 50% decline in enzymatic function.
DIF: Cognitive Level: Applying
REF: p. 977
OBJ: Nursing Process Step: Intervention TOP: Gerontology
MSC: NCLEX: Physiologic Integrity
4. An 82-year-old patient was admitted after an inferior myocardial infarction. Why would the nurse need to provide increased
attention to the patient’s skin integrity?
a. There is thickening of the epidermal skin layer.
b. There is a loss of sebaceous glands.
c. There is loss of subcutaneous tissue.
d. There is decreased melanocyte production.
ANS: C
Ecchymotic areas may be seen because of decreased protective subcutaneous tissue layers, increased capillary fragility, and
flattening of the capillary bed, predisposing older adults to developing ecchymoses. Medications and physiologic factors may result
in an augmented bleeding tendency and appearance of ecchymotic areas; nevertheless, consideration should be given to the
possibility of older adult abuse if ecchymosis is widespread or in unusual areas.
DIF: Cognitive Level: Understanding
REF: p. 978
OBJ: Nursing Process Step: Intervention TOP: Gerontology
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
5. A 78-year-old patient was admitted after an inferior myocardial infarction. The patient awakens during the night confused and
disoriented. The nurse suspects the patient may be developing what condition?
a. Stroke
b. Neurocognitive decline
c. Delirium
d. Dementia
ANS: C
Delirium is characterized by acute changes in mental status from baseline, inattention, and disorganized thinking or changes in
level of consciousness. Risk factors for delirium include alterations in sleep-wake cycle, sepsis, hypoxemia, electrolyte imbalances,
metabolic alterations, and medications that induce delirium.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 974
TOP: Gerontology
6. An older patient is admitted to the hospital with an acute onset of mental changes and recent falls. What is the one of the most
common causes of mental changes in older patients?
a. Dementia
b. Infection
c. Stroke
d. Depression
ANS: B
Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual
need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or
medications are usually reversible after identification and treatment.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 974
TOP: Gerontology
7. An older patient is started on spironolactone to control hypertension. The nurse knows to monitor for what side effect?
a. Hyperkalemia
b. Irregular heart rate
c. Confusion
d. Pulmonary edema
ANS: A
Clinical considerations for mineralocorticoid antagonists (e.g., spironolactone, eplerenone) include that they are useful in
hypertension when combined with other agents, cause potassium retention, and are not associated with adverse metabolic effects.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 967 | p. 969 | Table 40-2
TOP: Gerontology
8. A nurse is teaching an older patient about the signs and symptoms of a myocardial infarction. Which statement by the patient would
indicate that the teaching was effective?
a. “The pain in my chest may last a long time.”
b. “I will feel like I have an elephant sitting on the center of my chest.”
c. “The chest pain will be sharp and over the center of my chest.”
d. “The pain may not be severe and may not be in my chest.”
ANS: D
Myocardial infarction in older adults is often associated with ST-segment depression rather than ST elevation. Sensation of chest
pain may be altered and may be less intense and of shorter duration. Other atypical symptoms may include dyspnea, confusion, and
failure to thrive, which result in unrecognized signs and symptoms of cardiac problems and delays in diagnosis and treatment.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 967
TOP: Gerontology
9. Which sign or symptom would be a normal assessment finding for an older patient?
a. Inability to remember what was eaten yesterday
b. An increase in resting heart rate
c. Hypoactive bowel sounds
d. Brisk papillary response to light
ANS: A
Some slight memory dysfunction is common with increasing age, but a significant decline may represent a change in individual
need and may be a result of acute or chronic conditions. Acute mental status changes caused by infection, metabolic imbalances, or
medications are usually reversible after identification and treatment.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 974
TOP: Gerontology
2
10. Which sound may be difficult for an older person to hear?
a. Telephone ringing
b. Clothes dryer running
c. Car horn honking
d. Child crying
ANS: B
Assessment of older adults in critical care should also include consideration of age-related changes such as vision impairment,
hearing deficits (particularly low- and high-pitched sounds), slight loss of taste or dentition, and diminished sense of smell.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 976
TOP: Gerontology
11. An older patient is admitted to the hospital with a hip fracture. Which nursing intervention would be a priority?
a. Encourage frequent deep breathing.
b. Administer stool softeners.
c. Perform neurologic checks.
d. Frequently offer liquids to drink.
ANS: A
Although all the items are important, age-related changes in respiratory mechanics lead to airflow restrictions, which are reflected
in decreased forced expiratory volume in 1 second (FEV1). Age-related decrease in dynamic lung volume is probably caused by
decreased chest wall compliance, small airways closure during forced expiration, and decreased strength of expiratory muscles.
Breathing exercises generate lung volumes of forced vital capacity, which is an untimed lung volume, and FEV 1, which is a timed
lung volume. These spirometry tests can assist in assessing restrictive respiratory patterns. Reduced timed lung volume is exhibited
in chronic obstructive pulmonary disease, asthma, bronchiectasis, and cystic fibrosis.
DIF: Cognitive Level: Analyzing
REF: p. 971 | p. 972
OBJ: Nursing Process Step: Intervention TOP: Gerontology
MSC: NCLEX: Physiologic Integrity
12. An older patient is starting a new medication that is metabolized in the liver and excreted by the kidneys. Which is the best
assessment to monitor the patient’s ability to tolerate the medication?
a. Liver function tests
b. Drug side effects experienced by the patient
c. Kidney function tests
d. Therapeutic drug levels
ANS: B
Adverse drug effects and medication interactions may be related to pharmacokinetics or the manner in which the body absorbs,
distributes, metabolizes, and excretes a drug. The aging process is associated with changes in gastric acid secretion, which can alter
ionization or solubility of a drug and hence its absorption. Medication distribution depends on body composition and on
physiochemical drug properties. With advancing age, a patient’s fat content increases, lean body mass decreases, and total body
water decreases, which can alter drug disposition.
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 978
TOP: Gerontology
13. An older patient is receiving a nephrotoxic medication. Which parameter would be a priority for the nurse to monitor?
a. Electrocardiogram
b. Lung sounds
c. Blood pressure
d. Level of consciousness
ANS: C
A decrease in number of nephrons does not affect renal function initially, but over time the older adult patient loses renal reserve,
and the aging kidney is unable to concentrate urine, excrete hydrogen, or maintain sodium/potassium balance. Additionally, the
elderly are at high risk for dehydration and are more vulnerable to injury from decreases in renal blood flow such as episodes of
hypotension leading to acute kidney injury (AKI) or from extreme changes in body fluid composition and acid–base balance.
DIF: Cognitive Level: Analyzing
REF: p. 976
OBJ: Nursing Process Step: Intervention TOP: Gerontology
MSC: NCLEX: Physiologic Integrity
14. Which sign or symptom can be a normal assessment finding for an older patient?
a. Asymptomatic dysrhythmias
b. Decreased urine output
c. Increased respiratory effort
d. Difficulty problem solving
ANS: A
The incidence of asymptomatic cardiac dysrhythmias increases in older patients. The most common dysrhythmia is the premature
ventricular contraction. Other common types are atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia and
atrioventricular conduction disturbances. All of the other findings are abnormal.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 966
TOP: Gerontology
3
15. Which parameter remains unchanged in an older person when he or she exercises?
a. Cardiac output
b. Heart rate
c. Blood pressure
d. Heart rhythm
ANS: A
An older individual’s ability to exercise may be limited by reduction in cardiac reserve, increased vascular afterload,
arterial–ventricular load mismatching, pulmonary function, reduced intrinsic myocardial contractility, impaired autonomic
regulation, and physical deconditioning.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 966
TOP: Gerontology
16. An older adult is placed on a continuous infusion of high-dose loop diuretic for diuresis. What finding would alert the nurse to the
presence of a possible adverse effect?
a. Tremors
b. Bradycardia
c. Electrolyte imbalance
d. Hypoglycemia
ANS: C
Side effects of loop diuretics include increased glucose, headaches, fever, and electrolyte disturbances.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation
MSC: NCLEX: Physiologic Integrity
REF: p. 969 | Table 40-2
TOP: Gerontology
17. What age-related change can affect the absorption of medications?
a. Decreased renal blood flow
b. Decreased red blood cells
c. Decreased splanchnic blood flow
d. Decreased gastric acid pH
ANS: C
Age-related changes associated with absorption include decreased splanchnic blood flow, decreased absorptive surface area of
small intestine and gastrointestinal motility, increased gastric acid pH, and changes in body skin/fat.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 979 | Table 40-4
TOP: Gerontology
18. What is the chemical change in a drug called that renders it active or inactive?
a. Absorption
b. Metabolism
c. Excretion
d. Distribution
ANS: B
Metabolism is the chemical change in a drug that renders it active or inactive. Absorption is the receptor-coupled or diffusional
uptake of drug into the tissue. Distribution is the theoretic space (tissue) or body compartment into which a free form of a drug
distributes. Excretion is the removal of a drug through an eliminating organ, often the kidneys; some drugs are excreted in bile or
feces, in saliva, or through the lungs.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 979 | Table 40-4
TOP: Gerontology
19. Which medications are considered an alternative to angiotensin-converting enzyme (ACE) inhibitors in older adult hypertension
patients with diabetes mellitus and heart failure (HF)?
a. Angiotensin-receptor blockers
b. Beta-blockers
c. Calcium antagonists
d. Direct renin inhibitors
ANS: A
Angiotensin-receptor blockers are considered first line and as an alternative to angiotensin-converting enzyme (ACE) inhibitors in
older adult patients with diabetes mellitus, hypertension, and heart failure (HF) who cannot tolerate ACE inhibitors.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 970 | Table 40-3
TOP: Gerontology
4
20. Which nonsteroidal antiinflammatory drug (NSAID) has the side effect of renal failure, hypertension (HTN), heart failure, and
gastrointestinal (GI) bleed in the elderly population?
a. Indomethacin
b. Ketorolac
c. Aspirin greater than 325 mg
d. Naproxen
ANS: D
Possible side effects of select nonsteroidal antiinflammatory drugs (NSAIDs) include the following. Indomethacin: central nervous
system (CNS) effects (highest of all NSAIDs); ketorolac: asymptomatic gastrointestinal conditions (ulcers); aspirin (>325 mg):
asymptomatic gastrointestinal conditions (ulcers); and naproxen: gastrointestinal bleeding, renal failure, high blood pressure, and
heart failure.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 970 | Table 40-3
TOP: Gerontology
21. The focus on the relief of a patient’s suffering, in all of its dimensions, is referred to as what type of care?
a. Aggressive
b. Comfort
c. Hospice
d. Palliative
ANS: D
Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient’s illness. Palliative
care specialists offer specialized medical care for people with serious illnesses.
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 979
TOP: Gerontology
MULTIPLE RESPONSE
1. Which age-related changes contribute to a higher risk for myocardial ischemia in an older patient? (Select all that apply, one, some,
or all.)
a. Increased diastolic filling pressures
b. Decreased intracellular free calcium
c. Thinning of the left ventricular wall
d. Increased myocardial collagen content
e. Increased myocardial oxygen consumption
ANS: A, D, E
Age-related changes include increased myocardial collagen, thickening of the left ventricular wall, increased diastolic filling
pressures, and increased myocardial oxygen consumption.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiologic Integrity
REF: p. 967
TOP: Gerontologic Alterations and Management
2. Hospitalized critically ill older adults undergo a number of function changes each day they are in the hospital. What changes might
the nurse expect to see by day 3? (Select all that apply, one, some, or all.)
a. Decreased stroke volume
b. Orthostatic hypotension
c. Decreased heart rate
d. Decreased total lung capacity
e. Visible muscle weakness
ANS: A, B
Functional changes that occur in the critically ill hospitalized older adult include decreased stroke volume and cardiac output,
increased heart rate and cardiovascular workload, decreased plasma volume, and orthostatic hypotension. Visible muscle weakness
is evident on day 7.
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
REF: p. 979 | Table 40-5
TOP: Gerontologic Alterations and Management
3. Which factors contribute to diminished wound healing in the older adult? (Select all that apply, one, some, or all.)
a. Decreased cytokine production
b. Increased production of growth factor
c. Decreased inflammatory response
d. Decreased glucocorticoid secretion
e. Decreased cell proliferation
ANS: A, C, E
Wound healing is diminished because of decreased cytokine and growth factor production, diminished inflammatory response, and
reduction of cell proliferation.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 978
TOP: Gerontology
5
4. The nurse recognizes that there are numerous interventions that can decrease the negative physical, functional, and cognitive
long-term outcomes associated with critical illness. Identify a few of these interventions. (Select all that apply, one, some, or all.)
a. Avoid pharmacologic sleep agents.
b. Focus on planning for home.
c. Use restraints.
d. Use indwelling catheters.
e. Reduce noise at night.
ANS: A, B, E
Coordination of critical care interventions can decrease negative physical, functional, and cognitive long-term outcomes associated
with critical illness. Noise reduction at night, avoidance of pharmacologic sleep agents, and a focus on planning for home can
enhance orientation, decrease delirium, and improve long-term consequences of critical care.
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
REF: p. 974 | p. 979
TOP: Gerontology
6
Chapter 41: The Perianesthesia Patient
Urden: Critical Care Nursing, 9th Edition
MULTIPLE CHOICE
1. Which stage of general anesthesia begins with the initiation of an anesthetic agent and ends with loss of consciousness?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: A
Stage I, commonly called the stage of analgesia, begins with the initiation of an anesthetic agent and ends with the loss of
consciousness. This stage has been described as the lightest level of anesthesia and represents mild sensory and mental depression.
Patients can open their eyes on command, breathe normally, and maintain protective reflexes.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 983
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
2. Which stage of general anesthesia is known as surgical anesthesia?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: C
Stage III is the stage of surgical anesthesia. It is defined as lasting from the onset of regular pattern of breathing to cessation of
breathing. This is the goal for anesthesia because the response to surgical incision is absent. Patients experience a depression in all
elements of nervous system function.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 983
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
3. A patient is oversedated after receiving a benzodiazepine. Which medication would the nurse administer to reverse the effects of
the medication?
a. Naloxone
b. Neostigmine
c. Fentanyl
d. Flumazenil
ANS: D
Flumazenil antagonizes the sedative, amnesic, anxiolytic, and muscle-relaxant effects of benzodiazepines. It does not reverse
benzodiazepine-induced respiratory or cardiac depression. It is specific for the benzodiazepine receptors and therefore does not
reverse the effects of barbiturates or opiates.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 986 | p. 987
OBJ: Nursing Process Step: Evaluation
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
4. What are the effects of nitrous oxide?
a. Anesthesia, analgesia, and amnesia
b. Vasodilation, analgesia, and myocardial depression
c. Respiratory and cardiovascular depression
d. Bronchodilation, myocardial excitation, and muscle tremors
ANS: A
The effects of nitrous oxide include anesthetic and analgesic effects. There are minimal pulmonary, cardiac, or central nervous
system (CNS) effects. Nitric oxide also increases intracranial pressure and may be associated with amnesia.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 986 | Table 41-1
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
5. A nurse is administering a benzodiazepine to a patient to facilitate relaxation prior to surgery. Which benzodiazepine has a slow
onset of action and long duration?
a. Diazepam
b. Midazolam
c. Lorazepam
d. Droperidol
ANS: C
Lorazepam has a slow onset of action and long duration. Diazepam has rapid onset and a long half-life. Midazolam has a rapid
onset and short duration. Droperidol is a butyrophenone.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 987 | Table 41-2
OBJ: Nursing Process Step: Planning
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
1
6. A patient was oversedated and required a dose of naloxone. How long would the nurse expect the duration of action of the
medication to last?
a. 30 minutes to 1 hour
b. 1 to 4 hours
c. 4 to 6 hours
d. 6 to 10 hours
ANS: B
Naloxone is diluted and then titrated to the patient’s response, minimizing the risk of rapid reversal and subsequent adverse effects.
The onset of action is 1 to 2 minutes, and the duration of action is 1 to 4 hours. If adequate reversal has not been achieved after 3 to
5 minutes, naloxone administration is repeated until reversal is complete.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 986
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
7. The nurse is assisting with intubation of a patient. Which depolarizing skeletal muscle relaxant medication would the nurse
anticipate being given to the patient?
a. Succinylcholine
b. Pancuronium
c. Mivacurium
d. Rocuronium
ANS: A
The principal depolarizing skeletal muscle agent is succinylcholine (Anectine). When the succinylcholine attaches to the receptor, a
brief period of depolarization occurs, which is manifested by transient muscular fasciculations. Succinylcholine has a rapid onset,
30 to 60 seconds, and a short duration of action, 5 to 10 minutes.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 988
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
8. The nurse is caring for a patient who has just returned from surgery. The nurse is monitoring the patient’s heart rhythm. In the
postoperative period, when do dysrhythmias often occur?
a. During the first minute
b. During the first 2 minutes
c. During the first 5 minutes
d. At any time
ANS: D
Electrocardiographic monitoring is essential in the immediate postoperative recovery period. Dysrhythmias of any type may occur
at any time and in any patient during the postoperative period.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 992
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
9. The nurse is caring for a patient immediately after surgery. The patient is requesting something to drink. The nurse knows that oral
intake is prohibited after anesthesia until what occurs?
a. The patient is ambulatory.
b. The patient is strong enough to hold a cup of water.
c. All nausea has ceased.
d. Laryngeal and pharyngeal reflexes are fully regained.
ANS: D
Oral intake is prohibited after anesthesia until the patient regains laryngeal and pharyngeal reflexes. These reflexes are
demonstrated by the patient’s ability to gag and swallow effectively. In addition, the management of postoperative nausea and
vomiting remains critical.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 992
OBJ: Nursing Process Step: Planning
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
10. Nursing management of a patient in the immediate postoperative period includes implementation of the stir-up regimen. What
actions are parts of the stir-up regimen?
a. Deep-breathing exercises, suctioning, warming, and nausea management
b. Incentive spirometry, abdominal breathing, warming, drinking, and pain
management
c. Incentive spirometry, coughing, suctioning, warming, mobilization, and eating
d. Deep-breathing exercises, coughing, positioning, mobilization, and pain
management
ANS: D
The basics of the regimen are aimed at the prevention of complications, primarily atelectasis and venous stasis. Five major
activities—deep-breathing exercises, coughing, positioning, mobilization, and pain management—constitute the stir-up regimen.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 990
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
2
11. In the postanesthesia care unit, how often would the nurse stimulate the patient to take three to four deep breaths?
a. 1 to 2 minutes
b. 3 to 5 minutes
c. 5 to 10 minutes
d. 30 to 60 minutes
ANS: C
The major factor contributing to postoperative pulmonary complications is low lung volumes resulting from a shallow,
monotonous, sighless breathing pattern caused by general anesthesia, pain, and opioids. Therefore, the patient must be stimulated to
take three or four deep breaths every 5 to 10 minutes.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 990 | p. 991
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
12. The nurse is teaching a patient how to do the sustained maximal inspiration (SMI) maneuver. Which instruction to the patient is
correct?
a. Take a deep breath and hold it for 3 to 5 seconds before exhaling.
b. Take a slow deep breath and then forcefully exhale.
c. Take a deep breath and, at the peak of inspiration, expand the chest and take in a
little more air.
d. Take a slow deep breath and then exhale slowly.
ANS: A
The sustained maximal inspiration (SMI) maneuver is a method to enhance the lung volumes of postoperative patients. The patient
inhales as close to lung capacity as possible and, at the peak of inspiration, the patient holds that volume for 3 to 5 seconds before
exhalation.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 991
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
13. The coughing maneuver in which a patient takes a deep breath and then performs multiple coughs on exhalation of that breath is
known as what type of cough?
a. Serial
b. Cascade
c. Sustained maximal
d. Deep
ANS: B
In cascade cough, the patient is instructed to take a rapid, deep inhalation to the volume of air in the lungs and dilate the airways,
allowing air to pass behind the retained secretions. On exhalation, the patient performs multiple coughs. With each cough, the
length of the airways increases, enhancing the effectiveness of the cough.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 991
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
14. The nurse is caring for a patient who has developed laryngospasm. What action should the nurse take first?
a. Assist with intubation and then provide manual ventilation with 100% oxygen.
b. Hyperextend the patient’s head and administer positive-pressure ventilations on
c.
d.
100% oxygen.
Administer 10 mg of succinylcholine.
Administer nebulized racemic epinephrine.
ANS: B
Management is initiated by removing the stimulus along with any irritants such as secretions, blood, or an artificial airway that is
too long. The patient’s head must be hyperextended and a positive-pressure mask ventilation instituted on 100% oxygen. The
anesthesiologist is notified immediately. If complete obstruction is unrelieved by positive-pressure ventilations, a small dose of
succinylcholine (10 to 20 mg) may be needed to relax the vocal cords to allow for ventilation. Positive-pressure mask ventilation is
continued until full muscle function has resumed. Endotracheal intubation is required if the laryngospasm persists or if refractory
hypoxemia develops, even though it may cause further irritation of the airways. Medications that may be used in the treatment of
laryngospasm include lidocaine, steroids, and atropine.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 996
OBJ: Nursing Process Step: Planning
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
15. A patient returns from the surgical suite and is hypothermic. The nurse understands that hypothermia can lead to which problem?
a. Acute kidney failure
b. Metabolic alkalosis
c. Hypotension
d. Delayed emergence
ANS: D
Significant hypothermia slows metabolic processes, leading to reduced drug biotransformation and impaired renal transport. This
may prolong drug effects and delay emergence.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 999
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
3
16. The nurse is caring for a postoperative patient who is complaining of being cold and shivering. The patient’s temperature is normal.
The nurse understands that shivering can occur in the normothermic patient for what reason?
a. Dehydration
b. Delayed response to being hypothermic during surgery
c. Effects of anesthetic agents
d. Anxiety
ANS: C
The normothermic patient may shiver or complain of feeling cold, so warm blankets may provide psychological comfort. Shivering
may be a result of either the compensatory response to hypothermia or the effects of anesthetic agents, and it can produce a 500%
increase in the metabolic rate.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 995
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
17. The nurse is caring for a postoperative patient who is snoring and has stridor, nostril flaring, and intercostal retractions. The nurse
knows that these findings are clinical manifestations of what problem?
a. Angina
b. Airway obstruction
c. Pain
d. Oversedation
ANS: B
Clinical manifestation of airway obstruction includes snoring, stridor, flaring of the nostrils, retractions at the intercostal spaces and
suprasternal notch, abnormal use of accessory muscles, asynchronous movements of the chest and abdomen, increased pulse rate,
decreased oxygen saturation level, and decreased breath sounds.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 995
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
18. A postoperative patient has developed laryngeal edema. What medication would the nurse anticipate being administered to the
patient?
a. Racemic epinephrine
b. Succinylcholine
c. Albuterol
d. Morphine
ANS: A
Management consists of placing the patient in the upright position; using cool, humidified oxygen; and administering nebulized
racemic epinephrine. Reintubation is performed only if the patient’s symptoms cannot be controlled with an inhalation treatment
within 30 minutes, hypercarbia persists, or the patient appears to be in respiratory distress.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 995
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
19. A postoperative patient has developed laryngospasm. What medication would the nurse anticipate being administered to the
patient?
a. Racemic epinephrine
b. Succinylcholine
c. Albuterol
d. Morphine
ANS: B
If complete obstruction is unrelieved by positive-pressure ventilation, a small dose of succinylcholine (10 to 20 mg) may be needed
to relax the vocal cords to allow for ventilation.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 996
OBJ: Nursing Process Step: Planning
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
20. A postoperative patient has developed bronchospasms. What medication would the nurse anticipate being administered to the
patient?
a. Racemic epinephrine
b. Methylprednisolone
c. Albuterol
d. Morphine
ANS: C
The first line of therapy consists of inhaled bronchodilators. These inhalants cause fewer cardiovascular side effects than
systemically administered drugs. Common inhalant medications used are isoetharine, metaproterenol, albuterol, and
beclomethasone.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 996
OBJ: Nursing Process Step: Planning
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
4
21. What is the most common cause of hypoxemia in the immediate postoperative period?
a. Pulmonary vasoconstriction
b. Airway obstruction
c. Intrapulmonary shunting
d. Ventilation/perfusion mismatching
ANS: D
The most common cause of hypoxemia is ventilation/perfusion mismatching. When functional residual capacity falls below closing
capacity, dependent alveoli occlude, leading to increased mismatching. Impairment of hypoxic pulmonary vasoconstriction by
inhalation agents and some vasoactive drugs potentiate this effect.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 997
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
22. Which medication has a direct myocardial depressant effect on the heart?
a. Ketamine
b. Barbiturates
c. Succinylcholine
d. Opioids
ANS: A
Ketamine has a direct myocardial depressant effect that is usually counterbalanced by its indirect effect on the autonomic nervous
system to increase heart rate and blood pressure. Succinylcholine stimulates the cholinergic receptors, enhancing vagal tone, and it
can produce sinus bradycardia or junctional escape rhythms. Opioids may cause bradycardia because of direct stimulation of the
vagus nerve. Barbiturates depress the activity of the vasomotor center, causing peripheral vasodilation and hypotension.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 997
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
23. When a patient emerges in a very restless state, what is the first problem the nurse must suspect?
a. Anxiety
b. Hypoxia
c. Pain
d. Gastric distention
ANS: B
When a nurse encounters a restless, confused postoperative patient, the first measure is to ensure that the agitation is not the result
of hypoxia.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 1000
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
24. When a patient develops postoperative hypertension, what potential cause would the nurse investigate?
a. Opioid administration
b. Fluid overload
c. Bladder distention
d. Dysrhythmias
ANS: B
Most commonly, postoperative hypertension is related to fluid overload, heightened sympathetic nervous system activity, or
preexisting hypertension. Postoperative hypertension, even as a transient episode, may have significant cardiovascular and
intracranial consequences, and therefore aggressive diagnosis and treatment are indicated.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 998
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
25. A patient emerges from general anesthesia screaming, shouting, and thrashing wildly. The nurse suspects the patient is
experiencing what problem?
a. Emergence hallucination
b. Emergence fever
c. Emergence hyperactivity
d. Emergence delirium
ANS: D
Some patients emerge from anesthesia in a state of excitement, a condition characterized by restlessness, disorientation, crying,
moaning, or irrational talking. In the extreme form of excitement, which is referred to as emergence delirium, the patient screams,
shouts, and thrashes about wildly.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 1001
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
5
26. What is the most definitive test for detecting malignant hyperthermia (MH) susceptibility?
a. Creatine phosphokinase (CPK) test
b. Ionized calcium test
c. Core temperature reading
d. Skeletal muscle biopsy
ANS: D
The most definitive test for detecting malignant hyperthermia (MH) susceptibility is a biopsy of skeletal muscle. The skeletal
muscle of an MH-susceptible patient has an increased isometric tension when exposed to caffeine or halothane. Measurement of
blood creatine phosphokinase (CPK) is usually about 70% reliable in determining susceptibility to MH.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 1000
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
27. What is the most effective treatment of postoperative nausea and vomiting?
a. Prevention
b. Droperidol given immediately when nausea is reported
c. Phenergan given immediately when nausea is reported
d. Metoclopramide given immediately when nausea is reported
ANS: A
The most effective treatment of postoperative nausea and vomiting is prevention. Avoidance of gastric insufflation is paramount. In
addition, the swallowing of blood during oral, pharyngeal, or nasal surgery should be prevented. Distention is decompressed
intraoperatively.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 1002
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
28. A postoperative patient is experiencing delayed arousal after a transurethral prostatectomy. To assist with finding the cause, the
nurse would assess the patient’s laboratory values for which finding?
a. Hypercalcemia
b. Hyponatremia
c. Hyperkalemia
d. Hypermagnesemia
ANS: B
Severe electrolyte disturbances are most commonly seen after excessive water absorption during transurethral prostate surgery. The
subsequent dilution hyponatremia may manifest as sedation, coma, or hemiparesis. Dilution hyponatremia may also be seen after
the inappropriate release of antidiuretic hormone.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 1001
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
29. Nursing management of a postoperative patient who is experiencing prolonged vomiting might benefit from which intervention?
a. Withholding all pain medication until the nausea has subsided
b. Removing the nasogastric tube
c. Inserting an oral airway
d. Increasing intravenous fluids
ANS: D
Nursing management of a postoperative patient who is nauseated and vomiting includes increasing intravenous fluids.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 1002
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
30. A patient was transferred to the postanesthesia care unit from the operating room after the induction of halothane anesthesia. The
patient has no significant medical history. On admission, the patient appeared comatose and extremely diaphoretic, with severe
muscle rigidity and tremors. The patient’s vital signs were heart rate, 145 beats/min; monitor reveals sinus tachycardia; blood
pressure, 85/50 mm Hg; respiratory rate, 35 breaths/min; and temperature, 103.8° F. Arterial blood gases on 100% oxygen by
ventilator were PaO2, 70%; PaCO2, 35 mm Hg; pH, 7.21; HCO3, 16 mm Hg; and SaO2, 90%. Fluid resuscitation and vasoactive
therapy were started. Initial abnormal laboratory results were BUN, 66 mg/dL; sodium, 155 mEq/L; potassium, 5.5 mEq/L;
glucose, 68 mg/dL; creatinine, 2.4 mg/dL; and creatine phosphokinase, 1896 U/L. The nurse would anticipate a diagnosis of which
condition?
a. Noncardiogenic pulmonary edema
b. Sepsis
c. Malignant hyperthermia
d. Emergency delirium
ANS: C
Clinical manifestations of malignant hyperthermia include hypoxemia; metabolic acidosis; respiratory acidosis; hyperkalemia;
myoglobinuria; elevated creatine phosphokinase; tachycardia; tachypnea; ventricular dysrhythmias; cyanosis; skin mottling; fever
or hot, flushed skin; rigidity; profuse sweating; and unstable blood pressure.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 999 | p. 1000 | Box 41-8
OBJ: Nursing Process Step: Diagnosis
TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
6
31. The nurse suspects that a patient has aspirated. What action would the nurse take immediately?
a. Raise the head of the bed to a 45- to 90-degree angle.
b. Lower the bed and turn the head to the side.
c. Notify the physician and prepare to intubate the patient.
d. Call for chest radiography to verify aspiration.
ANS: B
If aspiration is suspected, management begins with lowering the patient’s head if possible. The patient is positioned to the side or
the head is turned to the side to permit gravity to pull secretions from the trachea. Management centers on promoting tissue
oxygenation by maintaining arterial oxygenation by means of continuous positive airway pressure (CPAP) and supplemental
oxygen. Positive-pressure ventilation by mask can be applied if the patient is awake and can protect his or her airway or by an
endotracheal tube if the patient cannot tolerate the mask or requires higher levels of airway pressure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 996
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
32. Management of an airway obstruction begins with immediate recognition and treatment. Place these nursing interventions in the
appropriate order for initial care of a postanesthesia patient with airway obstruction.
1. Positive-pressure mask ventilation
2. Head-tilt/chin-lift maneuver (nonreactive patient)
3. Insertion of oropharyngeal or nasopharyngeal airway
4. Intubation with mechanical intubation
5. Stimulation of the patient
a. 1, 2, 3, 5, 4
b. 5, 2, 3, 1, 4
c. 2, 3, 1, 5, 4
d. 4, 2, 3, 1, 5
ANS: B
Initially, stimulation may be all that is necessary to relieve the obstruction. In a nonreactive patient, use the head-tilt/chin-lift
maneuver to displace the tongue and open the airway. If unsuccessful, an oropharyngeal or nasopharyngeal airway is inserted. The
patient can also be turned on his or her side to a lateral position, which facilitates the displacement of the tongue and drainage of
secretions. If the obstruction is still unrelieved, positive-pressure mask ventilation, intubation, tracheotomy, or cricothyrotomy may
be required.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 995
OBJ: Nursing Process Step: Intervention TOP: Perianesthesia Management
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. The patient’s body temperature is 33° C. The patient is shivering and the nurse needs to initiate which interventions? (Select all
that apply, one, some, or all.)
a. Cover the patient with warm blankets.
b. Apply heat lamps.
c. Provide fluid and blood warming.
d. Apply supplemental oxygen.
e. Provide a thermal mattress.
ANS: C, D, E
If the patient’s body temperature is between 36° and 37° C, the patient can simply be covered with warmed blankets, and heat
lamps can be used to keep the patient adequately warm. If the patient’s body temperature is less than 36° C, rapid rewarming is
required to decrease the possible complications of hypothermia and the postanesthesia recovery time. Other methods of rewarming
are thermal mattresses, fluid and blood warming, and environmental warming. Supplemental oxygen may be needed to meet the
increased metabolic demand in shivering patients. Patients who are shivering may respond to a small dose of meperidine.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 999
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
2. What are the causes of a postoperative fever? (Select all that apply, one, some, or all.)
a. Medication reactions
b. Hypotension
c. Blood transfusion reaction
d. Pulmonary emboli
e. Atelectasis
ANS: A, C, D, E
Causes of postoperative fever include atelectasis, wound infection, abscess formation, fat emboli after bone trauma, medication
reactions, malignancy, silent aspiration, dehydration, blood transfusion reaction, central nervous system damage, urinary tract
infection, phlebitis, deep vein thrombosis, and pulmonary embolism.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 1000 | Box 41-7
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
7
3. Which of the following dysrhythmias are common in the postanesthetic period? (Select all that apply, one, some, or all.)
a. Ventricular tachycardia
b. Ventricular fibrillation
c. Supraventricular tachydysrhythmias
d. Sinus bradycardia
e. Premature ventricular contractions
ANS: A, C, D, E
In the immediate postanesthetic period, patients are predisposed to a variety of cardiac dysrhythmias. The most common
dysrhythmias are sinus tachycardia, sinus bradycardia, premature ventricular contractions, supraventricular tachycardia, and
ventricular tachycardia.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 997 | p. 998
OBJ: Nursing Process Step: Assessment TOP: Perianesthesia
MSC: NCLEX: Physiologic Integrity
Copyright © 2022, Elsevier Inc. All Rights Reserved.
8