Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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Table of Contents
Table of Contents
Chapter 01: Overview of Critical Care Nursing
Chapter 02: Patient and Family Response to the Critical Care Experience
Chapter 03: Ethical and Legal Issues in Critical Care Nursing
Chapter 04: Palliative and End-of-Life Care
Chapter 05: Comfort and Sedation
Chapter 06: Nutritional Therapy
Chapter 07: Dysrhythmia Interpretation and Management
Chapter 08: Hemodynamic Monitoring
Chapter 09: Ventilatory Assistance
Chapter 10: Rapid Response Teams and Code Management
Chapter 11: Organ Donation
Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Chapter 13: Cardiovascular Alterations
Chapter 14: Nervous System Alterations
Chapter 15: Acute Respiratory Failure
Chapter 16: Acute Kidney Injury
Chapter 17: Gastrointestinal Alterations
Chapter 17: Hematological and Immune Disorders
Chapter 19: Endocrine Alterations
Chapter 20: Trauma and Surgical Management
Chapter 21: Burns
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Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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Chapter 01: Overview of Critical Care Nursing
MULTIPLE CHOICE
1. Which of the following professional organizations best supports critical care nursing practice?
a.
American Association of Critical-Care Nurses
b.
American Heart Association
c.
American Nurses Association
d.
Society of Critical Care Medicine
ANS: A
The American Association of Critical-Care Nurses is the specialty organization that supports and represents
critical care nurses. The American Heart Association supports cardiovascular initiatives. The American Nurses
Association supports all nurses. The Society of Critical Care Medicine represents the multiprofessional critical
care team under the direction of an intensivist.
DIF: Cognitive Level: Knowledge REF: p. 4
OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.
TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
2. A nurse has been working as a staff nurse in the surgical intensive care unit for 2 years and is interested in
certification. Which credential would be most applicable for her to seek?
a.
ACNPC
b.
CCNS
c.
CCRN
d.
PCCN
ANS: C
The CCRN certification is appropriate for nurses in bedside practice who care for critically ill patients. The
ACNPC certification is for acute care nurse practitioners. The CCNS certification is for critical care clinical
nurse specialists. The PCCN certification is for staff nurses working in progressive care, intermediate care, or
step-down unit settings.
DIF: Cognitive Level: Application REF: p. 5
OBJ: Explain certification options for critical care nurses. TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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3. The main purpose of certification is to:
a.
assure the consumer that you will not make a mistake.
b.
prepare for graduate school.
c.
promote magnet status for your facility.
d.
validate knowledge of critical care nursing.
ANS: D
Certification assists in validating knowledge of the field, promotes excellence in the profession, and helps
nurses to maintain their knowledge of critical care nursing. Certification helps to assure the consumer that the
nurse has a minimum level of knowledge; however, it does not ensure that care will be mistake-free.
Certification does not prepare one for graduate school; however, achieving certification demonstrates
motivation for achievement and professionalism. Magnet facilities are rated on the number of certified nurses;
however, that is not the purpose of certification.
DIF: Cognitive Level: Analysis REF: pp. 4-5
OBJ: Explain certification options for critical care nurses. TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
4. The synergy model of practice focuses on:
a.
allowing unrestricted visiting for the patient 24 hours each day.
b.
holistic and alternative therapies.
c.
needs of patients and their families, which drives nursing competency.
d.
patients needs for energy and support.
ANS: C
The synergy model of practice states that the needs of patients and families influence and drive competencies
of nurses. Nursing practice based on the synergy model would involve tailored visiting to meet the patients and
familys needs and application of alternative therapies if desired by the patient, but that is not the primary focus
of the model.
DIF: Cognitive Level: Application REF: p. 5 | Fig. 1-3
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
5. The family of your critically ill patient tells you that they have not spoken with the physician in over 24
hours and they have some questions that they want clarified. During morning rounds, you convey this concern
to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room.
Which competency of critical care nursing does this represent?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Advocacy and moral agency in solving ethical issues
b.
Clinical judgment and clinical reasoning skills
c.
Collaboration with patients, families, and team members
d.
Facilitation of learning for patients, families, and team members
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ANS: C
Although one might consider that all of these competencies are being addressed, communication and
collaboration with the family and physician best exemplify the competency of collaboration.
DIF: Cognitive Level: Analysis REF: p. 9
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
6. The AACN Standards for Acute and Critical Care Nursing Practice use what framework to guide critical
care nursing practice?
a.
Evidence-based practice
b.
Healthy work environment
c.
National Patient Safety Goals
d.
Nursing process
ANS: D
The AACN Standards for Acute and Critical Care Nursing Practice delineate the nursing process as applied to
critically ill patients: collect data, determine diagnoses, identify expected outcomes, develop a plan of care,
implement interventions, and evaluate care. AACN promotes a healthy work environment, but this is not
included in the Standards. The Joint Commission has established National Patient Safety Goals, but these are
not the AACN Standards.
DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
7. The charge nurse is responsible for making the patient assignments on the critical care unit. She assigns the
experienced, certified nurse to care for the acutely ill patient with sepsis who also requires continuous renal
replacement therapy and mechanical ventilation. She assigns the nurse with less than 1 year of experience to
two patients who are more stable. This assignment reflects implementation of the:
a.
crew resource management model
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
National Patient Safety Goals
c.
Quality and Safety Education for Nurses (QSEN) model
d.
synergy model of practice
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ANS: D
This assignment demonstrates nursing care to meet the needs of the patient. The synergy model notes that the
nurse competencies are matched to the patient characteristics. Crew resource management concepts related to
team training, National Patient Safety Goals are specified by The Joint Commission to promote safe care but
do not incorporate the synergy model. The Quality and Safety Education for Nurses initiative involves targeted
education to undergraduate and graduate nursing students to learn quality and safety concepts.
DIF: Cognitive Level: Analysis REF: p. 5 | Fig. 1-3
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
8. The vision of the American Association of Critical-Care Nurses is a healthcare system driven by:
a.
a healthy work environment.
b.
care from a multiprofessional team under the direction of a critical care physician.
c.
the needs of critically ill patients and families.
d.
respectful, healing, and humane environments.
ANS: C
The AACN vision is a healthcare system driven by the needs of critically ill patients and families where critical
care nurses make their optimum contributions. AACN promotes initiatives to support a healthy work
environment as well as respectful and healing environments, but that is not the organizations vision. The
SCCM promotes care from a multiprofessional team under the direction of a critical care physician.
DIF: Cognitive Level: Knowledge REF: p. 4
OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.
TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
9. The most important outcome of effective communication is to:
a.
demonstrate caring practices to family members.
b.
ensure that patient teaching is done.
c.
meet the diversity needs of patients.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
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reduce patient errors.
ANS: D
Many errors are directly attributed to faulty communication. Effective communication has been identified as an
essential strategy to reduce patient errors and resolve issues related to patient care delivery. Communication
may demonstrate caring practices, be used for patient/family teaching, and address diversity needs; however,
the main outcome of effective communication is patient safety.
DIF: Cognitive Level: Knowledge REF: pp. 8-9
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
10. You are caring for a critically ill patient whose urine output has been low for 2 consecutive hours. After a
thorough patient assessment, you call the intensivist with the following report. Dr. Smith, Im calling about
Mrs. P., your 65-year-old patient in CCU 10. Her urine output for the past 2 hours totaled only 40 mL. She
arrived from surgery to repair an aortic aneurysm 4 hours ago and remains on mechanical ventilation. In the
past 2 hours, her heart rate has increased from 80 to 100 beats per minute and her blood pressure has
decreased from 128/82 to 100/70 mm Hg. She is being given an infusion of normal saline at 100 mL per hour.
Her right atrial pressure through the subclavian central line is low at 3 mm Hg. Her urine is concentrated. Her
BUN and creatinine levels have been stable and in normal range. Her abdominal dressing is dry with no
indication of bleeding. My assessment suggests that Mrs. P. is hypovolemic and I would like you to consider
increasing her fluids or giving her a fluid challenge. Using the SBAR model for communication, the
information the nurse gives about the patients history and vital signs is:
a.
Situation
b.
Background
c.
Assessment
d.
Recommendation
ANS: B
The history and vital signs are part of the background. Information regarding the low urine output is the
situation. Information regarding possible hypovolemia is part of the nurses assessment, and the suggestion for
fluids is the recommendation.
DIF: Cognitive Level: Analysis REF: pp. 8-9
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
11. The family members of a critically ill, 90-year-old patient bring in a copy of the patients living will to the
hospital, which identifies the patients wishes regarding health care. You discuss contents of the living will with
the patients physician. This is an example of implementation of which of the AACN Standards of Professional
Performance?
a.
Acquires and maintains current knowledge of practice
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Acts ethically on the behalf of the patient and family
c.
Considers factors related to safe patient care
d.
Uses clinical inquiry and integrates research findings in practice
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ANS: B
Discussing end-of-life issues is an example of a nurse acting ethically on behalf of the patient and family. The
example does not relate to acquiring knowledge, promoting patient safety, or using research in practice.
DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2
OBJ: Describe standards of care and performance for critical care nursing.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
12. Which of the following assists the critical care nurse in ensuring that care is appropriate and based on
research?
a.
Clinical practice guidelines
b.
Computerized physician order entry
c.
Consulting with advanced practice nurses
d.
Implementing Joint Commission National Patient Safety Goals
ANS: A
Clinical practice guidelines are being implemented to ensure that care is appropriate and based on research.
Some physician order entry pathways, but not all, are based on research recommendations. Some advanced
practice nurses, but not all, are well versed in evidence-based practices. The National Patient Safety Goals are
recommendations to reduce errors using evidence-based practices.
DIF: Cognitive Level: Analysis REF: p. 7
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
13. Comparing the patients current (home) medications with those ordered during hospitalization and
communicating a complete list of medications to the next provider when the patient is transferred within an
organization or to another setting are strategies to:
a.
improve accuracy of patient identification.
b.
prevent errors related to look-alike and sound-alike medications.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
reconcile medications across the continuum of care.
d.
reduce harms associated with administration of anticoagulants.
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ANS: C
These are steps recommended in the National Patient Safety Goals to reconcile medications across the
continuum of care. Improving accuracy of patient identification is another National Patient Safety Goal.
Preventing errors related to look-alike and sound-alike medications is done to improve medication safety, not
medication reconciliation. Reducing harms associated with administration of anticoagulants is another National
Patient Safety Goal.
DIF: Cognitive Level: Comprehension REF: p. 6 | Box 1-3
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
14. As part of nursing management of a critically ill patient, orders are written to keep the head of the bed
elevated at 30 degrees, awaken the patient from sedation each morning to assess readiness to wean from
mechanical ventilation, and implement oral care protocols every 4 hours. These interventions are done as a
group to reduce the risk of ventilator-associated pneumonia. This group of evidence-based interventions is
often called a:
a.
bundle of care.
b.
clinical practice guideline.
c.
patient safety goal.
d.
quality improvement initiative.
ANS: A
A group of evidence-based interventions done as a whole to improve outcomes is termed a bundle of care. This
is an example of the ventilator bundle. Oftentimes these bundles are derived from clinical practice guidelines
and are monitored for compliance as part of quality improvement initiatives. At some point, these may become
part of patient safety goals.
DIF: Cognitive Level: Analysis REF: p. 6
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
15. You work in an intermediate care unit that has experienced high nursing turnover. The nurse manager is
often considered to be an autocratic leader by staff members and her leadership style is contributing to
turnover. You have asked to be involved in developing new guidelines to prevent pressure ulcers in your
patient population. The nurse manager tells you that you do not yet have enough experience to be on the
prevention task force. This situation and setting is an example of:
a.
a barrier to handoff communication.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
a work environment that is unhealthy.
c.
ineffective decision making.
d.
nursing practice that is not evidence-based.
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ANS: B
These are examples of an unhealthy work environment. A healthy work environment values communication,
collaboration, and effective decision making. It also has authentic leadership. It is not an example of handoff
communication, which is communication that occurs to transition patient care from one staff member to
another. Neither does it relate to ineffective decision making. As a nurse, you can still implement evidencebased practice, but your influence in the unit is limited by the unhealthy work environment.
DIF: Cognitive Level: Analysis REF: p. 7
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
16. Which of the following statements describes the core concept of the synergy model of practice?
a.
All nurses must be certified in order to have the synergy model implemented.
b.
Family members must be included in daily interdisciplinary rounds.
c.
Nurses and physicians must work collaboratively and synergistically to influence care.
d.
Unique needs of patients and their families influence nursing competencies.
ANS: D
The synergy model of practice is care based on the unique needs and characteristics of the patient and family
members. Although critical care certification is based on the synergy model, the model does not specifically
address certification. Inclusion of family members into the daily rounds is an example of implementation of the
synergy model. With the focus on patients and family members with nurse interaction, the synergy model does
not address physician collaboration.
DIF: Cognitive Level: Application REF: p. 5 | Fig. 1-3
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
17. A nurse who plans care based on the patients gender, ethnicity, spirituality, and lifestyle is said to:
a.
be a moral advocate.
b.
facilitate learning.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
respond to diversity.
d.
use clinical judgment.
10
ANS: C
Response to diversity considers all of these aspects when planning and implementing care. A moral agent helps
resolve ethical and clinical concerns. Consideration of these factors does not necessarily facilitate learning.
Clinical judgment uses other factors as well.
DIF: Cognitive Level: Comprehension REF: p. 3 | Box 1-1
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. Which of the following is a National Patient Safety Goal? (Select all that apply.)
a.
Accurately identify patients.
b.
Eliminate use of patient restraints.
c.
Reconcile medications across the continuum of care.
d.
Reduce risks of healthcare-acquired infection.
ANS: A, C, D
All except for eliminating use of restraints are current National Patient Safety Goals. Hospitals have policies
regarding use of restraints and are attempting to reduce the use of restraints; however, this is not a National
Patient Safety Goal.
DIF: Cognitive Level: Analysis REF: p. 6 | Box 1-3
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
2. Which of the following is (are) official journal(s) of the American Association of Critical-Care Nurses?
(Select all that apply.)
a.
American Journal of Critical Care
b.
Critical Care Clinics of North America
c.
Critical Care Nurse
d.
Critical Care Nursing Quarterly
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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ANS: A, C
American Journal of Critical Care and Critical Care Nurse are two official AACN publications. Critical Care
Clinics and Critical Care Nursing Quarterly are not AACN publications.
DIF: Cognitive Level: Knowledge REF: p. 4
OBJ: Discuss the purposes and functions of the professional organizations that support critical care practice.
TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
3. The first critical care units were: (Select all that apply.)
a.
burn units.
b.
coronary care units
c.
recovery rooms.
d.
neonatal intensive care units.
ANS: B, C
Recovery rooms and coronary care units were the first units designated to care for critically ill patients. Burn
and neonatal intensive care units were established as specialty units evolved.
DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: Define critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following nursing activities demonstrates implementation of the AACN Standards of
Professional Performance? (Select all that apply.)
a.
Attending a meeting of the local chapter of the American Association of Critical-Care Nurses in
which a continuing education program on sepsis is being taught
b.
Collaborating with a pastoral services colleague to assist in meeting spiritual needs of the patient
and family
c.
Participating on the units nurse practice council
d.
Posting an article from Critical Care Nurse on management of venous thromboembolism for your
colleagues to read
e.
Using evidence-based strategies to prevent ventilator-associated pneumonia
ANS: A, B, C, D, E
All answers are correct. Attending a program to learn about sepsisAcquires and maintains current
knowledge
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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and competency in patient care. Collaborating with pastoral servicesCollaborates with the healthcare team to
provide care in a healing, humane, and caring environment. Posting information for othersContributes to the
professional development of peers and other healthcare providers. Nurse practice councilProvides leadership
in the practice setting. Evidence-based practicesUses clinical inquiry in practice.
DIF: Cognitive Level: Analysis REF: p. 5 | Box 1-2
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
5. Which scenarios contribute to effective handoff communication at change of shift? (Select all that apply.)
a.
The nephrology consultant physician is making rounds and asks you to update her on the patients
status and assist in placing a central line for hemodialysis.
b.
The noise level is high because twice as many staff members are present and everyone is giving
report in the nurses station.
c.
The unit has decided to use a standardized checklist/tool for change-of-shift reports and patient
transfers.
d.
You and the oncoming nurse conduct a standardized report at the patients bedside and review key
assessment findings.
ANS: C, D
A reporting tool and bedside report improve handoff communication by ensuring standardized communication
and review of assessment findings. Conducting report at the bedside also reduces noise that commonly occurs
at the nurses station during a change of shift. The nephrologist has created an interruption that can impede
handoff with the next nurse. Likewise, noise in the nurses station can cause distractions that can impair
concentration and listening.
DIF: Cognitive Level: Analysis REF: p. 8-9
OBJ: Describe quality and safety initiatives related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
6. Which strategy is important to addressing issues associated with the aging workforce? (Select all that apply.)
a.
Allowing nurses to work flexible shift durations
b.
Encouraging older nurses to transfer to an outpatient setting that is less stressful
c.
Hiring nurse technicians that are available to assist with patient care, such as turning the patient
d.
Remodeling patient care rooms to include devices to assist in patient lifting
ANS: A, C, D
Modifying the work environment to reduce physical demands is one strategy to assist the aging workforce.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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Examples include overhead lifts to prevent back injuries. Twelve-hour shifts can be quite demanding;
therefore, allowing nurses flexibility in choosing shifts of shorter duration is a good option as well. Adequate
staffing, including non-licensed assistive personnel, to help with nursing and non-nursing tasks is helpful.
Encouraging experienced, knowledgeable critical care nurses to leave the critical care unit is not wise as the
unit loses the expertise of this group.
DIF: Cognitive Level: Analysis REF: p. 11
OBJ: Identify current trends and issues in critical care nursing. TOP: Nursing Process Step: N/A
MSC: NCLEX: Safe and Effective Care Environment
7. Which of the following strategies will assist in creating a healthy work environment for the critical care
nurse? (Select all that apply.)
a.
Celebrating improved outcomes from a nurse-driven protocol with a pizza party
b.
Implementing a medication safety program designed by pharmacists
c.
Modifying the staffing pattern to ensure a 1:1 nurse/patient ratio
d.
Offering quarterly joint nurse-physician workshops to discuss unit issues
e.
Using the Situation-Background-Assessment-Recommendation (SBAR) technique for handoff
communication
ANS: A, D, E
Meaningful recognition, true collaboration, and skilled communication are elements of a healthy work
environment. Implementing a medication safety program enhances patient safety, and if done without nursing
input, could have negative outcomes. Staffing should be adjusted to meet patient needs and nurse
competencies, not have predetermined ratios that are unrealistic and possibly not needed.
DIF: Cognitive Level: Analysis REF: p. 7
OBJ: Describe standards of professional practice for critical care nursing.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
14
Chapter 02: Patient and Family Response to the Critical Care
Experience
MULTIPLE CHOICE
1. Family members have a need for information. Which interventions best assist in meeting this need?
a.
Handing family members a pamphlet that explains all of the critical care equipment
b.
Providing a daily update of the patients progress and facilitating communication with the
intensivist
c.
Telling them that you are not permitted to give them a status report but that they can be present at
4:00 PM for family rounds with the intensivist
d.
Writing down a list of all new medications and doses and giving the list to family members during
visitation
ANS: B
The nurse can give a status report related to the patients condition and current treatment plan as well as ensure
that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like.
Pamphlets are helpful; however, the nurse should also explain the equipment that is at this patients bedside and
not assume that everyone can read and understand written material. Limiting the information to that provided
by the physician is unnecessary and will not meet the familys information needs. Most family members are
concerned about the patients general condition and treatment plan. They do not want or need a detailed list of
medications, doses, or other treatments.
DIF: Cognitive Level: Analysis REF: p. 20
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
2. The nurse is a member of a committee to design a critical care unit in a new building. Which design trend
would best to facilitate family-centered care?
a.
Ensure that the patients room is large enough and has adequate space for a sleeper sofa and storage
for family members personal belongings.
b.
Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel
far for testing.
c.
Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities
such as coffee and tea.
d.
Provide access to a scenic garden for meditation.
ANS: A
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
15
New unit design trends to promote family-centered care include larger patient rooms that include a larger
family space and comfortable furniture and storage to promote open visitation, including overnight stays in the
patients room. Ready access to diagnostic testing, including portable equipment, is an important trend;
however, the purpose for this is to prevent the need for transport, not to foster family-centered care. A waiting
room in close proximity to the unit with amenities is a nice feature; however, it does not need to be large if
adequate space is incorporated into the patients room. A scenic garden for medication may assist in reducing
family members stress, but proximity to the patient is the greatest need.
DIF: Cognitive Level: Analysis REF: Table 2-2
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
3. The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which
intervention is most appropriate while bathing the patient?
a.
Ask a family member to help you bathe the patient, and discuss the family structure with the family
member during the procedure.
b.
Because she is unconscious, complete care as quickly and quietly as possible.
c.
Tell the patient the day and time, and that you are bathing her. Reassure her that you are there.
d.
Turn the television on to the evening news so that you and the patient can be updated to current
events.
ANS: C
Although unconscious, many patients can hear, understand, and respond to stimuli. Therefore, it is important to
converse with the patient and reorient her to the environment. Some, but not all, family members may want to
get involved in direct care; it is not known if this individual is a willing participant, and talking about whos
who in the family is not appropriate while providing direct care to the patient. Although she is unconscious,
communication and simple conversations remain important interventions. Use of the television to provide
sensory input that the patient regularly enjoys is a nursing intervention, but turning on the news for the sake of
the nurse is not appropriate.
DIF: Cognitive Level: Application REF: p. 16
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
4. Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote
sleep and rest?
a.
Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between
intervals.
b.
Encourage family members to talk with the patient whenever they are present in the room.
c.
Keep the television on to provide white noise and distraction.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
16
Leave the lights on in the room so that the patient is not frightened of his or her surroundings.
ANS: A
Planning care to promote periods of uninterrupted rest is important. Consulting with the pharmacist to adjust a
medication schedule is an excellent example of this intervention. It is important for family members to
communicate with the patient; however, rest periods must be scheduled. Family members can be present in the
room while remaining quiet during these scheduled times. The television may be useful if it is part of the
patients normal routine for sleep; however, it does not consistently provide white noise or distraction. Lights
should be dimmed during scheduled rest periods and at night to facilitate sleep and rest.
DIF: Cognitive Level: Analysis REF: p. 16
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
5. Family assessment is essential in order to meet family needs. Which of the following must be assessed first
to assist the nurse in providing family-centered care?
a.
Assessment of patient and familys developmental stages and needs
b.
Description of the patients home environment
c.
Identification of immediate family, extended family, and decision makers
d.
Observation and assessment of how family members function with each other
ANS: C
Assessment of the family structure is the first step and is essential before specific interventions can be
designed. It identifies immediate family, extended family, and decision makers in the family. Structural
assessment also includes ethnicity and religion. The developmental assessment is done after the structural
assessment and includes the developmental stages of the patient and family. Functional assessment is also
important to assess how family members function with each other; however, it is not done first. Assessment of
the home environment is important when identifying discharge planning needs.
DIF: Cognitive Level: Analysis REF: pp. 17-18
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
6. Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest
conflict?
a.
A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides
with her mother. The parents are amicable with each other and have similar values. The father
blames the daughters boyfriend for causing the accident.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
17
b.
A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have written
advance directives. His parents arrive from out-of-state and are asked to make decisions about his
health care. He has not seen them in over a year.
c.
A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his samesex partner for 20 years in a committed relationship. He has designated his sister, a registered
nurse, as his healthcare proxy in a written advance directive.
d.
A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a
critical level. She is a Jehovahs Witness and refuses the treatment of a blood transfusion. She is
capable of making her own decisions and has a clearly written advance directive declining any
transfusions. Her son is upset with her and tells her she is committing suicide.
ANS: B
Each of these situations may result in family conflict. The situation with the unmarried couple without written
advance directives results in the distant parents being legally responsible for his healthcare decisions. Because
of his long-standing commitment with his partner, and lack of recent contact with his parents, this scenario is
likely to cause the most conflict. The parents may make decisions based on their wishes, as they may not be
knowledgeable of the patients wishes. The supportive parents of the college student may create conflict with
the boyfriend, but their ongoing friendship and shared values will assist in reducing conflict. The male
admitted for bypass surgery, although in a same-sex relationship, has clearly identified who he wants to make
healthcare decisions for him. The elderly female may have conflict with her son; however, she is capable of
making her own decisions and has written advance directives to support her decisions.
DIF: Cognitive Level: Analysis REF: pp. 17-18
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
7. Which nursing interventions would best support the family of a critically ill patient?
a.
Encourage family members to stay all night in case the patient needs them.
b.
Give a condition update each morning and whenever changes occur.
c.
Limit visitation from children into the critical care unit.
d.
Provide beverages and snacks in the waiting room.
ANS: B
The need for information is one of the highest identified by family members of critically ill patients. New room
designs provide space for family members to spend the night if desired; however, if the patient is stable, family
members should be encouraged to sleep at home to ensure that they are well rested and can support the patient.
Restriction of children in the critical care unit is not supported by research evidence. Child visitation should be
individualized based on the needs and wishes of the patient and family. Beverages and snacks are important
but not as important as information.
DIF: Cognitive Level: Analysis REF: Box 2-2
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
18
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
8. Which intervention is appropriate to assist the patient to cope with admission to the critical care unit?
a.
Allowing unrestricted visiting by several family members at one time
b.
Explaining all procedures in easy-to-understand terms
c.
Providing back massage and mouth care
d.
Turning down the alarm volume on the cardiac monitor
ANS: B
Communication and explanations of procedures are priority interventions to help patients cope with admission.
Comfort is an important intervention but not the priority. Noise control is an important intervention but not the
priority. Open visitation is recommended; however, the number of family members may need to be limited to
promote rest and sleep.
DIF: Cognitive Level: Analysis REF: pp. 20-21
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
9. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to:
a.
anxiety.
b.
pain.
c.
powerlessness.
d.
sensory overload.
ANS: D
Constant noise is a source of sensory overload. Pain and lack of information contribute to anxiety. Noise does
not cause physical pain. Lack of involvement in care causes powerlessness.
DIF: Cognitive Level: Application REF: pp. 14-15
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
10. Which of the following statements about family assessment is false?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Assessment of structure (who comprises the family) is the last step in assessment.
b.
Interaction among family members is assessed.
c.
It is important to assess communication among family members to understand roles.
d.
Ongoing assessment is important, because family functioning may change during the course of
illness.
19
ANS: A
Assessment of structure should be done first so that the nurse can identify such things as who comprises the
family and who assumes leadership and decision-making responsibilities. This assessment also assists in
identifying which individuals are most important to the patient and how many people may be seeking
information. Family member interaction must be assessed, so this answer is true. Family member
communication must be assessed, so this answer is true. Ongoing assessment of family is necessary as
functions may change, so this answer is true.
DIF: Cognitive Level: Application REF: pp. 16-17
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
11. Which intervention about visitation in the critical care unit is true?
a.
The majority of critical care nurses implement restricted visiting hours to allow the patient to rest.
b.
Children should never be permitted to visit a critically ill family member.
c.
Visitation that is individualized to the needs of patients and family members is ideal.
d.
Visiting hours should always be unrestricted.
ANS: C
Visiting should be based on the needs of patients and their families. There may be times that visiting needs to
be limited (e.g., to allow the patient to rest; however, it is important to individualize visitation. Sometimes it is
appropriate for children to visit; research has not found child visitation to be harmful to either the patient or the
child. Visiting should be adjusted to patient needs.
DIF: Cognitive Level: Analysis REF: pp. 21-22 | Box 2-2
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
12. Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or
decreased quality of life after hospitalization. Assuming each of these patients was discharged from the
hospital, which of the following patients is at greatest risk for decreased functional status and quality of life?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
20
a.
A 70-year-old who had coronary artery bypass surgery. He developed complications after surgery
and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and
gastrostomy. He is being discharged to a long-term, acute care hospital. He is a widower.
b.
A 79-year-old admitted for exacerbation of heart failure. She manages her care independently but
needed diuretic medications adjusted. She states that she is compliant with her medications but
sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves
to be independent and support each other.
c.
A 90-year-old admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF)
but is cognitively intact. He is the social butterfly at all of the events at the ALF. He is hospitalized
for 4 days and discharged to the ALF.
d.
An 84-year-old who had stents placed to treat coronary artery occlusion. She has diabetes that has
been managed, lives alone, and was driving prior to hospitalization. She was discharged home
within 3 days of the procedure.
ANS: A
Although he is younger, the 70-year-old with the complicated critical care course, with limited social support,
who is being discharged to a long-term acute care facility, is at greatest risk for decreased quality of life and
functional decline. He will continue to need high-level nursing care and support for rehabilitation. The other
cases are examples of individuals with shorter hospital stays, uncomplicated courses, and social support
systems.
DIF: Cognitive Level: Analysis REF: p. 17
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Growth and Development
13. Patients often have recollections of the critical care experience. Which is likely the most common
recollection from a patient who required endotracheal intubation and mechanical ventilation?
a.
Difficulty communicating
b.
Inability to get comfortable
c.
Pain
d.
Sleep disruption
ANS: A
Although the patient may recall all of these potential experiences, recollection of difficult communication is
most likely secondary to the endotracheal tube placement.
DIF: Cognitive Level: Analysis REF: p. 16 | Box 2-1
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
21
14. Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach?
a.
Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening.
You know that this is the best approach to ensure uninterrupted rest time for the patient. Tell the
patient, Mr. J., your family is in the waiting room. They will be permitted to come in at 2:00 PM
after you take a short nap.
b.
Explain the unit routine. Mr. J., assessments are done every 4 hours; patients are bathed on the
night shift around 5:00 AM; family members are permitted to visit you after the physicians make
their morning rounds. They can spend the day. Lights are out every night at 10:00 PM.
c.
State, Mr. J., its time to turn you. I am going to ask another nurse to come in and help me. We will
turn you to your left side. During the turn, Im going to inspect the skin on your back and rub some
lotion on your back. This should help to make you feel better.
d.
Suction Mr. J.s endotracheal tube immediately when he starts to cough. Tell him, Mr. J., your tube
needs suctioned; you should feel better after Im done.
ANS: C
Anxiety is reduced when procedures are explained prior to completing them. In this example, the nurse clearly
explains what will be done and what the patient can expect during turning. Limiting family members,
especially if they are already present in the hospital, is not an approach that will reduce anxiety. Family
members can be present in the room while allowing the patient to rest. It is important to orient the patient to the
unit, but the explanation of a unit routine does not give the patient any control over things such as bathing,
sleep times, and visitors. Suctioning is important, but only when indicated, which might not be with every
coughing episode. Additionally, it is important to explain the procedure and tell the patient what to expect.
DIF: Cognitive Level: Analysis REF: pp. 16-17
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
15. Which statement is a likely response from someone who has survived a stay in the critical care unit?
a.
I dont remember much about being in the ICU, but if I had to be treated there again, it would be
okay. Im glad I can see my grandchildren again.
b.
If I get that sick again, do not take me to the hospital. I would rather die than go through having a
breathing tube put in again.
c.
My family is thrilled that I am home. I know I need some extra attention, but my children have
rearranged their schedules to help me out.
d.
Since I have been transferred out of the ICU, I cannot get enough to eat. They didnt let me eat in
the ICU, so Im making up for it now.
ANS: A
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
22
Survivors of critical illness express a variety of concerns; however, most identify a willingness to undergo
critical care treatment to prolong survival. Most survivors are not going to decline treatment for future
hospitalizations (B). Although the patients family may be thrilled that he or she is home, challenges to family
dynamics often occur, especially if family members schedules and routines are disrupted (C). Many patients
have poor appetites after discharge from critical care, not ravenous ones (D).
DIF: Cognitive Level: Analysis REF: p. 17
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
16. The nurse is assigned to care for a patient who is a non-native English speaker. What is the best way to
communicate with the patient and family to provide updates and explain procedures?
a.
Conduct a Google search on the computer to identify resources for the patient and family in their
native language. Print these for their use.
b.
Contact the hospitals interpreter service for someone to translate.
c.
Get in touch with one of the residents that you know is fluent in the native language and ask him if
he can come up to the unit.
d.
Use the 8-year old child who is fluent in both English and the native language to translate for you.
ANS: B
The best approach when communicating with someone whose primary language is not English is to contact the
interpreter services of the agency. These individuals are trained and knowledgeable. If the nurse conducted a
search on the computer, she would not know if the information retrieved was valid nor would she know if the
patient or family can read in their native language. Although one of the residents might be fluent in the
language, you do not know his abilities to translate. In addition, his availability is likely to be limited.
Although the child might be able to translate, the nurse cannot ensure that the child is translating healthcare
concepts correctly.
DIF: Cognitive Level: Analysis REF: p. 18
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
17. Family assessment can be challenging and each nurse may obtain additional information regarding family
structure and dynamics. What is the best way to share this information from shift to shift?
a.
Create an informal family information sheet that is kept on the bedside clipboard. That way,
everyone can review it quickly when needed.
b.
Develop a standardized reporting form for family information that is incorporated into the patients
medical record and updated as needed.
c.
Require that the charge nurse have a detailed list of information about each patient and family
member. Thus, someone on the unit is always knowledgeable about potential issues.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
23
Try to remember to discuss family structure and dynamics as part of the change-of-shift report.
ANS: B
A standardized method for gathering data about family structure and function and recording it in an official
document is the best approach. This strategy ensures that data are collected and kept in the medical record.
Data are also easily retrievable by anyone who needs to know this information. Informal documentation is
often kept to assist in follow-up and change-of-shift reporting; however, this strategy is not recommended, as
data collected are likely to vary and not be part of a permanent record. Although the charge nurse often has
some information regarding families, the primary responsibility for assessment and follow-up belongs to the
bedside nurse. Family information should be shared at change of shift using a standardized format, not try to
remember to discuss .
DIF: Cognitive Level: Analysis REF: p. 18
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
18. The wife of a patient who is hospitalized in the critical care unit following resuscitation for a sudden
cardiac arrest at work demands to meet with the nursing manager. She states, I want you to reassign my
husband to another nurse. His current nurse is not in the room enough to make sure he is okay. The nurse
recognizes that this response most likely is due to the wifes:
a.
desire to pursue a lawsuit if the assignment is not changed.
b.
inability to participate in the husbands care.
c.
lack of prior experience in a critical care setting.
d.
sense of loss of control of the situation.
ANS: D
Demanding behaviors often occur when the family member has a sense of loss of control or has had adverse
outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this scenario. No information
is provided regarding whether the family member is participating in care or not. It is not known if she had a
prior negative experience or not.
DIF: Cognitive Level: Analysis REF: pp. 17-18
OBJ: Discuss the impact of critical care hospitalization on the patient and family.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
19. Open visitation policies are expected by many professional organizations. Which statement reflects
adherence to current recommendations?
a.
Allow animals on the unit; however, these can only be therapy animals through the hospitals pet
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
24
therapy program.
b.
Allow family visitation throughout the day except at change of shift and during rounds.
c.
Determine, in collaboration with the patient and family, who can visit and when. Facilitate open
visitation policies.
d.
Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.
ANS: C
Open visitation is recommended by both the Society of Critical Care Medicine (SCCM) and the American
Association of Critical-Care Nurses. SCCM suggests developing visitation schedules in collaboration with the
patient and family. Animals do not need to be limited to therapy animals. Many patients benefit by the
presence of their personal pets that are brought to the unit according to hospital policy. Although many units
restrict visitation during report and rounds, the organizations encourage that such restrictions be loosened.
Many institutions encourage family participation during report and rounds. Children should not be banned
arbitrarily from the unit or have hours limited.
DIF: Cognitive Level: Analysis REF: pp. 21-22 | Box 2-2
OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
20. The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically
ill patients. Which of the following statements describes a VALUE strategy?
a.
View the family as guests on the unit.
b.
Acknowledge family emotions.
c.
Learn as much as you can about family structure and function.
d.
Use a trained interpreter if the family does not speak English.
e.
Evaluate each encounter with the family.
ANS: B
The VALUE mnemonic includes the following:
VValue what the family tells you.
AAcknowledge family emotions.
LListen to the family members.
UUnderstand the patient as a person.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
25
EElicit (ask) questions of family members.
DIF: Cognitive Level: Comprehension REF: pp. 20-21 | Box 2-3
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
21. Changing visitation policies can be challenging. The nurse manager recognizes the following as an
effective strategy for promoting changes in practice:
a.
Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked
to read one research article about visitation.
b.
Discuss pros and cons of open visitation at the next staff meeting.
c.
Invite the nurses with the most experience to develop a revised policy.
d.
Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the
current policy toward more liberal visitation.
ANS: D
Changes in policy are most effective through willing champions as part of a unit-based, staff-led practice
council. Discussion of evidence-based findings is important, but it is not logical to expect every nurse to read a
research article and share findings. Discussion of pros and cons at a staff meeting is likely to be prolonged and
based on opinion rather than evidence. Nurses with the most experience are not necessarily the ones to develop
a new policy. They may be the least likely to change; therefore, it is important to solicit volunteers from all
staff members, not just the experienced ones.
DIF: Cognitive Level: Analysis REF: pp. 21-22 | Box 2-2
OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.)
a.
asking the family to leave during the morning bath to promote the patients privacy.
b.
encouraging family members to make notes of questions they have for the physician during family
rounds.
c.
if possible, providing continuity of nursing care.
d.
providing a daily update of the patients condition to the family spokesperson.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
26
ANS: B, C, D
Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent
staff members assists in reducing stress. Communication of patient condition update meets the need for
information. Family members often want to assist with simple activities of patient care, so limiting
participation is the exception to this list.
DIF: Cognitive Level: Application REF: pp. 18-19
OBJ: Describe common family needs and family-centered nursing interventions.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
2. Family presence is encouraged during resuscitation and invasive procedures. The nurse knows that nurses
are often reluctant to allow this to occur, yet families often perceive benefits. Which findings have been
reported in the literature? (Select all that apply.)
a.
Families benefit by witnessing that everything possible was done.
b.
Families report reduced anxiety and fear about what is being done to the patient.
c.
Presence encourages family members to seek litigation for improper care.
d.
Presence reduces nurses involvement in explaining things to the family.
ANS: A, B
Families benefit from witnessing procedures and resuscitation. Being present helps family members to remove
doubt about the condition, witness that everything was done, and decrease anxiety about what is occurring.
Increased litigation has not been associated with family presence. Policies and procedures are needed to
facilitate family presence. A facilitator is needed, and it may initially require more nursing involvement. It
does not eliminate nurses responsibility for communicating with the family.
DIF: Cognitive Level: Analysis REF: p. 22
OBJ: Identify strategies for promoting visitation and family presence in the critical care setting.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
3. Noise in the critical care unit can have negative effects on the patient. Which of the following interventions
assists in reducing noise levels in the critical care setting? (Select all that apply.)
a.
Ask the family to bring in the patients i-Pod or other device with favorite music.
b.
Invite the volunteer harpist to play on the unit on a regular basis.
c.
Remodel the unit to have two-patient rooms to facilitate nursing care.
d.
Remodel the unit to install acoustical ceiling tiles.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
e.
27
Turn the volume of equipment alarms as low as they can be adjusted, and off if possible.
ANS: A, B, D
A personal device with favorite music and headphones can be helpful in reducing ambient unit noise. Music
therapy programs, such as harpists, can provide soothing sedative music that is often comforting to both
patients and family members. Acoustical tiles help to reduce noise in the critical care setting and should be
included in remodeling plans as well as new unit construction. Multiple patients in a single room would
increase noise levels and contribute to an increased risk of infection. Alarms on critical equipment must never
be turned off. The volume should be loud enough that the alarm can be heard by the nurse if outside the room.
The lowest setting may not be loud enough, depending on the unit layout and patient assignment.
DIF: Cognitive Level: Analysis REF: p. 15
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
4. It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in
the critical care setting? (Select all that apply.)
a.
Allow family members to remain at the bedside.
b.
Be sure to consult with the charge nurse before making any patient care decisions.
c.
Provide informal conversation by discussing your plans for after work.
d.
Respond promptly to call bells or other communication for assistance.
ANS: A, D
Patients feel safe when nurses exhibit technical competence, meet their needs, and provide reorientation.
Family member presence may also contribute to feeling safe. Consulting with the charge nurse before making
decisions may be interpreted as incompetence or insecurity. The nurses personal activities should never be
discussed with patients.
DIF: Cognitive Level: Analysis REF: p. 16
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
5. The critical care environment is often stressful to a critically ill patient. Identify stressors that are common.
(Select all that apply.)
a.
Alarms that sound from various devices
b.
Bright, fluorescent lighting
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Lack of day-night cues
d.
Sounds from the mechanical ventilator
e.
Visiting hours tailored to meet individual needs
28
ANS: A, B, C, D
Adjustment of visiting hours to meet needs of patients and families assists in reducing the stress of critical
illness. All other responses are environmental stressors that increase anxiety, affect sleep, and the like.
DIF: Cognitive Level: Comprehension REF: pp. 15-16
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
6. A patient and his family are excited that he is transferring from the critical care unit to the intermediate care
unit. However, they are also fearful of the change in environment and nursing staff. To reduce relocation stress,
the nurse can: (Select all that apply.)
a.
ask the nurses on the intermediate care unit to give the family a tour of the new unit.
b.
contact the intensivist to see if the patient can stay one additional day in the critical care unit so that
he and his family can adjust better to the idea of a transfer.
c.
ensure that the patient will be located near the nurses station in the new unit.
d.
invite the nurse who will be assuming the patients care to meet with the patient and family in the
critical care unit prior to transfer.
ANS: A, D
Patients often have stress when they are moved from the safety of the critical care unit. Introducing the patient
and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation
stress. Although the patient and his family may feel safer in a room near the nurses station, bed placement is
determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and
once the physician has determined that the patient no longer meets critical care admission requirements, it is
essential that transfers be made once a bed on the intermediate care unit is available.
DIF: Cognitive Level: Analysis REF: p. 17
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
7. The critical care environment is stressful to the patient. Which interventions assist in reducing this stress?
(Select all that apply.)
a.
Adjust lighting to promote normal sleep-wake cycles.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Provide clocks, calendars, and personal photos in the patients room.
c.
Talk to the patient about other patients you are caring for on the unit.
d.
Tell the patient the day and time when you are providing routine nursing interventions.
29
ANS: A, B, D
Manipulation of the environment, such as adjusting lighting, is helpful in promoting sleep and rest; clocks,
calendars, photos, and other personal items promote orientation and personalize the environment; telling the
patient the day and time and other current events assists in maintaining the patients orientation. Conversations
about other patients are private and should take place away from other patients.
DIF: Cognitive Level: Analysis REF: pp. 15-16
OBJ: Describe stressors in the critical care environment and strategies to reduce them.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
30
Chapter 03: Ethical and Legal Issues in Critical Care Nursing
MULTIPLE CHOICE
1. Ideally, an advance directive should be developed by the:
a.
family, if the patient is in critical condition.
b.
patient as part of the hospital admission process.
c.
patient before hospitalization.
d.
patients healthcare surrogate.
ANS: C
Advance directives should be made and signed while a person is in good health and in a state of mind to make
decisions about what should happen if he or she becomes incapacitated (e.g., during a critical illness). Families
help to make decisions based on written advance directives, but families are not responsible for developing
them for the patient. Developing advance directives during the admission process is not feasible, and the
patient may not be capable of making an advance directive. The surrogate or proxy is one who has been
already designated by a person to make healthcare decisions based on written advance directives.
DIF: Cognitive Level: Application REF: p. 33 | Table 3-2
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
2. A critically ill patient has a living will in his chart. His condition has deteriorated. His wife says she wants
everything done, regardless of the patients wishes. Which ethical principle is the wife violating?
a.
Autonomy
b.
Beneficence
c.
Justice
d.
Nonmaleficence
ANS: A
Autonomy is respect for the individual and the ability of individuals to make decisions with regard to their own
health and future. The wife is violating the patients autonomy in decision making. Beneficence consists of
actions intended to benefit the patients or others. Justice is being fair. Nonmaleficence is the duty to prevent
harm.
DIF: Cognitive Level: Analysis REF: p. 27 | Box 3-1
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
31
3. Which statement regarding ethical concepts is true?
a.
A living will is the same as a healthcare proxy.
b.
A signed donor card ensures that organ donation will occur in the event of brain death.
c.
A surrogate is a competent adult designated by a person to make healthcare decisions in the event
the person is incapacitated.
d.
A persistent vegetative state is the same as brain death in most states.
ANS: C
A surrogate is a competent adult designated by a person to make healthcare decisions if that person becomes
incapacitated. A living will is a witnessed document that states a persons wishes regarding life-prolonging
procedures, whereas a healthcare proxy is a person authorized by state statute to make healthcare decisions. In
many states, consent by family members or healthcare proxy is required for organ donation even if an
individual has a signed donor card. A persistent vegetative state is a permanent, irreversible unconscious
condition that demonstrates an absence of voluntary action or cognitive behavior, or an inability to
communicate or interact; brain death is cessation of brain function.
DIF: Cognitive Level: Analysis REF: p. 34
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following statements about resuscitation is true?
a.
Family members should never be present during resuscitation.
b.
It is not necessary for a physician to write do not resuscitate orders in the chart if a patient has a
healthcare surrogate.
c.
Slow codes are ethical and should be considered in futile situations if advanced directives are not
available.
d.
Withholding extraordinary resuscitation is legal and ethical if specified in advance directives and
physician orders.
ANS: D
Withholding resuscitation and other care is legal and ethical if based on the patients wishes. Formal orders
should be written that specify what is to be done if a patient suffers a cardiopulmonary arrest. Family presence
during resuscitation and invasive procedures should be encouraged. A written order for do not resuscitate must
be documented in the medical record. The decision to write the order is made in collaboration with the
healthcare surrogate. Slow codes sometimes occur in the clinical setting while attempts are made to contact the
healthcare surrogate or proxy; however, they are neither legal nor ethical. Specific written orders determine
what is to be done for resuscitation efforts.
DIF: Cognitive Level: Analysis REF: p. 33
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
32
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for an elderly patient who is in cardiogenic shock. The patient has failed to respond to
medical treatment. The intensivist in charge of the patient conducts a conference to explain that they have
exhausted treatment options and suggest that the patient be made a do not resuscitate status. This scenario
illustrates the concept of:
a.
brain death.
b.
futility.
c.
incompetence.
d.
life-prolonging procedures.
ANS: B
This is the definition of futility. Brain death is cessation of brain function and is not described in this scenario.
Incompetence (in this chapter) is when a patient is unable to make decisions regarding healthcare treatment. A
life-prolonging procedure is one that sustains, restores, or supplants a spontaneous vital function.
DIF: Cognitive Level: Analysis REF: p. 28, 33
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
6. The nurse is caring for a patient admitted with a traumatic brain injury following a motor vehicle crash. The
patients Glasgow Coma Score is 3 and intermittently withdraws when painful stimuli are introduced. The
patient is ventilator dependent and occasionally takes a spontaneous breath. The physician explains to the
family that the patient has severe neurological impairment and he does not expect the patient to recover
consciousness. The nurse recognizes that this patient is:
a.
an organ donor.
b.
brain dead.
c.
in a persistent vegetative state.
d.
terminally ill.
ANS: C
A persistent vegetative state is a permanent, irreversible unconscious condition that demonstrates an absence of
voluntary action or cognitive behavior, or an inability to communicate or interact purposefully with the
environment. She is not brain dead, as occasionally she reacts to painful stimuli and takes a spontaneous
breath; therefore, she cannot be an organ donor at this time. Treatment of her condition may be considered
futile; however, she would not be defined as terminally ill.
DIF: Cognitive Level: Analysis REF: p. 34 | Table 3-2
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
33
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
7. A nurse caring for a patient with neurological impairment often must use painful stimuli to elicit a patients
response. The nurse uses subtle measures of painful stimuli, such as nailbed pressure. She neither slaps the
patient nor pinches the nipple to elicit a response to pain. In this scenario, the nurse is exemplifying the ethical
principle of:
a.
beneficence.
b.
fidelity.
c.
nonmaleficence.
d.
veracity.
ANS: C
Nonmaleficence is not to intentionally harm others. Beneficence demonstrates actions intended to benefit the
patients or others. Fidelity is the moral duty to be faithful to the commitments that one makes to others.
Veracity is the obligation to tell the truth.
DIF: Cognitive Level: Analysis REF: p. 28 | Box 3-1
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
8. Which of the following organizations requires a mechanism for addressing ethical issues?
a.
American Association of Critical-Care Nurses
b.
American Hospital Association
c.
Society of Critical Care Medicine
d.
The Joint Commission
ANS: D
The Joint Commission requires that a formal mechanism be in place to address patients ethical concerns. The
other organizations do not address formal ethics committees.
DIF: Cognitive Level: Knowledge REF: p. 29
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
9. The nurse is caring for a patient who is not responding to medical treatment. The intensivist holds a
conference with the family, and a decision is made to withdraw life support. The nurses religious beliefs are
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
34
not in agreement with withdrawal. However, she assists with the process to avoid confronting the charge nurse.
Afterward she feels guilty and believes she killed the patient. This scenario is likely to cause:
a.
abandonment.
b.
family stress.
c.
moral distress.
d.
negligence.
ANS: C
Moral distress occurs when the nurse acts in a manner contrary to personal or professional values.
Abandonment is defined as the unilateral severance of a professional relationship while a patient is still in need
of health care. Family stress would not be impacted in this situation if the nurse responded appropriately during
the procedure. Negligence is failure to act according to the standard of care.
DIF: Cognitive Level: Comprehension REF: p. 29
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
10. The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential
organ donor. In order to proceed with donation, the nurse understands that:
a.
a signed donor card mandates that organs be retrieved in the event of brain death.
b.
after brain death has been determined, perfusion and oxygenation of organs is maintained until
organs can be removed in the operating room.
c.
the healthcare proxy does not need to give consent for the retrieval of organs.
d.
once a patient has been established as brain dead, life support is withdrawn and organs are
retrieved.
ANS: B
After brain death has been determined, the organs must be perfused to maintain viability. Therefore, the patient
remains on life support even though he or she is legally dead. A signed donor card indicates the individuals
wishes; however, most organ procurement agencies require family consent even if a donor card has been
signed. In most states, the healthcare surrogate or proxy is required to give consent for organ donation. After
brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be
removed in the operating room.
DIF: Cognitive Level: Analysis REF: p. 34
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
35
11. The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events
occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and
writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ
retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac
monitor shows flatline. What is the official time of death recorded in the medical record?
a.
1300
b.
1330
c.
1400
d.
1800
e.
1810
ANS: B
The time of death is when brain death is confirmed and documented in the chart, even though the patients heart
is still beating. Organs are retrieved after brain death has been documented.
DIF: Cognitive Level: Analysis REF: p. 34
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
12. The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need
for a bronchoscopy, which requires informed consent. If the physician were to obtain consent from the patient,
the patient must be able to:
a.
be weaned from mechanical ventilation.
b.
have knowledge and competence to make the decision.
c.
nod his head that it is okay to proceed.
d.
read and write in English.
ANS: B
Informed consent requires that a person know what is to be done and have the competence to make an
informed decision. Most critically ill patients do not have this capacity; however, an assessment should be
made to determine the patients capacity. Some patients on mechanical ventilation are able to give written
consent. Reading and writing in English are not requirements for informed consent.
DIF: Cognitive Level: Analysis REF: p. 30
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
36
13. The nurse is caring for a critically ill patient with terminal cancer. The monitor alarms and shows
ventricular tachycardia. The patient does not have a do not resuscitate order written on the chart. What is the
appropriate nursing action?
a.
Contact the attending physician immediately to determine if CPR should be initiated.
b.
Contact the family immediately to determine if they want CPR to be started.
c.
Give emergency medications but withhold intubation.
d.
Initiate CPR and call a code.
ANS: D
Because no orders have been written, it is imperative that a code be called. In this example, decisions regarding
resuscitation status should be determined as soon as possible before a code event. The physician and family
should be contacted immediately to determine treatment options, but CPR is not withheld. It is not appropriate
to conduct a partial code by giving medications only.
DIF: Cognitive Level: Analysis REF: p. 33
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
14. When addressing an ethical dilemma, contextual, physiological, and personal factors of the situation must
be considered. Which of the following is an example of a personal factor?
a.
The hospital has a policy that everyone must have an advanced directive on the chart.
b.
The patient has lost 20 pounds in the past month and is fatigued all of time.
c.
The patient has told you what quality of life means and his or her wishes.
d.
The physician considers care to be futile in a given situation.
ANS: C
Personal factors include competence, stated wishes, goals and hopes, definition of quality of life, and family
relationships. Hospital policy is a contextual factor. Weight loss and fatigue are physiological factors. The
physicians belief is a contextual factor.
DIF: Cognitive Level: Analysis REF: Figure 3-1
OBJ: Apply the components of a systematic, ethical decision-making model.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
15. A specific request made by a competent person that directs medical care related to life-prolonging
procedures if the patient loses capacity to make decisions is called a:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
do not resuscitate order.
b.
healthcare proxy.
c.
informed consent.
d.
living will.
37
ANS: D
A living will is a formal advance directive that directs medical care related to life-prolonging procedures when
a person does not have the capacity to make decisions regarding health care and treatment. A do not resuscitate
order is a legal medical order prohibiting resuscitation measures in the event of clinical death. A healthcare
proxy is an individual designated by the person to make decisions if incapacitated. Informed consent involves
decisions regarding treatments and procedures following explanation of risks and benefits.
DIF: Cognitive Level: Knowledge REF: p. 33 | Table 3-2
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
16. The American Nurses Credential Center Magnet Recognition Program supports many actions to ensure that
nurses are engaged and empowered to participate in ethical decision making. Which of the following would
assist nurses in being involved in research studies?
a.
Education on protection of human subjects
b.
Participation of staff nurses on ethics committees
c.
Written descriptions of how nurses participate in ethics programs
d.
Written policies and procedures related to response to ethical issues
ANS: A
Completion of education related to human subject protection assists nurses in research. Ethics committees,
ethics programs, and policies address ethics issues rather than prepare nurses for research.
DIF: Cognitive Level: Comprehension REF: p. 29 | Box 3-2
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
17. The critical care nurse wants a better understanding of when to initiate an ethics consult. After attending an
educational program, she understands that the following situation would require an ethics consultation:
a.
Conflict has occurred between the physician and family regarding treatment decisions. A family
conference is held, and the family and physician agree to a treatment plan that includes aggressive
treatment for 24 hours followed by re-evaluation.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
38
b.
Family members disagree as to a patients course of treatment. The patient has designated a
healthcare proxy and has a written advance directive.
c.
Patient postoperative coronary artery bypass surgery who sustained a cardiopulmonary arrest in the
operating room. He was successfully resuscitated, but now is not responding to treatment. He has a
written advance directive and his wife is present.
d.
Patient with multiple trauma and is not responding to treatment. No family members are known,
and care is considered futile.
ANS: D
In the case of a seriously ill patient who is incapacitated and does not have a surrogate, an ethics consultation is
warranted. The conflict has been resolved in the case of the family and physician agreeing on a course of
treatment for 24 hours followed by re-evaluation. Although family members disagree, if a patient has a written
advance directive and a designated healthcare proxy, an ethics consultation is not warranted; the patients
wishes are clearly known. The cardiac surgery patient has a written directive to guide his treatment.
DIF: Cognitive Level: Analysis REF: p. 29 | Box 3-3
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
18. The nurse is aware that a shortage of organs exists. She knows that which of the following statements is
true?
a.
Anyone who is comfortable approaching the family should discuss the option of organ donation.
b.
Brain death determination is required before organs can be retrieved for transplant.
c.
Donation of selected organs after cardiac death is ethically acceptable.
d.
Family members should consider withdrawing life support so that the patient can become an organ
donor.
ANS: C
Donation of selected organs after cardiac death is ethically and legally appropriate. Specific policies and
procedures for donation after cardiac death facilitate this procedure. Only designated requestors who are
knowledgeable and trained in organ donation should approach the family to discuss donation. Organs can be
retrieved not only after brain death but also after cardiac death. The decision to withdraw life support should be
made separately from the decision to donate organs.
DIF: Cognitive Level: Analysis REF: p. 34
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. Warning signs that can assist the critical care nurse in recognizing that an ethical dilemma may exist include
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
39
which of the following? (Select all that apply.)
a.
Family members are confused about what is happening to the patient.
b.
Family members are in conflict as to the best treatment options. They disagree with each other and
cannot come to consensus.
c.
The family asks that the patient not be told of treatment plans.
d.
The patients condition has changed dramatically for the worse and is not responding to
conventional treatment.
e.
The physician is considering trying a medication that is not approved to treat the patients condition.
ANS: A, B, C, D, E
All of these are potential signs of an ethical dilemma.
DIF: Cognitive Level: Analysis REF: p. 27
OBJ: Apply the components of a systematic, ethical decision-making model.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
2. The nurse is caring for a patient whose condition has deteriorated and who is not responding to standard
treatment. The physician calls for an ethical consultation with the family to discuss potential withdrawal versus
aggressive treatment. The nurse understands that applying a model for ethical decision making involves which
of the following? (Select all that apply.)
a.
Burden versus benefit
b.
Familys wishes
c.
Patients wishes
d.
Potential outcomes of treatment options
ANS: A, C, D
According to the ethical decision-making process, decisions should be made in light of the patients wishes
(autonomy, burden versus benefit (beneficence, other relevant principles, and potential outcomes of various
options. The patients wishes may differ from those of the family.
DIF: Cognitive Level: Analysis REF: p. 27-28 | Fig 3-1
OBJ: Apply the components of a systematic, ethical decision-making model.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
3. The nurse understands that many strategies are available to address ethical issues that may occur; these
strategies include which of the following? (Select all that apply.)
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Change-of-shift report updates
b.
Ethics consultation services
c.
Formal multiprofessional ethics committees
d.
Pastoral care services
40
ANS: B, C
Formal mechanisms such as multiprofessional ethics committees or referral services are strategies to address
ethical issues. Nurse-to-nurse communication can help share information from shift to shift, but it is not the
best way to address ethical issues. Pastoral care representatives may serve on an ethics committee; however,
their primary role is to support the spiritual needs of the patient and family.
DIF: Cognitive Level: Comprehension REF: p. 30
OBJ: Discuss ethical principles and legal concepts related to critical care nursing.
TOP: Nursing Process Step: N/A MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a patient with severe neurological impairment following a massive stroke. The
physician has ordered tests to determine brain death. The nurse understands that criteria for brain death
include: (Select all that apply.)
a.
absence of cerebral blood flow.
b.
absence of brainstem reflexes on neurological examination.
c.
Cheyne-Stokes respirations.
d.
flat electroencephalogram.
ANS: A, B, D
Criteria for brain death include absence of cerebral blood flow, absence of brainstem reflexes, and flat
electroencephalograph. The presence of Cheyne-Stokes respirations would indicate some brain function.
DIF: Cognitive Level: Analysis REF: Table 3-2
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for 80-year-old patient who has been treated for gastrointestinal bleeding. The family has
agreed to withhold or withdraw additional treatment. The patient has a written advance directive specifying
requests. The directive notes that the patient wants food and fluid to be continued. The nurse anticipates that
several orders may be written to comply with this request, including which of the following? (Select all that
apply.
a.
Do not resuscitate.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Change antibiotic to a less expensive medication.
c.
Discontinue tube feeding.
d.
Stop any further blood transfusions.
41
ANS: A, D
All orders except antibiotic adjustment may be considered withdrawal or withholding of life support and
should be written only after informed consent from the healthcare surrogate or family has been obtained.
Because the patient has expressed a request to not have food or fluids withdrawn, it would not be appropriate
for the physician to write an order to discontinue the tube feeding.
DIF: Cognitive Level: Analysis REF: p. 33
OBJ: Discuss ethical and legal issues that arise in the critical care setting.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
42
Chapter 04: Palliative and End-of-Life Care
MULTIPLE CHOICE
1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient
is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as
needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most
appropriate nursing intervention to control agitation?
a.
Administer fentanyl (Duragesic) 25 mg IV bolus.
b.
Administer lorazepam (Ativan) 1 mg IV now.
c.
Increase the rate of the morphine infusion by 50%.
d.
Request an order for a paralytic agent.
ANS: B
Lorazepam (Ativan) 1 mg IV is an appropriate loading dose for a patient who is benzodiazepine nave and
experiencing agitation during withdrawal of life support. Fentanyl treats pain and morphine controls pain.
Paralytic agents are not warranted.
DIF: Cognitive Level: Analysis REF: Figure 4-1
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required
ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement
of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and
personally didnt want what was being done. After holding a family conference with the spouse, the medical
team concurs and the feeding tube is not placed. This situation is an example of:
a.
euthanasia.
b.
palliative care.
c.
withdrawal of life support.
d.
withholding of life support.
ANS: D
Because the tube feeding had not been placed in the care of this patient, this scenario is an example of
withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life
support involves discontinuation of previously established therapies in a terminally ill patient.
DIF: Cognitive Level: Analysis REF: p. 40
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
43
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of
Treatment (SUPPORT)?
a.
Clear communication is typical in the relationships between most patients and healthcare providers.
b.
Critical care units often meet the needs of dying patients and their families.
c.
Disparities exist between patients care preferences and actual care provided.
d.
Pain and suffering of patients at end of life is well controlled in the hospital.
ANS: C
Disparities and lack of communication are common in the relationships between patients and healthcare
providers. Critical care units are often poorly equipped to meet the needs of dying patients. The SUPPORT
study demonstrated that pain and suffering is widespread in hospitals.
DIF: Cognitive Level: Knowledge REF: p. 37
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment
4. A statement that provides a legally recognized description of an individuals desires regarding care at the end
of life is a (an):
a.
advance directive.
b.
guardianship ad litem.
c.
healthcare proxy.
d.
power of attorney.
ANS: A
Legally recognized documents that provide guidance on an individuals end-of-life choices are advance
directives. Advance directives include living wills, durable power of attorney for health care, and healthcare
surrogate designations. A guardianship ad litem is a parent who files legal action on the behalf of a child. A
healthcare proxy is an individual who is legally designated through statute to make decisions for an
incapacitated person. A power of attorney is an individual who is, through filing of legal papers, authorized to
act on the behalf of an incapacitated person in legal matters.
DIF: Cognitive Level: Comprehension REF: p. 42
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
44
OBJ: Describe ethical and legal concerns related to end-of-life care.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
5. A 65-year-old patient with a history of metastatic lung carcinoma has been unresponsive to chemotherapy.
The medical team has determined that there are no additional treatments available that will prolong life or
improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive
chemotherapy and full nutrition support. This is an example of what end-of-life concept?
a.
Medical futility
b.
Palliative care
c.
Terminal weaning
d.
Withdrawal of treatment
ANS: A
Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of
improvement in the patients health status. Palliative care focuses on symptom relief and is not limited to the
dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment
refers to removal of established therapies in a terminally ill patient.
DIF: Cognitive Level: Analysis REF: Box 4-1
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment
6. Designated healthcare surrogates should base healthcare decisions on:
a.
personal beliefs and values.
b.
recommendations of family members and friends.
c.
recommendations of the physician and healthcare team.
d.
wishes previously expressed by the patient.
ANS: D
Healthcare surrogates attempt to have decisions match the wishes of the patient. Although suggestions of
family and friends may provide insight into patient desires, actual decisions should be based upon known
patient wishes. The physician and healthcare team may provide recommendations, but decisions should be
based upon the patients wishes.
DIF: Cognitive Level: Analysis REF: p. 38
OBJ: Describe ethical and legal concerns related to end-of-life care.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
45
TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
7. Which statement made by a staff nurse identifying guidelines for palliative care would need corrected?
a.
Basic nursing care is a critical element in palliative care management.
b.
Common conditions that require palliative management are nausea, agitation, and sleep
disturbance.
c.
Palliative care practices are reserved for the dying client.
d.
Palliative care practices relieve symptoms that negatively affect the quality of life of a patient.
ANS: C
The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient.
Palliative care is an integral part of every injured or ill patients care. Basic nursing care, including
repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all
commonly require palliative care techniques.
DIF: Cognitive Level: Analysis REF: p. 38
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment
8. Which statement is true regarding the impact of culture on end-of-life decision making?
a.
African-Americans prefer more conservative, less invasive care options during the end of life.
b.
Caucasians prefer aggressive and more invasive care options during the end of life.
c.
Culture and religious beliefs may affect end-of-life decision making.
d.
Perspectives regarding end-of-life care are similar between and within religious groups.
ANS: C
Religious doctrines and cultural beliefs have profound impact on end-of-life decisions.
African-Americans prefer more aggressive and invasive end-of-life care options. Caucasians prefer less
aggressive care options at the end of life. Perspectives on end-of-life care vary within and between religious
groups.
DIF: Cognitive Level: Analysis REF: p. 43 | Box 4-3
OBJ: Discuss cultural considerations in end-of-life care.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
46
9. The most critical element of effective early end-of-life decision making is:
a.
control of distressing symptoms such as nausea, anxiety, and pain.
b.
effective communication between the patient, family, and healthcare team throughout the course of
the illness.
c.
organizational support of palliative care principles.
d.
relocation the dying patient from the critical care unit to a lower level of care.
ANS: B
The failure of clinicians, family members, and patients to openly discuss prognoses, end-of-life wishes, and
preferences contributes to care conflicts such as in the Schiavo case. Early discussion of end-of-life wishes is
required to promote positive outcomes for the patient and family, and actually should predate illness. Even
though symptom control is a significant dimension of palliative care, it is not involved in initial end-of-life
decision making. Adequate staffing and facility policies that support the dying patient are critical but should
not impact family decision making. The patient should be cared for in an environment that best supports the
needs of the patient and family. Even though organizational support of palliative principles is important, it
should not drive individual decision making.
DIF: Cognitive Level: Analysis REF: p. 38 | Box 4-2
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity
10. A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate pharmacological
management of this symptom includes:
a.
administration of 6 mg of midazolam (Versed) and initiation of a continuous midazolam infusion.
b.
administration of morphine, 5 mg IV bolus, and initiation of a continuous morphine infusion.
c.
hourly increases of the midazolam (Versed) infusion by 100% dose increments.
d.
hourly increases of the morphine infusion by 100% dose increments.
ANS: B
Morphine is an excellent agent to control the symptom of dyspnea. A 5-mg IV bolus and initiation of a
morphine drip is an appropriate initial intervention to control dyspnea. Initial dosing of midazolam should be 2
to 4 mg, and more is indicated for anxiety. The morphine dose should be titrated incrementally by 50% dose
increases. Midazolam is indicated for management of dyspnea and is titrated incrementally by 50% dose
increases.
DIF: Cognitive Level: Analysis REF: Figure 4-1
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
47
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
11. Which statement is consistent with societal views of dying in the United States?
a.
Dying is viewed as a failure on the part of the system and providers.
b.
Most Americans would prefer to die in a hospital to spare loved ones the burden of care.
c.
People die of indistinct, complex illness for which a cure is always possible.
d.
The purpose of the healthcare system is to prevent disease and treat symptoms.
ANS: A
Death is viewed as a failure by society and healthcare providers that results in aggressive management of
disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at
home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible.
There is a commonly held belief that the healthcare system exists to treat illness, disease, and injury and to
save lives.
DIF: Cognitive Level: Comprehension REF: pp. 37-38
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment
12. Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent
with the principles of effective end-of-life care?
a.
Control of distressing symptoms such as dyspnea, nausea, and pain through use of pharmacological
and nonpharmacological interventions
b.
Limitation of visitation to reduce the emotional distress experienced by family members
c.
Patient and family education on anticipated patient responses to withdrawal of therapy
d.
Provision of spiritual care resources as desired by the patient and family
ANS: B
Active involvement of family is a critical dimension of end-of-life care. Family members should have access to
the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective
end-of-life care practices.
Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance
are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and
family through provision of spiritual resources and bereavement care is a critical element of end-of-life care.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
48
DIF: Cognitive Level: Application REF: p. 37
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
13. In which of the following situations would a healthcare surrogate or proxy assume the end-of-life decisionmaking role for a patient?
a.
When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to
control distressing symptoms
b.
When a dying patient who is competent requests to withdraw treatment against the wishes of the
family
c.
When a dying patient who is competent requests to continue treatment against the
recommendations of the healthcare team
d.
When a dying patient who is competent is receiving prn treatment for pain and anxiety
ANS: A
A patient who requires heavy sedation, such as IV infusions of pain medications or anxiolytic medications,
would not be competent to make healthcare decisions. A healthcare proxy or surrogate would be required in
this situation. A patient who is deemed competent by the medical team may be responsible for healthcare
decisions even if these are not consistent with family beliefs. A surrogate would not assume decision-making
responsibilities in this situation. A healthcare team member who cannot support decisions would be
responsible for finding an alternative care provider who could support the patients wishes.
DIF: Cognitive Level: Analysis REF: p. 37
OBJ: Describe ethical and legal concerns related to end-of-life care.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment
14. Which statement is true regarding the effects of caring for dying patients on nurses?
a.
Attendance at funerals is inappropriate and will only create additional stress in nurses who are
already at risk for burnout.
b.
Caring for dying patients is an expected part of nursing and will not affect the emotional health of
the nurse if he or she maintains a professional approach with each patient and family.
c.
Most nurses who work with dying patients are able to balance care needs of patients with personal
emotional needs.
d.
Provision of aggressive care to patients for whom they believe it is futile may result in personal
ethical conflicts and burnout for nurses.
ANS: D
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
49
Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or
when care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals
may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often
requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance
and being human when working with the dying is a difficult task that requires a great deal of balancing.
DIF: Cognitive Level: Analysis REF: p. 38
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
15. The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that
ethical principles for withholding or withdrawing life-sustaining treatments include which of the following?
a.
Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood
products.
b.
Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed
usual recommended limits.
c.
Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents.
d.
The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.
ANS: A
Any treatment that is used to sustain life, including nutrition, fluids, antibiotics, blood products, and respiratory
support, may be withdrawn in consultation with the patient and/or surrogate provided that the patient has been
deemed terminal or persistently vegetative. Any dose of anxiolytics or analgesics may be used to relieve
suffering, although these may have the potential to hasten death. Life-sustaining treatment should not be
withdrawn while the patient is receiving paralytic treatments. Death occurs as a consequence of the underlying
disease, and the goal of care is to relieve suffering, not hasten death.
DIF: Cognitive Level: Analysis REF: p. 40 | Box 4-3
OBJ: Describe ethical and legal concerns related to end-of-life care.
TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment
16. The patients husband is terrified by the prospect of removing life-sustaining treatments from the patient. He
asks why anyone would do that. The nurse explains,
a.
It is to save you money so you wont have such a large financial burden.
b.
It will preserve limited resources for the hospital so other patients may benefit from them.
c.
It is to discontinue treatments that are not helping your wife and may be very uncomfortable for
her.
d.
We have done all we can for your wife and any more treatment would be futile.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
50
ANS: C
The goal of withdrawal of life-sustaining treatments is to remove treatments that are not beneficial and may be
uncomfortable.
DIF: Cognitive Level: Application REF: p. 40, 42
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
17. All of the patients children are distressed by the possibility of removing life-support treatments from their
mother. The child who is most upset tells the nurse, This is the same as killing her! I thought you were
supposed to help her! The nurse explains to the family,
a.
This is a process of allowing your mother to die naturally after the injuries that she sustained in a
serious accident.
b.
The hospital would never allow us to do that kind of thing.
c.
Lets talk about this calmly, and I will explain why assisted suicide is appropriate in this case.
d.
Shes lived a long and productive life.
ANS: A
Forgoing life-sustaining treatments is not the same as active euthanasia or assisted suicide. Killing is an action
causing anothers death, whereas allowing dying is avoiding any intervention that interferes with a natural death
following illness or trauma.
DIF: Cognitive Level: Application REF: p. 40
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
18. To prevent any unwanted resuscitation after life-sustaining treatments have been withdrawn, the nurse
should ensure that:
a.
do-not-resuscitate (DNR) orders are written before discontinuation of the treatments.
b.
the family is not allowed to visit until the death occurs.
c.
DNR orders are written as soon as possible after the discontinuation of the treatments.
d.
the change-of-shift report includes the information that the patient is not to be resuscitated.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
51
ANS: A
DNR orders should be written before withdrawal of life support; this will prevent any unfortunate errors in
unwanted resuscitation during the time period between initiation of withdrawal and the actual death.
DIF: Cognitive Level: Application REF: p. 33
OBJ: Describe ethical and legal concerns related to end-of-life care.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
19. The patients husband is very upset because his wife, who is near death, has dyspnea and restlessness. The
nurse explains to him that there are some ways to decrease her discomfort, including:
a.
respiratory therapy treatments.
b.
opioid medications given as needed.
c.
incentive spirometry.
d.
increased hydration.
ANS: B
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).
DIF: Cognitive Level: Application REF: Figure 4-1
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
20. The patients husband, experiencing anticipatory grieving, tells the nurse that he doesnt see any point in
continuing to visit at the bedside, because the patient is unresponsive. The best response for the nurse supports
him by saying,
a.
Youre right, she is not aware of anything going on around her now.
b.
Although she is not responding, she may be able to hear you and benefit from your presence.
c.
Ill call you if she starts responding again.
d.
Why dont you check to see if any other family member would like to visit her?
ANS: B
The patient may still be able to hear despite appearing to be nonresponsive.
DIF: Cognitive Level: Application REF: p. 42
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
52
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity
21. Which of the following statements about comfort care is accurate?
a.
Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the
legal community.
b.
Each procedure should be evaluated for its effect on the patients comfort before being
implemented.
c.
Only the patient can determine what constitutes comfort care for him or her.
d.
Withdrawing life-sustaining treatments is considered euthanasia in most states.
ANS: B
The goal of comfort care is to provide treatments that do not cause pain or other discomfort to the patient.
DIF: Cognitive Level: Comprehension REF: p. 38
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: N/A
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. Select interventions that may be included during terminal weaning include which of the following? (Select
all that apply.)
a.
Complete extubation following ventilator withdrawal
b.
Discontinuation of artificial ventilation but maintenance of the artificial airway
c.
Discontinuation of anxiolytic and pain medications
d.
Titration of ventilator support based upon blood gas determinations
e.
Titration of ventilator support to minimal levels based upon patient assessment of comfort
ANS: A, B, E
Terminal weaning may include titration of ventilator support to minimal levels, removal of the ventilator with
maintenance of the artificial airway, and complete extubation. Pain and anxiolytic medications may be required
to control dyspnea and anxiety that may accompany ventilator withdrawal. Blood gas determinations would be
used in therapeutic ventilator management.
DIF: Cognitive Level: Analysis REF: p. 40 | Fig. 4-1 | Clinical Alert
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
53
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that
apply.)
a.
Antibiotics
b.
Dialysis
c.
Nutrition
d.
Pain medications
e.
Simple nursing interventions such as repositioning and hygiene
ANS: A, B, C
Any treatment that is life sustaining may be withheld from a terminally ill patient during the end of life. These
treatments include nutrition, dialysis, fluids, antibiotics, respiratory support, therapeutic medications, and blood
products. Any dose of analgesic or anxiolytic medication may be used to prevent suffering and should not be
withdrawn.
Dignity should be maintained during the course of dying. This would include ongoing provision of basic
nursing care and comfort.
DIF: Cognitive Level: Analysis REF: p. 40 | Box 4-3
OBJ: Describe ethical and legal concerns related to end-of-life care.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. Which interventions can the nurse use to facilitate communication with patients and families who are in the
process of making decisions regarding end-of- life care options? (Select all that apply.)
a.
Communication of uniform messages from all healthcare team members
b.
An integrated plan of care that is developed collaboratively by the patient, family, and healthcare
team
c.
Facilitation of continuity of care through accurate shift-to-shift and transfer reports
d.
Limitation of time for families to express feelings in order to control family grief
e.
Reassuring the patient and family that they will not be abandoned as the goals of care shift from
aggressive treatment to comfort care
ANS: A, B, C, E
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
54
Effective and consistent communication between the patient, family, and healthcare team members is required
to promote positive outcomes during end-of-life care.
Family members should be provided ample time to express feelings in order to improve the level of satisfaction
and prevent dysfunctional bereavement patterns.
DIF: Cognitive Level: Analysis REF: Box 4-2
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
4. Palliation may include: (Select all that apply.)
a.
relieving pain.
b.
relieving nausea.
c.
psychological support.
d.
withdrawing life-support interventions.
e.
withholding tube feedings.
ANS: A, B, C
Palliation includes relieving symptoms that may have a negative effect on the family or the patient.
DIF: Cognitive Level: Analysis REF: p. 38
OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution;
withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare
providers. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. When providing palliative care, the nurse must keep in mind that the family may include which of the
following? (Select all that apply.)
a.
Unmarried life partners of same sex
b.
Unmarried life partners of opposite sex
c.
Roommates
d.
Close friends
e.
Parents
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
ANS: A, B, D, E
The definition of family varies and may include unmarried life partners of the same or opposite sex, close
friends, and other close individuals who have no legal relationship with the patient.
DIF: Cognitive Level: Analysis REF: p. 43
OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
55
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
56
Chapter 05: Comfort and Sedation
MULTIPLE CHOICE
1. Nociceptors differ from other nerve receptors in the body in that they:
a.
b.
c.
d.
adapt very little to continual pain response.
inhibit the infiltration of neutrophils and eosinophils.
play no role in the inflammatory response.
transmit only the thermal stimuli.
ANS: A
Nociceptors are stimulated by mechanical, chemical, or thermal stimuli. Nociceptors differ from other nerve
receptors in the body in that they adapt very little to the pain response. The body continues to experience pain
until the stimulus is discontinued or therapy is initiated. This is a protective mechanism so that the body tissues
being damaged will be removed from harm. Nociceptors usually initiate inflammatory responses near injured
capillaries. As such, the response promotes infiltration of injured tissues with neutrophils and eosinophils.
DIF: Cognitive Level: Remember/Knowledge REF: p. 54
OBJ:Discuss the physiology of pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
2. A postsurgical patient is on a ventilator in the critical care unit. The patient has been tolerating the ventilator
well and has not required any sedation. On assessment, the nurse notes the patient is tachycardic and
hypertensive with an increased respiratory rate of 28 breaths/min. The patient has been suctioned recently via
the endotracheal tube, and the airway is clear. The patient responds appropriately to the nurse’s commands.
The nurse should:
a.
b.
c.
d.
assess the patient’s level of pain.
decrease the ventilator rate.
provide sedation as ordered.
suction the patient again.
ANS: A
Pulse, respirations, and blood pressure frequently result from activation of the sympathetic nervous system by
the pain stimulus. Because the patient is postoperative, the patient should be assessed for the presence of pain
and need for pain medication. Decreasing the ventilator rate will not help in this situation. Providing sedation
may calm the patient but will not solve the problem if the physiological changes are from pain. The patient has
just been suctioned and the airway is clear. There is no need to suction again.
DIF: Cognitive Level: Analyze/Analysis REF: p. 55
OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
3. The assessment of pain and anxiety is a continuous process. When critically ill patients exhibit signs of
anxiety, the nurse’s first priority is to
a.
b.
c.
d.
administer antianxiety medications as ordered.
administer pain medication as ordered.
identify and treat the underlying cause.
reassess the patient hourly to determine whether symptoms resolve on their own.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
57
ANS: C
When patients exhibit signs of anxiety or agitation, the first priority is to identify and treat the underlying
cause, which could be hypoxemia, hypoglycemia, hypotension, pain, or withdrawal from alcohol and drugs.
Treatment is not initiated until assessment is completed. Medication may not be needed if the underlying cause
can be resolved.
DIF: Cognitive Level: Apply/Application REF: p. 70 | Table 5-11
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
4. Both the electroencephalogram (EEG) monitor and the Bispectral Index Score (BIS) or Patient State Index
(PSI) analyzer monitors are used to assess patient sedation levels in critically ill patients. The BIS and PSI
monitors are simpler to use because they
a.
b.
c.
d.
can be used only on heavily sedated patients.
can be used only on pediatric patients.
provide raw EEG data and a numeric value.
require only five leads.
ANS: C
The BIS and PSI have very simple steps for application, and results are displayed as raw EEG data and the
numeric value. A single electrode is placed across the patient’s forehead and is attached to a monitor. These
monitors can be used in both children and adults and in patients with varying levels of sedation.
DIF: Cognitive Level: Understand/Comprehension REF: p. 60
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
5. The nurse is caring for a patient who requires administration of a neuromuscular blocking agent to facilitate
ventilation with nontraditional modes. The nurse understands that neuromuscular blocking agents provide:
a.
b.
c.
d.
antianxiety effects.
complete analgesia.
high levels of sedation.
no sedation or analgesia.
ANS: D
Neuromuscular blocking (NMB) agents do not possess any sedative or analgesic properties. Patients who
receive NMBs must also receive sedatives and pain medication.
DIF: Cognitive Level: Remember/Knowledge REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
6. The patient is receiving neuromuscular blockade. Which nursing assessment indicates a target level of
paralysis?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
b.
c.
d.
58
Glasgow Coma Scale score of 3
Train-of-four yields two twitches
Bispectral index of 60
CAM-ICU positive
ANS: B
A train-of-four response of two twitches (out of four) using a peripheral nerve stimulator indicates adequate
paralysis. The Glasgow Coma Scale does not assess paralysis; it is an indicator of consciousness. The
bispectral index provides an assessment of sedation. The CAM-ICU is a tool to assess delirium.
DIF: Cognitive Level: Remember/Knowledge REF: p. 73
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
7. The nurse is concerned that the patient will pull out the endotracheal tube. As part of the nursing
management, the nurse obtains an order for
a.
b.
c.
d.
arm binders or splints.
a higher dosage of lorazepam.
propofol.
soft wrist restraints.
ANS: D
The priority in caring for agitated patients is safety. The least restrictive methods of keeping the patient safe
are appropriate. If possible, the tube or device causing irritation should be removed, but if that is not possible,
the nurse must prevent the patient from pulling it out. Restraints are associated with an increased incidence of
agitation and delirium. Therefore, restraints should not be used unless as a last resort for combative patients.
The least amount of sedation is also recommended; therefore, neither increasing the dosage of lorazepam nor
adding propofol is indicated and would be likely to prolong mechanical ventilation.
DIF: Cognitive Level: Apply/Application REF: p. 61
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce
anxiety.TOP:Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
8. The primary mode of action for neuromuscular blocking agents used in the management of some ventilated
patients is
a.
b.
c.
d.
analgesia.
anticonvulsant therapy.
paralysis.
sedation.
ANS: C
These agents cause respiratory muscle paralysis. They do not provide analgesia or sedation. They do not have
anticonvulsant properties.
DIF: Cognitive Level: Remember/Knowledge REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
59
MSC: NCLEX Client Needs Category: Physiological Integrity
9. The most important nursing intervention for patients who receive neuromuscular blocking agents is to
a.
b.
c.
d.
administer sedatives in conjunction with the neuromuscular blocking agents.
assess neurological status every 30 minutes.
avoid interaction with the patient, because he or she won’t be able to hear.
restrain the patient to avoid self-extubation.
ANS: A
Neuromuscular blocking agents cause paralysis only; they do not cause sedation. Therefore, concomitant
administration of sedatives is essential. Neurological status is monitored according to unit protocol. Nurses
should communicate with all critically ill patients, regardless of their status. If the patient is paralyzed,
restraining devices may not be needed.
DIF: Cognitive Level: Apply/Application REF: p. 72
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
10. The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the:
a.
b.
c.
d.
Confusion Assessment Method (CAM-ICU).
FACES assessment tool.
Glasgow Coma Scale.
Richmond Agitation Sedation Scale.
ANS: D
Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing
response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been
validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale
assesses neurological status.
DIF: Cognitive Level: Remember/Knowledge REF: p. 59 | Table 5-5
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
11. The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse
recognizes which laboratory assessment to be a possible side effect of the ibuprofen?
a.
b.
c.
d.
Creatinine: 3.1 mg/dL
Platelet count 350,000 billion/L
White blood count 13, 550 mm3
ALT 25 U/L
ANS: A
Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level.
Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An
elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is
also important to assess liver function, which would show elevated liver enzymes, not low values such as
shown here.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
60
DIF: Cognitive Level: Analyze/Analysis REF: p. 71
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce
anxiety.TOP:Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity
12. The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse
recognizes __________ as indicating the greatest level of pain.
a.
b.
c.
d.
brow lowering
eyelid closing
grimacing
relaxed facial expression
ANS: C
The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of
facial grimacing.
DIF: Cognitive Level: Understand/Comprehension REF: p. 58 | Table 5-3
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
13. The nurse wishes to assess the quality of a patient’s pain. Which of the following questions is appropriate
to obtain this assessment if the patient is able to give a verbal response?
a.
b.
c.
d.
“Is the pain constant or intermittent?”
“Is the pain sharp, dull, or crushing?”
“What makes the pain better? Worse?”
“When did the pain start?”
ANS: B
If the patient can describe the pain, the nurse can assess quality, such as sharp, dull, or crushing. The other
responses relate to continuous or intermittent presence, what provides relief, and duration.
DIF: Cognitive Level: Understand/Comprehension REF: p. 56
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
14. The nurse is assessing the patient’s pain using the Critical Care Pain Observation Tool. Which of the
following assessments would indicate the greatest likelihood of pain and need for nursing intervention?
a.
b.
c.
d.
Absence of vocal sounds
Fighting the ventilator
Moving legs in bed
Relaxed muscles in upper extremities
ANS: B
Fighting the ventilator is rated with the greatest number of points for compliance with the ventilator, and could
indicate pain or anxiety. Absence of vocal sounds (e.g., no crying and relaxed muscles do not indicate pain
and are not given a point value. The patient may be moving the legs as a method of range of motion, not
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
61
necessarily in response to pain. The patient needs to be assessed for restlessness if the movement is excessive.
DIF: Cognitive Level: Apply/Application REF: p. 59 | Table 5-4
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
15. The nurse is caring for four patients on the progressive care unit. Which patient is at greatest risk for
developing delirium?
a.
b.
c.
d.
36-year-old recovering from a motor vehicle crash; being treated with an evidence-based alcohol
withdrawal protocol.
54-year-old postoperative aortic aneurysm resection with a 40 pack-year history of smoking
86-year-old from nursing home with dementia, postoperative from colon resection, still being
mechanically ventilated
95-year-old with community-acquired pneumonia; family has brought in eyeglasses and hearing aid
ANS: C
From this list, the 86-year-old postoperative nursing home resident is at greatest risk due to advanced age,
cognitive impairment, and some degree of respiratory failure. The 96-year-old has been provided eyeglasses
and a hearing aid, which will decrease the risk of delirium. Smoking is a possible risk for delirium. The 36year-old is receiving medications as part of an alcohol withdrawal protocol, which should decrease the risk for
delirium.
DIF: Cognitive Level: Analyze/Analysis REF: p. 61 | Table 5-8
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
16. The nurse is caring for a patient with hyperactive delirium. The nurse focuses interventions toward keeping
the patient:
a.
b.
c.
d.
comfortable.
nourished.
safe.
sedated.
ANS: C
The greatest priority in managing delirium is to keep the patient safe. Sedation may contribute to the
development of delirium. Comfort and nutrition are important, but they are not priorities.
DIF: Cognitive Level: Understand/Comprehension REF: p. 61
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and
prevent delirium. TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
17. The nurse is caring for a critically ill trauma patient who is expected to be hospitalized for an extended
period. Which of the following nursing interventions would improve the patient’s well-being and reduce
anxiety the most?
a.
Arrange for the patient’s dog to be brought into the unit (per protocol).
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
c.
d.
62
Provide aromatherapy with scents such as lavender that are known to help anxiety.
Secure the harpist to come and play soothing music for an hour every afternoon.
Wheel the patient out near the unit aquarium to observe the tropical fish.
ANS: A
Nonpharmacological approaches are helpful in reducing stress and anxiety, and each of these activities has the
potential for improving the patient’s well-being. The patient is likely to benefit most from the presence of his
or her own dog rather than the other activities, however; if unit protocol does not allow the patient’s own dog,
the nurse should investigate the use of therapy animals or the other options.
DIF: Cognitive Level: Apply/Application REF: p. 64
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and
prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Psychological Integrity
18. The nurse recognizes that which patient is likely to benefit most from patient-controlled analgesia (PCA)?
a.
b.
c.
d.
Patient with a C4 fracture and quadriplegia
Patient with a femur fracture and closed head injury
Postoperative patient who had elective bariatric surgery
Postoperative cardiac surgery patient with mild dementia
ANS: C
The patient undergoing bariatric surgery (an elective procedure) is the best candidate for PCA as this patient
should be awake, cognitively intact, and will have the acute pain related to the surgical procedure. The
quadriplegic would be unable to operate the PCA pump. The cardiac surgery patient with mild dementia may
not understand how to operate the pump. Likewise, the patient with the closed head injury may not be
cognitively intact.
DIF: Cognitive Level: Analyze/Analysis REF: p. 71 | Box 5-6
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and
prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
19. The nurse is caring for a patient receiving a benzodiazepine intermittently. The nurse understands that the
best way to administer such drugs is to:
a.
b.
c.
d.
administer around the clock, rather than as needed, to ensure constant sedation.
administer the medications through the feeding tube to prevent complications.
give the highest allowable dose for the greatest effect.
titrate to a predefined endpoint using a standard sedation scale.
ANS: D
The best approach for administering benzodiazepines (and all sedatives is to administer and titrate to a desired
endpoint using a standard sedation scale. Administering around the clock as well as giving the highest
allowable dose without basing it on an assessment target may result in excessive sedation. For greatest effect,
most benzodiazepines are given intravenously.
DIF: Cognitive Level: Apply/Application REF: p. 72
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and
prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
63
20. The nurse is concerned about the risk of alcohol withdrawal syndrome in a postoperative patient. Which
statement by the nurse indicates understanding of management of this patient?
a.
b.
c.
d.
“Alcohol withdrawal is common; we see it all of the time in the trauma unit.”
“There is no way to assess for alcohol withdrawal.”
“This patient will require less pain medication.”
“We have initiated the alcohol withdrawal protocol.”
ANS: D
The most important treatment of alcohol withdrawal syndrome is prevention. Many units have protocols that
are initiated early to prevent the syndrome. Alcohol withdrawal syndrome is common; however, this statement
does not indicate knowledge of management. The patient experiencing alcohol withdrawal may exhibit a
variety of symptoms, such as disorientation, agitation, and tachycardia. Patients with substance abuse require
increased dosages of pain medications.
DIF: Cognitive Level: Understand/Comprehension REF: p. 74
OBJ: Identify nonpharmacological and pharmacological strategies to promote comfort, reduce anxiety, and
prevent delirium. TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
MULTIPLE RESPONSE
1. Nonpharmacological approaches to pain and/or anxiety that may best meet the needs of critically ill patients
include: (Select all that apply.)
a.
b.
c.
d.
e.
anaerobic exercise.
art therapy.
guided imagery.
music therapy.
animal therapy.
ANS: C, D, E
Guided imagery is a powerful technique for controlling pain and anxiety, especially that associated with
painful procedures. Similar to guided imagery, a music therapy program offers patients a diversionary
technique for pain and anxiety relief. Likewise animal therapy has many benefits for the critically ill patient.
Anaerobic exercise is not a nonpharmacological approach for managing pain and anxiety. Most critically ill
patients are not able to participate in art therapy.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 62-64
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce
anxiety.TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
2. Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
a.
b.
c.
d.
e.
Anxiety is a state marked by apprehension, agitation, autonomic arousal, and/or fearful withdrawal.
Critically ill patients often experience anxiety, but they rarely experience pain.
Pain and anxiety are often interrelated and may be difficult to differentiate because their
physiological and behavioral manifestations are similar.
Pain is defined by each patient; it is whatever the person experiencing the pain says it is.
While anxiety is unpleasant, it does not contribute to mortality or morbidity of the critically ill
patient.
ANS: A, C, D
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
64
Pain is defined by each patient, anxiety is associated with marked apprehension, and pain and anxiety are often
interrelated. Critically ill patients commonly have both pain and anxiety. Anxiety does increase both morbidity
and mortality in critically ill patients, especially those with cardiovascular disease.
DIF: Cognitive Level: Understand/Comprehension REF: p. 53
OBJ: Define pain and anxiety. TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
3. Which of the following factors predispose the critically ill patient to pain and anxiety? (Select all that
apply.)
a.
b.
c.
d.
e.
Inability to communicate
Invasive procedures
Monitoring devices
Nursing care
Preexisting conditions
ANS: A, B, C, D, E
All of these factors predispose the patient to pain or anxiety.
DIF: Cognitive Level: Remember/Knowledge REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
4. Choose the items that are common to both pain and anxiety. (Select all that apply.)
a.
b.
c.
d.
e.
Cyclical exacerbation of one another
Require good nursing assessment for proper treatment
Response only to real phenomena
Subjective in nature
Perception may be influenced by prior experience
ANS: A, B, D, E
Both pain and anxiety are subjective in nature. One can exacerbate the other in a vicious cycle that often
requires good nursing assessment to manage the precipitating problem and break the cycle. Anxiety is a
response to a real or perceived fear. Pain is a response to real or “phantom” phenomenon but always involves
transmission of nerve impulses. Both relate to the patient’s perceptions of pain and fear. Previous experiences
of both pain and/or anxiety can influence the patient’s perception of both. Anxiety is a response to real or
perceived fear, and pain is a response to a real or “phantom” phenomenon.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
5. Anxiety differs from pain in that: (Select all that apply.)
a.
b.
c.
it is confined to neurological processes in the brain.
it is linked to reward and punishment centers in the limbic system.
it is subjective.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
e.
65
there is no actual tissue injury.
it can be increased by noise and light.
ANS: A, B, D, E
Unlike pain, anxiety is linked to the reward and punishment centers in the limbic system of the brain. It is
totally neurological and does not involve tissue injury. Like pain, it is a subjective phenomenon. Noise, light,
and other stimuli can increase the intensity of anxiety. Both anxiety and pain are subjective in nature.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-55
OBJ:Discuss the physiology of pain and anxiety.
TOP: Nursing Process Step: Assessment
6. Factors in the critical care unit that may predispose the client to increased pain and anxiety include: (Select
all that apply.)
a.
b.
c.
d.
e.
an endotracheal tube.
frequent vital signs.
monitor alarms.
room temperature.
hostile environment.
ANS: A, B, C, D, E
Anxiety is likely to result from loss of control, the inability to communicate, continuous noise and lighting,
excessive stimulation (including repeated vital sign measurements), lack of mobility, and uncomfortable room
temperatures. Increased anxiety levels often lead to increased pain perception. Environments that are perceived
as hostile also contribute.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 53-54
OBJ: Identify factors that place the critically ill patient at risk for developing pain and anxiety.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
7. In the healthy individual, pain and anxiety: (Select all that apply.)
a.
b.
c.
d.
e.
activate the sympathetic nervous system (SNS).
decrease stress levels.
help remove one from harm.
increase performance levels.
limit sympathetic nervous system activity.
ANS: A, C, D
In the healthy person, pain and anxiety are adaptive mechanisms used to increase performance levels or to
remove one from potential harm. The “fight or flight” response occurs in response to pain and/or anxiety and
involves the activation of the sympathetic nervous system. Pain and anxiety, however, can induce significant
stress. The SNS is activated, not limited, by pain and/or anxiety.
DIF: Cognitive Level: Remember/Knowledge REF: p. 55
OBJ: Describe the positive and negative effects of pain and anxiety in critically ill patients.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
66
8. The nurse is caring for a patient who is intubated and on a ventilator following extensive abdominal surgery.
Although the patient is responsive, the nurse is not able to read the patient’s lips as the patient attempts to
mouth the words. Which of the following assessment tools would be the most appropriate for the nurse to use
when assessing the patient’s pain level? (Select all that apply.)
a.
b.
c.
d.
e.
The FACES scale
Pain Intensity Scale
The PQRST method
The Visual Analogue Scale
The CAM tool
ANS: A, D
The PQRST method and the Pain Intensity Scale require verbalization and/or writing to communicate pain
level. The FACES scale and the Visual Analogue Scale can be used by simply having the patient point to the
appropriate place. Because of this, they are the easiest to use with children, people with language barriers, and
intubated patients. The CAM tool is used to assess delirium.
DIF: Cognitive Level: Apply/Application REF: pp. 57-58
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
9. In the critically ill patient, an incomplete assessment and/or management of pain or anxiety may be
hampered by which of the following? (Select all that apply.)
a.
b.
c.
d.
e.
Administration of neuromuscular blocking agents
Delirium
Effective nurse communication and assessment skills
Nonverbal patients
Ventilated patient
ANS: A, B, D
Delirium appears in approximately 80% of patients in the intensive care unit. Delirium is characterized by
changing mental status, inattention, disorganized thinking, and altered levels of consciousness. Patients in the
intensive care unit may not be able to verbalize because of the presence of an artificial airway, sedative
medication, neuromuscular blocking agents, or brain injury. Effective nurse-to-patient communication and
assessment skills would facilitate assessment of pain and anxiety. There are tools and assessment methods to
assess pain in ventilated patients.
DIF: Cognitive Level: Understand/Comprehension REF: p. 56
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
10. Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in
critically ill patients? (Select all that apply.)
a.
b.
c.
d.
e.
Environmental manipulation
Explanations of monitoring equipment
Guided imagery
Music therapy
Provision of personal items
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
67
ANS: A, B, C, D, E
Manipulating the environment so that it appears less hostile helps decrease anxiety, as does continually
reorienting the patient. Focus techniques such as guided imagery and music therapy can create a state of
relaxation. Personal items can reduce anxiety and provide a pleasant distraction.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 61-64
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce
anxiety.TOP:Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity
11. The nurse is caring for a postoperative patient in the critical care unit. The physician has ordered patientcontrolled analgesia (PCA) for the patient. The nurse understands that the PCA: (Select all that apply.)
a.
b.
c.
d.
e.
is a safe and effective method for administering analgesia.
has potentially fewer side effects than other routes of analgesic administration.
is an ideal method to provide most critically ill patients some control over their treatment.
provides good quality analgesia.
does not work well without family assistance.
ANS: A, B, D
PCA is safe and effective, provides good-quality analgesia, and has potentially fewer side effects than other
routes. PCA management is rarely appropriate for critically ill patients because most patients are unable to
depress the button, or they are too ill to manage their pain effectively. If the patient is cognitively intact, family
assistance is not needed to use this modality and is not advisable; the patient needs to be able to push the
button.
DIF: Cognitive Level: Understand/Comprehension REF: pp. 69-70
OBJ:Identify nonpharmacological and pharmacological strategies to promote comfort and reduce
anxiety.TOP:Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
12. A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The
nursing care for this patient includes: (Select all that apply.)
a.
b.
c.
d.
e.
administration of sedatives concurrently with neuromuscular blockade.
dangling the patient’s feet over the edge of the bed and assisting the patient to sit up in a chair at
least twice each day.
ensuring that deep vein thrombosis prophylaxis is initiated.
providing interventions for eye care, oral care, and skin care.
ensuring good nutrition with frequent feedings throughout the day.
ANS: A, C, D
Pancuronium is a neuromuscular blocking agent (NMB resulting in complete paralysis of the patient. Patients
receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at
high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be
administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill
patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise
is most appropriate. Feeding the patient on an NMB orally is not possible.
DIF: Cognitive Level: Analyze/Analysis REF: p. 73
OBJ: Discuss assessment and management challenges in subsets of critically ill patients.
TOP:Nursing Process Step: Implementation
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
68
MSC: NCLEX Client Needs Category: Physiological Integrity
13. The nurse is assessing the critically ill patient for delirium. The nurse recognizes which characteristics that
indicate hyperactive delirium? (Select all that apply.)
a.
b.
c.
d.
e.
Agitation
Apathy
Biting
Hitting
Restlessness
ANS: A, C, D, E
All except for apathy are characteristics of hyperactive delirium. Apathy is seen in hypoactive cases.
DIF: Cognitive Level: Understand/Comprehension REF: p. 59 | Table 5-4
OBJ: Describe methods and tools for assessing pain and anxiety in the critically ill patient.
TOP:Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
69
Chapter 06: Nutritional Therapy
MULTIPLE CHOICE
1. A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings
are not possible, the decision is to initiate parenteral feedings. What are the major complications for this
therapy?
a.
Aspiration pneumonia and sepsis
b.
Fluid and electrolyte imbalances and sepsis
c.
Fluid overload and pulmonary edema
d.
Hypoglycemia and renal insufficiency
ANS: B
Because of the high dextrose concentration, including the fluid and electrolyte content, the patient is placed at
high risk for sepsis and fluid and electrolyte imbalances. Aspiration pneumonia is a potential complication of
enteral feedings; sepsis is a potential complication of parenteral nutrition. Fluid overload is possible but
unlikely and is not a major complication of parenteral nutrition. Hyperglycemia is more of a concern than
hypoglycemia with parenteral nutrition; however, renal insufficiency is not related to parenteral nutrition.
DIF: Cognitive Level: Application REF: p. 89
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. A patient is being ventilated and has been started on enteral feedings with a nasogastric small-bore feeding
tube. What is the primary reason the nurse must frequently assess tube placement?
a.
To assess for paralytic ileus
b.
To maintain the patency of the feeding tube
c.
To monitor for skin breakdown on the nose
d.
To prevent aspiration of the feedings
ANS: D
Patients who are on a ventilator and who are receiving tube feedings are at a high risk for aspiration and
ventilator-associated pneumonia. Assessment of tube placement will neither determine presence of paralytic
ileus nor maintain patency. Assessment of tube placement is performed to minimize aspiration risk, not skin
breakdown on the nose.
DIF: Cognitive Level: Application REF: p. 89 | Evidence-Based Practice box
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
70
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The patient is to start parenteral nutrition. The nurse knows to prepare which site for catheter insertion?
a.
Basilic vein
b.
Femoral vein
c.
Radial artery
d.
Subclavian vein
ANS: D
Total parenteral nutrition is administered through a central intravenous line, such as the subclavian vein.
Arteries are never used. The femoral site is avoided. The basilic vein is not a central site.
DIF: Cognitive Level: Application REF: p. 83
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. A patient has been admitted to the critical care unit after a stroke. After failing a swallow study, the patient is
placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical
step?
a.
Administer medications.
b.
Cap off and wait 24 hours before starting feedings.
c.
Obtain a chest radiograph.
d.
Start the tube feeding.
ANS: C
Correct placement must be verified by radiograph before use of the tube.
DIF: Cognitive Level: Analysis REF: p. 83 | Clinical Alert
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
5. A patients feeding tube has been successfully placed in the small intestine with continuous flow tube
feeding. The nurse knows that this approach was chosen because:
a.
intermittent feedings cause increased nausea and vomiting.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
the increased filling of the stomach increases absorption.
c.
the intestinal mucosa normally receives nutrients from the stomach in peristaltic waves.
d.
this will prevent malabsorption syndrome.
71
ANS: C
The small intestine usually receives nutrients from the stomach in peristaltic waves; this simulates normal
peristalsis.
DIF: Cognitive Level: Analysis REF: p. 80
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. A patient is being fed through a nasogastric tube placed in his stomach. The nurse would carry out which
intervention to minimize aspiration risk?
a.
Add blue dye to the formula.
b.
Assess the residual every hour.
c.
Elevate the head of the bed 30 degrees.
d.
Provide feedings via continuous infusion.
ANS: C
The head of the bed should be kept elevated at least 30 degrees if possible during tube feedings to minimize
reflux. Blue dye should not be used. Neither continuous feedings nor checking for residual will minimize
aspiration.
DIF: Cognitive Level: Analysis REF: Table 6-4
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. This is
a concern because this most likely demonstrates that the patient has:
a.
a bowel obstruction.
b.
developed an ileus.
c.
gastrointestinal bleeding.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
72
tube feeding intolerance.
ANS: D
Nausea and vomiting are signs of tube feeding intolerance.
DIF: Cognitive Level: Analysis REF: p. 88
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. A patient is receiving enteral feedings and has just vomited 250 mL of milky green liquid. The nurse holds
the tube feeding, which had been infusing at 100 mL/hr. The nurse knows that the next action should be:
a.
connect the feeding tube to suction.
b.
continue the tube feeding.
c.
decrease the tube feeding.
d.
recheck the residual in 2 hours.
ANS: D
The patient is not tolerating the tube feeding. It should be held until he has absorbed the remaining tube
feeding. Feedings may resume when residuals are less than 250 mL.
DIF: Cognitive Level: Analysis REF: p. 87
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
9. In addition to residual stomach volume, what other evidence suggests feeding intolerance?
a.
Abdominal distention
b.
Absence of tympany on percussion
c.
Active bowel sounds
d.
Elevated blood glucose by fingerstick
ANS: A
Abdominal distention is expected if the feedings are not being absorbed. Tympany occurs along with
distention.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
73
DIF: Cognitive Level: Application REF: p. 88
OBJ: Discuss methods for evaluating nutritional status.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
10. Approximately 5 days after starting tube feedings, a patient develops extreme diarrhea. A stool specimen is
collected to check for which possible cause?
a.
Clostridium difficile
b.
Escherichia coli
c.
Occult blood
d.
Ova and parasites
ANS: A
Patients receiving enteral nutrition who develop diarrhea are evaluated for antibiotic- associated causes,
including Clostridium difficile.
DIF: Cognitive Level: Application REF: Table 6-4
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible
interventions for this patient. Which intervention needs correction before finalizing the plan of care?
a.
Change the intravenous tubing every 24 hours.
b.
Infuse antibiotics through the intravenous line.
c.
Monitor the blood glucose every 6 hours.
d.
Monitor the fluid and electrolyte balance.
ANS: B
Medications should not be infused through the IV line infusing parenteral nutrition.
DIF: Cognitive Level: Analysis REF: p. 89
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. In evaluating a patients nutrition, the nurse would monitor which blood test as the most sensitive indicator
of protein synthesis and catabolism?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Albumin
b.
BUN
c.
Prealbumin
d.
Triglycerides
ANS: C
Prealbumin is the most sensitive indicator of protein synthesis and catabolism.
DIF: Cognitive Level: Comprehension REF: Laboratory Alert
OBJ: Discuss methods for evaluating nutritional status.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
13. A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse
recognizes which drug as having the potential for causing drug-nutrient reactions?
a.
Aspirin
b.
Enoxaparin
c.
Ibuprofen
d.
Phenytoin
ANS: D
Bioavailability of phenytoin is reduced when administered with enteral feedings.
DIF: Cognitive Level: Comprehension REF: p. 89
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. Which statement is true about normal function of the gastrointestinal (GI) tract?
a.
Failure of the tight junctions allows bacteria to invade the GI tract.
b.
The gut lacks protective mechanisms; thus, infection is always a concern.
c.
Water is reabsorbed at the beginning of the colon.
d.
Without nutritional stimulation, mucosal villi atrophy.
74
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
ANS: D
Mucosal villi replenish every 3 to 4 days; without nutritional stimulation, they atrophy.
DIF: Cognitive Level: Comprehension REF: p. 80
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. An important nutritional consideration in the elderly population is:
a.
decreased protein requirements.
b.
increasing caloric requirements with age.
c.
potential for drug-nutrient interaction related to polypharmacy.
d.
presence of other diseases that decrease caloric needs.
ANS: C
Patients taking multiple medications have a greater potential for drug-nutrient interactions; elderly persons
may be taking multiple medications.
DIF: Cognitive Level: Analysis REF: Geriatric Considerations box
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. Objective data designating that the nutrition goals are not being met include:
a.
hyperglycemia, normovolemia, and increased protein level.
b.
overhydration, hypoglycemia, and weight gain.
c.
weight gain, inconsistent glucose, and normovolemia.
d.
weight loss, elevated glucose, and dehydration.
ANS: D
When nutritional goals are not being met, the patient experiences weight loss, elevated glucose levels, and
either overhydration or dehydration.
DIF: Cognitive Level: Analysis REF: p. 90
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
17. In trauma patients, enteral nutrition via nasogastric tube feedings into the small bowel is best initiated
75
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
within what time frame following the injury?
a.
24 hours
b.
48 hours
c.
7 days
d.
72 hours
ANS: A
Feedings into the small bowel are frequently initiated within 24 hours after the injuryor illness.
DIF: Cognitive Level: Application REF: p. 83
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a
ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is
underweight. Which formula for nutritional assessment is most appropriate?
a.
Elemental protein formula
b.
Fiber-added formula
c.
High mediumchain triglyceride formula
d.
Lactose-free formula
ANS: B
Added fiber helps control blood glucose and reduce hyperlipidemia.
DIF: Cognitive Level: Analysis REF: p. 86
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. Select the physiological reasoning behind enteral therapy as the preferred source of nutritional therapy.
a.
Gut overgrowth increases.
b.
Gastroparesis increases.
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Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Bacterial translocation is initiated.
d.
Gut mucosa is preserved.
77
ANS: D
Enteral feedings prevent bacterial overgrowth and potential bacterial translocation from the gastrointestinal
tract and preserve the gut mucosa.
DIF: Cognitive Level: Comprehension REF: p. 86
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
20. The nurse identifies which patient at greatest risk for malabsorption of protein?
a.
The patient with gallbladder obstruction
b.
The patient with ileitis
c.
The patient with distal colon resection
d.
The patient with jejunal tumor
ANS: B
The ileum is where protein is broken down and absorbed; the patient with ileitis would be at greatest risk for
protein malabsorption.
DIF: Cognitive Level: Analysis REF: p. 81
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
21. The best nursing approach to prevent feeding tube obstruction is:
a.
dilute the feeding to make it flow more easily.
b.
flush the tube every 4 hours with 20 to 30 mL of tap water.
c.
pass a stylet daily to keep the tubing clear.
d.
use a larger bore tube where possible.
ANS: B
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78
Flushing the tubing every 4 hours helps prevent obstruction. Diluting tube feedings can cause water
intoxication. Stylets are never used to clear a tube, and the smallest bore possible should be used for best
tolerance.
DIF: Cognitive Level: Analysis REF: Table 6-4
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. Patients experiencing severe physiological stress increase their nutritional requirements to:
a.
20 kcal/kg/day.
b.
30 kcal/kg/day.
c.
35 kcal/kg/day.
d.
50 kcal/kg/day.
ANS: C
Severely stressed individuals require 35 kcal/kg/day; 50 kcal/kg/day exceeds caloric needs. A total of 20
kcal/kg/day is less than normal caloric requirements. A total of 30 kcal/kg/day is the caloric requirement for a
moderately stressed individual.
DIF: Cognitive Level: Application REF: Table 6-2
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
23. Malnutrition contributes to infection risk by:
a.
hampering normal gastrointestinal motility.
b.
impairing immune function.
c.
increasing blood glucose.
d.
increasing drug interactions.
ANS: B
Malnutrition impairs immune function.
DIF: Cognitive Level: Application REF: p. 84
OBJ: Review the anatomy and physiology related to utilization of nutrients.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
24. A patient, who has a tube feeding, requires a chest x-ray study for evaluation of a cough. To reduce the
risk
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79
of aspiration, the nurse:
a.
helps the radiology technician to position the patient to avoid dislodging the tube.
b.
holds feedings until placement has been verified.
c.
slows the infusion rate by half.
d.
stops feedings 10 to 15 minutes before placing flat to obtain the radiograph.
ANS: D
Temporarily stopping feedings when flat minimizes the risk of aspiration if the patient will be supine.
DIF: Cognitive Level: Analysis REF: p. 89 | Table 6-4 | Evidence-Based Practice
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Which statement(s) about total parenteral nutrition is (are) true? (Select all that apply.)
a.
Assessing fluid volume status and preventing infection are important nursing considerations.
b.
Fingerstick glucose levels are assessed every 6 hours and prn.
c.
Total parenteral nutrition is administered through a feeding tube and pump.
d.
Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates,
and fats.
ANS: A, B, D
All are correct except administration via a feeding tube and pump. A tube and pump are used to deliver enteral
nutrition.
DIF: Cognitive Level: Analysis REF: p. 89
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Which intervention(s) is (are) critical during intravenous lipid administration? (Select all that apply).
a.
Assess glucose levels.
b.
Change the tubing every 24 hours.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Hold lipids when administering antibiotics through the same line.
d.
Monitor triglyceride levels.
80
ANS: B, D
Lipids are very good media for bacterial growth; lipid tubing should be changed every 24 hours. Triglyceride
levels must be monitored until stable when administering lipids.
DIF: Cognitive Level: Analysis REF: pp. 89-90
OBJ: Monitor and evaluate the nutrition plan of care.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. Calorie-dense feedings: (Select all that apply.)
a.
are most useful in heart failure and liver disease.
b.
are most useful in malabsorption syndromes.
c.
contain 2 kcal/mL and 70 g protein/L.
d.
include increased fiber.
ANS: A, C
Calorie-dense feedings are used when volume should be minimized and protein requirements are high, such as
in heart failure or liver disease. They contain 2 kcal/mL and 70 g protein/L.
DIF: Cognitive Level: Comprehension REF: Table 6-3
OBJ: Describe interventions to achieve nutritional goals.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. Risks of total parenteral nutrition include: (Select all that apply.)
a.
diarrhea.
b.
elevated blood sugar.
c.
infection at the catheter site.
d.
volume overload.
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81
ANS: B, C, D
Diarrhea is more common with enteral tube feedings; the other risks are common with total parenteral
nutrition.
DIF: Cognitive Level: Comprehension REF: p. 89
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. Which of the following statements is true about insulin and parenteral nutrition? (Select all that apply.)
a.
Amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values.
b.
Insulin may be added to a parenteral nutrition solution.
c.
Subcutaneous insulin is used on a sliding scale during parenteral nutrition.
d.
Supplemental insulin is rarely required for patients receiving parenteral nutrition.
ANS: A, B, C
Hyperglycemia is common when receiving parenteral nutrition; insulin may be administered on a sliding scale
for glucose control and/or added to the parenteral solution. Amount of insulin added to the parenteral solution
is calculated based on the previous 24-hour laboratory values.
DIF: Cognitive Level: Analysis REF: p. 89
OBJ: Describe strategies for monitoring and evaluating the nutrition care plan.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
COMPLETION
1. The correct order of actions for a patient starting enteral nutrition with a feeding tube is: _______________,
_______________, _______________, _______________, _______________. (Put a comma and space
between each answer choice.)
A. Initiate tube feeding.
B. Insert feeding tube.
C. Flush tube to verify patency.
D. Obtain chest radiograph.
E. Assess residuals.
ANS:
B, D, C, A, E
Initially the feeding tube will be inserted and final placement verified via chest radiograph. The next step is to
flush the feeding tube and start the tube feedings. Residuals are checked every 4 hours.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
DIF: Cognitive Level: Analysis REF: pp. 87-88
OBJ: Discuss practice guidelines related to nutritional support.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
82
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83
Chapter 07: Dysrhythmia Interpretation and Management
MULTIPLE CHOICE
1. The nurse is caring for a patient who is on a cardiac monitor. The nurse realizes that the sinus node is the
pacemaker of the heart because it is:
a.
the fastest pacemaker cell in the heart.
b.
the only pacemaker cell in the heart.
c.
the only cell that does not affect the cardiac cycle.
d.
located in the left side of the heart.
ANS: A
The cardiac cycle begins with an impulse that is generated from a small concentrated area of pacemaker cells
high in the right atria called the sinoatrial node (sinus node or SA node). The SA node has the fastest rate of
discharge and thus is the dominant pacemaker of the heart. The AV node has pacemaker properties and can
discharge an impulse if the SA node fails. The ventricles have pacemaker capabilities if the sinus node or the
AV node ceases to generate impulses.
DIF: Cognitive Level: Comprehension REF: p. 95
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. One of the functions of the atrioventricular (AV) node is to:
a.
pace the heart if the ventricles fail.
b.
slow the impulse arriving from the SA node.
c.
send the impulse to the SA node.
d.
allow for ventricular filling during systole.
ANS: B
The impulse from the SA node quickly reaches the atrioventricular (AV node located in the area called the
AV junction, between the atria and the ventricles. Here the impulse is slowed to allow time for ventricular
filling during relaxation or ventricular diastole. The AV node has pacemaker properties and can discharge an
impulse if the SA node (not the ventricle fails. The electrical impulse is then rapidly conducted through the
bundle of His to the ventricles (not the SA node via the left and right bundle branches.
DIF: Cognitive Level: Comprehension REF: p. 95
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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84
3. The normal rate for the SA node when the patient is at rest is:
a.
40 to 60 beats per minute.
b.
60 to 100 beats per minute.
c.
20 to 40 beats per minute.
d.
more than100 beats per minute.
ANS: B
The sinus node reaches threshold at a rate of 60 to 100 times per minute. Because this is the fastest pacemaker
in the heart, the SA node is the dominant pacemaker of the heart. The AV node has an inherent rate of 40 to 60
beats per minute and the His-Purkinje system can fire at a rate of 20 to 40 beats per minute. Sinus tachycardia
results when the SA node fires faster than 100 beats per minute.
DIF: Cognitive Level: Knowledge REF: p. 97, 112
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. When assessing the 12-lead electrocardiogram (ECG) or a rhythm strip, it is helpful to understand that the
electrical activity is viewed in relation to the positive electrode of that particular lead. When an electrical signal
is aimed directly at the positive electrode, the inflection will be:
a.
negative.
b.
upside down.
c.
upright.
d.
equally positive and negative.
ANS: C
When an electrical signal is aimed directly at the positive electrode, an upright inflection is visualized. If the
impulse is going away from the positive electrode, a negative deflection is seen; and if the signal is
perpendicular to the imaginary line between the positive and negative poles of the lead, the tracing is
equiphasic, with equally positive and negative deflection.
DIF: Cognitive Level: Comprehension REF: p. 98
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. The patient is admitted with a condition that requires cardiac rhythm monitoring. To apply the monitoring
electrodes, the nurse must first:
a.
apply a moist gel to the chest.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
make certain that the electrode gel is dry.
c.
avoid soaps to avoid skin irritation.
d.
clip chest hair if needed.
85
ANS: D
Adequate skin preparation of electrode sites requires clipping the hair, cleansing the skin, and drying
vigorously (moisture gels are not applied). Cleansing includes washing with soap and water, or alcohol, to
remove skin debris and oils. Before application, the electrodes are checked to ensure that the gel is moist. It is
difficult for electrodes to adhere to the chest in the presence of chest hair. Clipping, not shaving, is
recommended since shaving may create small nicks that can become a portal for infection.
DIF: Cognitive Level: Application REF: p. 102
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. Electrocardiogram (ECG) paper contains a standardized grid where the horizontal axis measures time and
the vertical axis measures voltage or amplitude. The nurse must understand that each horizontal box indicates:
a.
200 milliseconds or 0.20 seconds duration.
b.
40 milliseconds or 0.04 seconds duration.
c.
3 seconds duration.
d.
millivolts of amplitude.
ANS: B
ECG paper contains a standardized grid where the horizontal axis measures time and the vertical axis measures
voltage or amplitude. Horizontally, the smaller boxes denote 0.04 seconds each or 40 milliseconds; the larger
box contains five smaller boxes and thus equals 0.20 seconds or 200 milliseconds.
DIF: Cognitive Level: Comprehension REF: p. 105
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. The nurse is examining the patients cardiac rhythm strip in lead II and notices that all of the P waves are
upright and look the same except one that has a different shape and is inverted. The nurse realizes that the P
wave with the abnormal shape is probably:
a.
from the SA node since all P waves come from the SA node.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
from some area in the atria other than the SA node.
c.
indicative of ventricular depolarization.
d.
normal even though it is inverted in lead II.
86
ANS: B
Normally a P wave indicates that the SA node initiated the impulse that depolarized the atrium. However, a
change in the shape of the P wave may indicate that the impulse arose from a site in the atria other than the SA
node. The P wave represents atrial depolarization. It is usually upright in leads I and II and has a rounded,
symmetrical shape. The amplitude of the P wave is measured at the center of the waveform and normally does
not exceed three boxes, or 3 millimeters, in height.
DIF: Cognitive Level: Analysis REF: p. 105
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The QT interval is the total time taken for ventricular depolarization and repolarization. Prolongation of the
QT interval:
a.
decreases the risk of lethal dysrhythmias.
b.
usually occurs when heart rate increases.
c.
increases the risk of lethal dysrhythmias.
d.
can only be measured with irregular rhythms.
ANS: C
The QT interval is measured from the beginning of the QRS complex to the end of the T wave. This interval
measures the total time taken for ventricular depolarization and repolarization. Abnormal prolongation of the
QT interval increases vulnerability to lethal dysrhythmias, such as ventricular tachycardia and fibrillation.
Normally, the QT interval becomes longer with slower heart rates and shortens with faster heart rates, thus
requiring a correction of the value (QTc). Generally, the QT interval is less than half the RR interval. QTc
accuracy is based on a regular rhythm. In irregular rhythms such as atrial fibrillation, an average QTc may be
necessary because the QT varies from beat to beat.
DIF: Cognitive Level: Comprehension REF: p. 107
OBJ: Explain the relationships between electrical and mechanical events in the heart.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. The patient has an irregular heart rhythm. To determine an accurate heart rate, the nurse first:
a.
identifies the markers on the ECG paper that indicate a 6-second strip.
b.
counts the number of large boxes between two consecutive P waves.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
counts the number of small boxes between two consecutive QRS complexes.
d.
divides the number of complexes in a 6-second strip by 10.
87
ANS: A
Six-second method: A quick and easy estimate of heart rate can be accomplished by counting the number of P
waves or QRS waves within a 6-second strip to obtain atrial and ventricular heart rates per minute. This is the
optimal method for irregular rhythms. Identify the lines above the ECG paper that represent 6 seconds, and
count the number of P waves within the lines; then add a zero (multiply by 10) to identify the atrial heart rate
estimate for 1 minute. Next, identify the number of QRS waves in the 6-second strip and again add a zero to
identify the ventricular rate. Large box method: In this method, two consecutive P and QRS waves are located.
The number of large boxes between the highest points of two consecutive P waves is counted, and that number
of large boxes is divided into 300 to determine the atrial rate in beats per minute. The number of large boxes
between the highest points of two consecutive QRS waves is counted, and that number of large boxes is
divided into 300 to determine the ventricular rate. This method is accurate only if the rhythm is regular.
Small box method: The small box method is used to calculate the exact rate of a regular rhythm. In this
method, two consecutive P and QRS waves are located. The number of small boxes between the highest points
of these consecutive P waves is counted, and that number is divided into 1500 to determine the atrial rate in
beats per minute. The number of small boxes between the highest points of two consecutive QRS waves is
counted, and that number is divided into 1500 to determine the ventricular rate. This method is accurate only if
the rhythm is regular.
DIF: Cognitive Level: Application REF: p. 108
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and
20 small boxes between each R wave. What is the ventricular rate?
a.
50 beats/min
b.
75 beats/min
c.
85 beats/min
d.
100 beats/min
ANS: B
The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the
highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to
determine the ventricular rate. 1500/20 = 75 beats/min. This method is accurate only if the rhythm is regular.
DIF: Cognitive Level: Application REF: p. 108
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
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88
MSC: NCLEX: Physiological Integrity
11. The patient is admitted with a fever and rapid heart rate. The patients temperature is 103 F (39.4 C).The
nurse places the patient on a cardiac monitor and finds the patients atrial and ventricular rates are above 105
beats per minute. P waves are clearly seen and appear normal in configuration. QRS complexes are normal in
appearance and 0.08 seconds wide. The rhythm is regular, and blood pressure is normal. The nurse should
focus on providing:
a.
medications to lower heart rate.
b.
treatment to lower temperature.
c.
treatment to lower cardiac output.
d.
treatment to reduce heart rate.
ANS: B
Sinus tachycardia results when the SA node fires faster than 100 beats per minute. Sinus tachycardia is a
normal response to stimulation of the sympathetic nervous system. Sinus tachycardia is also a normal finding
in children younger than 6 years. Both atrial and ventricular rates are greater than 100 beats per minute, up to
160 beats per minute, but may be as high as 180 beats per minute. Sinus tachycardia is regular or essentially
regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves are
consistent in shape. P waves are small and rounded. A P wave precedes every QRS complex, which is then
followed by a T wave. The fast heart rhythm may cause a decrease in cardiac output because of the shorter
filling time for the ventricles. Lowering cardiac out further may complicate the situation. The dysrhythmia
itself is not treated, but the cause is identified and treated appropriately. For example, if the patient has a fever
or is in pain, the infection or pain is treated appropriately.
DIF: Cognitive Level: Analysis REF: p. 112
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The nurse is working on the night shift when she notices sinus bradycardia on the patients cardiac monitor.
The nurse should:
a.
give atropine to increase heart rate.
b.
begin transcutaneous pacing of the patient.
c.
start a dopamine infusion to stimulate heart function.
d.
assess for hemodynamic instability.
ANS: D
Sinus bradycardia may be a normal heart rhythm for some individuals such as athletes, or it may occur during
sleep. Assess for hemodynamic instability related to the bradycardia. If the patient is symptomatic,
interventions include administration of atropine. If atropine is not effective in increasing heart rate, then
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
89
transcutaneous pacing, dopamine infusion, or epinephrine infusion may be administered. Atropine is avoided
for treatment of bradycardia associated with hypothermia.
DIF: Cognitive Level: Application REF: p. 113
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. Which of the following is true about a patient diagnosed with sinus arrhythmia?
a.
The heart rate varies, dependent on vagal tone and respiratory pattern.
b.
Immediate treatment is essential to prevent death.
c.
Sinus arrhythmia is not well tolerated by most patients.
d.
PR and QRS interval measurements are prolonged.
ANS: A
Sinus arrhythmia is a cyclical change in heart rate that is associated with respiration. The heart rate increases
slightly during inspiration and slows slightly during exhalation because of changes in vagal tone. The ECG
tracing demonstrates an alternating pattern of faster and slower heart rate that changes with the respiratory
cycle. Interval measurements are normal. This rhythm is tolerated well, and no treatment is required.
DIF: Cognitive Level: Knowledge REF: p. 113
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. The patient is admitted with sinus pauses causing periods of loss of consciousness. The patient is
asymptomatic, awake and alert, but fatigued. He answers questions appropriately. When admitting this patient,
the nurse should first:
a.
prepare the patient for temporary pacemaker insertion.
b.
prepare the patient for permanent pacemaker insertion.
c.
assess the patients medication profile.
d.
apply transcutaneous pacemaker paddles.
ANS: C
AV nodal blocking medications (such as beta-blockers, calcium channel blockers, and digoxin and increased
vagal tone may cause sinus exit block. Causes are explored, and prescribed medications may need to be
adjusted or discontinued. If patients are symptomatic, significant numbers of pauses may require treatment,
including temporary (including transcutaneous) and permanent implantation of a pacemaker.
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90
DIF: Cognitive Level: Application REF: p. 114
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The patients heart rate is 165 beats per minute. His cardiac monitor shows a rapid rate with narrow QRS
complexes. The P waves cannot be seen, but the rhythm is regular. The patients blood pressure has dropped
from 124/62 to 78/30. His skin is cold and diaphoretic and he is complaining of nausea. The nurse prepares the
patient for:
a.
administration of beta-blockers.
b.
administration of atropine.
c.
transcutaneous pacemaker insertion.
d.
emergent cardioversion.
ANS: D
If an abnormal P wave cannot be visualized on the ECG but the QRS complex is narrow, the term
supraventricular tachycardia (SVT) is often used. This is a generic term that describes any tachycardia that is
not ventricular in origin; it is also used when the source above the ventricles cannot be identified, usually
because the rate is too fast. Treatment is directed at assessing the patients tolerance of the tachycardia. If the
rate is higher than 150 beats per minute and the patient is symptomatic, emergent cardioversion is considered.
Cardioversion is the delivery of a synchronized electrical shock to the heart by an external defibrillator. Betablockers are a possibility if the patient is not symptomatic. Atropine is used in the treatment of bradycardia. If
atropine is not effective in increasing heart rate, then transcutaneous pacing is implemented.
DIF: Cognitive Level: Analysis REF: p. 123
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. The nurse is reading the cardiac monitor and notes that the patients heart rhythm is extremely irregular and
there are no discernible P waves. The ventricular rate is 90 beats per minute, and the patient is
hemodynamically stable. The nurse realizes that the patients rhythm is:
a.
atrial fibrillation.
b.
atrial flutter.
c.
atrial flutter with rapid ventricular response.
d.
junctional escape rhythm.
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91
ANS: A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and
ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these
impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P
waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial
flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate,
between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth
appearance. The ventricular response may be regular or irregular based on how many flutter waves are
conducted through the AV node. Atrial flutter with rapid ventricular response occurs when atrial impulses
cause a ventricular response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate
between 40 and 60 beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the
QRS complex. If a P wave is present before the QRS complex, the PR interval is shortened less than 0.12
milliseconds. QRS complex is normal.
DIF: Cognitive Level: Analysis REF: p. 119
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17. The patients heart rhythm shows an inverted P wave with a PR interval of 0.06 seconds. The heart rate is
54 beats per minute. The nurse recognizes the rhythm as a junctional escape rhythm, and understands that the
rhythm is due to the:
a.
loss of sinus node activity.
b.
increased rate of the AV node.
c.
increased rate of the SA node.
d.
decreased rate of the AV node.
ANS: A
Junctional escape rhythm occurs when the dominant pacemaker, the SA node, fails to fire. The normal heart
rate of the AV node is 40 to 60 beats per minute, so the AV node rate has neither increased nor decreased. An
increased SA node rate would override the AV node.
DIF: Cognitive Level: Knowledge REF: p. 121
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
18. The patients heart rate is 70 beats per minute, but the P waves come after the QRS complex. The nurse
correctly determines that the patients heart rhythm is:
a.
a normal junctional rhythm.
b.
an accelerated junctional rhythm.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
a junctional tachycardia.
d.
atrial fibrillation.
92
ANS: B
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can
accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for
junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside
down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR
interval is shortened less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the atria,
causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with
hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
DIF: Cognitive Level: Analysis REF: p. 121
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
19. The patient is having premature ventricular contractions (PVCs). The nurses greatest concern should be:
a.
the proximity of the R wave of the PVC to the T wave of a normal beat.
b.
the fact that PVCs are occurring, because they are so rare.
c.
if the number of PVCs are decreasing.
d.
if the PVCs are wider than 0.12 seconds.
ANS: A
The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which
coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular
tachycardia may occur. When the R wave of PVC falls on the T wave of a normal beat, it is referred to as the
R-on-T phenomenon. PVCs may occur in healthy individuals and usually do not require treatment. The nurse
must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse
should evaluate for potential causes such as electrolyte imbalances, myocardial ischemia or injury, and
hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to development of sustained
ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS
complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often
wider than 0.16 seconds.
DIF: Cognitive Level: Analysis REF: pp. 123-124
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
20. The nurse notices ventricular tachycardia on the heart monitor. When the patient is assessed, the patient is
found to be unresponsive with no pulse. The nurse should:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
treat with intravenous amiodarone or lidocaine.
b.
begin cardiopulmonary resuscitation and advanced life support.
c.
provide electrical cardioversion.
d.
ignore the rhythm since it is benign.
93
ANS: B
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in
the ventricles. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and
advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is
stable, the patient can be treated with intravenous amiodarone or lidocaine. Cardioversion is used as an
emergency measure in patients who become hemodynamically unstable but continue to have a pulse. It also
may be used in nonemergency situations, such as when a patient has asymptomatic VT.
DIF: Cognitive Level: Application| Cognitive Level: Analysis REF: p. 126
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation|Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21. The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST
complex. The nurse should:
a.
defibrillate the patient immediately.
b.
initiate basic life support.
c.
initiate advanced life support.
d.
assess the patient and the electrical leads.
ANS: D
Ventricular fibrillation (VF is a chaotic rhythm characterized by a quivering of the ventricles, which results in
total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the
treatment is, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because
a loose lead or electrical interference can produce a waveform similar to VF, it is always important to
immediately assess the patient for pulse and consciousness.
DIF: Cognitive Level: Analysis| Cognitive Level: Application REF: p. 126
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation|Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22. The nurse notices that the patient has a first-degree AV block. Everything else about the rhythm is normal.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
94
The nurse should:
a.
prepare to place the patient on a transcutaneous pacemaker.
b.
give the patient atropine to shorten the PR interval.
c.
monitor the rhythm and patients condition.
d.
give the patient an antiarrhythmic medication.
ANS: C
First-degree AV block is a common dysrhythmia in the elderly and in patients with cardiac disease. As the
normal conduction pathway ages or becomes diseased, impulse conduction becomes slower than normal. It is
well tolerated. No treatment is required. Continue to monitor the patient and the rhythm.
DIF: Cognitive Level: Application| Cognitive Level: Analysis REF: p. 129
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation|Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
23. The nurse understands that in a third-degree AV block:
a.
every P wave is conducted to the ventricles.
b.
some P waves are conducted to the ventricles.
c.
none of the P waves are conducted to the ventricles.
d.
the PR interval is prolonged.
ANS: C
In first-degree AV block, a P wave precedes every QRS complex, which is followed by a T wave indicating
complete conduction. It is represented on the ECG as a prolonged PR interval. Second-degree heart block
refers to AV conduction that is intermittently blocked. Therefore, some P waves are conducted and some are
not. Third-degree block is often called complete heart block because no atrial impulses are conducted through
the AV node to the ventricles.
DIF: Cognitive Level: Knowledge REF: pp. 131-132
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
24. The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz I. The patient is on
digitalis medication at home. The nurse should expect that:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
the patient has had an anterior wall myocardial infarction.
b.
the physician will order the digitalis to be continued in the hospital.
c.
a digitalis level would be ordered upon admission.
d.
the patient will require a transcutaneous pacemaker.
95
ANS: C
Digitalis toxicity is a major cause of this rhythm, and further digitalis doses should not be given until a digitalis
level is obtained. Other causes of Mobitz I include AV nodal blocking drugs, acute inferior wall myocardial
infarction or right ventricular infarction, ischemic heart disease, and excess vagal response. This type of block
is usually well tolerated and no treatment is indicated unless the dropped beats occur frequently.
DIF: Cognitive Level: Analysis REF: pp. 129-130
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. The patient is scheduled to have a permanent pacemaker implanted. The patient asks the nurse, How long
will the battery in this thing last? The nurse should answer,
a.
Life expectancy is about 1 year. Then it will need to be replaced.
b.
Pacemaker batteries can last up to 25 years with constant use.
c.
Battery life varies depending on usage, but it can last up to 10 years.
d.
Pacemakers are used to treat temporary problems so the batteries dont last long.
ANS: C
Implanted permanent pacemakers are used to treat chronic conditions. These devices have a battery life of up
to 10 years, which varies based on the manufacturers recommendations.
DIF: Cognitive Level: Knowledge REF: p. 132
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
26. The patient is in chronic junctional escape rhythm with no atrial activity noted. Studies have demonstrated
normal AV node function. This patient may be a candidate for which type of pacing?
a.
Atrial pacing
b.
Ventricular pacing
c.
Dual-chamber pacing
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
96
Transcutaneous pacing
ANS: A
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers).
Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick.
This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is
commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows
for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal
cardiac cycle. However, with this patient, ventricular and AV function are normal.
DIF: Cognitive Level: Analysis REF: p. 133
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
27. The patient has a permanent pacemaker inserted. The provider has set the pacemaker to the demand mode
at a rate of 60 beats per minute. The nurse realizes that:
a.
the pacemaker will pace only if the patients intrinsic heart rate is less than 60 beats per minute.
b.
the demand mode often competes with the patients own rhythm.
c.
the demand mode places the patient at risk for the R-on-T phenomenon.
d.
the fixed rate mode is safer and is the mode of choice.
ANS: A
Pacemakers can be operated in a demand mode or a fixed rate (asynchronous) mode. The demand mode paces
the heart when no intrinsic or native beat is sensed. For example, if the rate control is set at 60 beats per
minute, the pacemaker will only pace if the patients heart rate drops to less than 60. The fixed rate mode paces
the heart at a set rate, independent of any activity the patients heart generates. The fixed rate mode may
compete with the patients own rhythm and deliver an impulse on the T wave (R-on-T phenomenon), with the
potential for producing ventricular tachycardia or fibrillation. The demand mode is safer and is the mode of
choice.
DIF: Cognitive Level: Comprehension REF: p. 133
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
28. The patient has a permanent pacemaker in place with a demand rate set at 60 beats/min. The cardiac
monitor is showing a heart rate of 44 beats/min with no pacemaker spikes. The nurse realizes this as:
a.
normal pacemaker function.
b.
failure to capture.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
failure to pace.
d.
failure to sense.
97
ANS: C
Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The
problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or
pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal
pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no depolarization
is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P
wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Common causes of failure to capture
include output (milliamperes) set too low, or displacement of the pacing lead wire from the myocardium
(transvenous or epicardial leads). Other causes of failure to capture include battery failure, fracture of the
pacemaker wire, or increased pacing threshold as a result of medication or electrolyte imbalance. When the
pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is called failure
to sense. Failure to sense manifests as pacer spikes that fall too closely to the patients own rhythm, earlier than
the programmed rate. The most common cause is displacement of the pacemaker electrode wire.
DIF: Cognitive Level: Analysis REF: p. 135 | Figure 7-61
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
29. The rhythm on the cardiac monitor is showing numerous pacemaker spikes, but no P waves or QRS
complexes following the spikes. The nurse realizes this as:
a.
normal pacemaker function.
b.
failure to capture.
c.
failure to pace.
d.
failure to sense.
ANS: B
When the pacemaker generates an electrical impulse (pacer spike and no depolarization is noted, it is
described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P wave (atrial
pacemaker or a QRS complex (ventricular pacemaker. Common causes of failure to capture include output
(milliamperes set too low, or displacement of the pacing lead wire from the myocardium (transvenous or
epicardial leads. Other causes of failure to capture include battery failure, fracture of the pacemaker wire, or
increased pacing threshold as a result of medication or electrolyte imbalance. This is not normal pacemaker
function. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it
should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace
include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections.
When the pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is
called failure to sense. Failure to sense manifests as pacer spikes that fall too closely to the patients own
rhythm, earlier than the programmed rate. The most common cause is displacement of the pacemaker electrode
wire.
DIF: Cognitive Level: Analysis REF: p. 135 | Figure 7-62
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
98
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
30. Interpret the following rhythm:
a.
Normal sinus rhythm
b.
Sinus bradycardia
c.
Sinus tachycardia
d.
Sinus arrhythmia
ANS: A
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles.
Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or
essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves
are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in
heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly
slows during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analysis REF: p. 111 | Figure 7-24
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
31. Interpret the following rhythm:
a.
Normal sinus rhythm
b.
Sinus bradycardia
c.
Sinus tachycardia
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
99
Sinus arrhythmia
ANS: C
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles.
Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or
essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves
are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in
heart rate that is associated with respiration. The heart rate slightly increases during inspiration and slightly
slows during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analysis REF: p. 112 | Figure 7-25
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
32. Interpret the following rhythm:
a.
Normal sinus rhythm
b.
Sinus bradycardia
c.
Sinus tachycardia
d.
Sinus arrhythmia
ANS: B
Normal sinus rhythm (NSR reflects normal conduction of the sinus impulse through the atria and ventricles.
Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or
essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves
are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
Bradycardia is defined as a heart rate less than 60 beats per minute. Sinus arrhythmia is a cyclical change in
heart rate that is associated with respiration. The heart rate increases slightly during inspiration and slows
slightly during exhalation because of changes in vagal tone.
DIF: Cognitive Level: Analysis REF: pp. 112-113 | Figure 7-26
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
100
33. Interpret the following rhythm:
a.
Sinus rhythm with PACs
b.
Normal sinus rhythm
c.
Sinus tachycardia
d.
Sinus bradycardia
ANS: A
The underlying rhythm is identified first. Following this step, the dysrhythmia that is occurring to disrupt the
underlying rhythm is then determined. A premature atrial contraction (PAC) is a single ectopic beat arising
from atrial tissue, not the sinus node. The PAC occurs earlier than the next normal beat and interrupts the
regularity of the underlying rhythm. The P wave of the PAC has a different shape than the sinus P wave
because it arises from a different area in the atria; it may follow or be in the T wave of the preceding normal
beat. If the early P wave is in the T wave, this T wave will look different from the T wave of a normal beat.
Normal sinus rhythm (NSR) reflects normal conduction of the sinus impulse through the atria and ventricles.
Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or
essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.06 to 0.10 seconds. P and QRS waves
are consistent in shape. Sinus tachycardia results when the SA node fires faster than 100 beats per minute.
Bradycardia is defined as a heart rate less than 60 beats per minute.
DIF: Cognitive Level: Analysis REF: p. 114, 116 | Figure 7-29A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
34. Interpret the following rhythm:
a.
Atrial flutter with variable conduction
b.
Ventricular fibrillation
c.
Atrial fibrillation
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
101
Atrial flutter with RVR (rapid ventricular response)
ANS: B
Atrial flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular
rate, between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth
appearance. The ventricular response may be regular or irregular based on how many flutter waves are
conducted through the AV node. The number of flutter waves to each QRS complex is called the conduction
ratio.The conduction ratio may remain the same or vary depending on the number of flutter waves that are
conducted to the ventricles. The description of atrial flutter might be constant at 2:1, 3:1, 4:1, 5:1, and so forth,
or it may be variable. Because this patients rhythm has varying P waves for each QRS, the ventricular
conduction (rate) varies from 2:1 to 6:1. Atrial flutter with RVR occurs when atrial impulses cause a
ventricular response greater than 100 beats per minute. Atrial fibrillation arises from multiple ectopic foci in
the atria, causing chaotic quivering of the atria and ineffectual atrial contraction.
DIF: Cognitive Level: Analysis REF: pp. 118-119 | Figure 7-33
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
35. Interpret the following rhythm:
a.
Atrial Fibrillation
b.
Atrial Flutter
c.
Atrial flutter with RVR
d.
Junctional escape rhythm
ANS: A
Atrial fibrillation arises from multiple ectopic foci in the atria, causing chaotic quivering of the atria and
ineffectual atrial contraction. The AV node is bombarded with hundreds of atrial impulses and conducts these
impulses in an unpredictable manner to the ventricles. The atrial rate may be as high 700 and no discernible P
waves can be identified, resulting in a wavy baseline and an extremely irregular ventricular response. Atrial
flutter arises from a single irritable focus in the atria. The atrial focus fires at an extremely rapid, regular rate,
between 240 and 320 beats per minute. The P waves are called flutter waves and may have a sawtooth
appearance. The ventricular response may be regular or irregular based on how many flutter waves are
conducted through the AV node. Atrial flutter with RVR occurs when atrial impulses cause a ventricular
response greater than 100 beats per minute. A junctional escape rhythm is a ventricular rate between 40 and 60
beats per minute with a regular rhythm. P waves may be absent, inverted, or follow the QRS complex. If a P
wave is present before the QRS complex, the PR interval is shortened to less than 0.12 milliseconds. QRS
complex is normal.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
102
DIF: Cognitive Level: Analysis REF: p. 119 | Figure 7-34
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
36. Interpret the following rhythm:
a.
Junctional rhythm
b.
An accelerated junctional rhythm
c.
A junctional tachycardia
d.
Atrial fibrillation
ANS: A
The normal intrinsic rate for the AV node and junctional tissue is 40 to 60 beats per minute, but rates can
accelerate. An accelerated junctional rhythm has a rate between 60 and 100 beats per minute, and the rate for
junctional tachycardia is greater than 100 beats per minute. If P wave precedes QRS, it is inverted or upside
down; the P wave may not be visible, or it may follow the QRS. If a P wave is present before the QRS, the PR
interval is shortened to less than 0.12 milliseconds. Atrial fibrillation arises from multiple ectopic foci in the
atria, causing chaotic quivering of the atria and ineffectual atrial contraction. The AV node is bombarded with
hundreds of atrial impulses and conducts these impulses in an unpredictable manner to the ventricles.
DIF: Cognitive Level: Analysis REF: pp. 120-121 | Figure 7-37B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
37. Interpret the following rhythm:
a.
Sinus rhythm with multifocal premature ventricular contractions
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Sinus rhythm with unifocal premature ventricular contractions
c.
Sinus rhythm with bigeminal premature ventricular contractions
d.
Sinus rhythm with paired premature ventricular contractions (couplets)
103
ANS: A
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs
arising from multiple foci are not identical and are called multifocal PVCs.
PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or
every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair, and
three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analysis REF: pp. 123-124 | Figure 7-41B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
38. Interpret the following rhythm:
a.
Sinus rhythm with multifocal premature ventricular contractions
b.
Sinus rhythm with unifocal premature ventricular contractions
c.
Sinus rhythm with bigeminal premature ventricular contractions
d.
Sinus rhythm with paired premature ventricular contractions (couplets)
ANS: B
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs
arising from multiple foci are not identical and are called multifocal PVCs.
PVCs may occur in a predictable pattern, such as every other beat (bigeminal, every third beat (trigeminal, or
every fourth beat (quadrigeminal. PVCs also can occur sequentially. Two PVCs in a row are called a pair, and
three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analysis REF: pp. 123-124 | Figure 7-41A
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
104
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
39. Interpret the following rhythm:
a.
Sinus rhythm with multifocal premature ventricular contractions
b.
Sinus rhythm with unifocal premature ventricular contractions
c.
Sinus rhythm with bigeminal premature ventricular contractions
d.
Sinus rhythm with paired premature ventricular contractions (couplets)
ANS: C
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs
arising from multiple foci are not identical and are called multifocal PVCs.
PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or
every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair
(couplet), and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analysis REF: pp. 123-124
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
40. Interpret the following rhythm:
a.
Sinus rhythm with multifocal premature ventricular contractions
b.
Sinus rhythm with unifocal premature ventricular contractions
c.
Sinus rhythm with bigeminal premature ventricular contractions
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
105
Sinus rhythm with paired premature ventricular contractions (couplets)
ANS: D
A single ectopic focus produces PVC waveforms that look alike, called unifocal PVCs. Waveforms of PVCs
arising from multiple foci are not identical and are called multifocal PVCs.
PVCs may occur in a predictable pattern, such as every other beat (bigeminal), every third beat (trigeminal), or
every fourth beat (quadrigeminal). PVCs can also occur sequentially. Two PVCs in a row are called a pair
(couplet), and three or more in a row are called nonsustained ventricular tachycardia.
DIF: Cognitive Level: Analysis REF: pp. 123-124 | Figure 7-41C
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
41. Interpret the following rhythm:
a.
R-on-T phenomenon
b.
Sinus rhythm with multifocal premature ventricular contractions
c.
Nonsustained ventricular tachycardia
d.
Sinus rhythm with bigeminal premature ventricular contractions
ANS: A
The peak of the T wave through the downslope of the T wave is considered the vulnerable period, which
coincides with partial repolarization of the ventricles. If a PVC occurs during the T wave, ventricular
tachycardia may occur. When the R wave of a PVC falls on the T wave of a normal beat, it is referred to as the
R-on-T phenomenon. PVCs may occur in healthy individuals and usually do not require treatment. The nurse
must determine if PVCs are increasing in number by evaluating the trend. If PVCs are increasing, the nurse
should evaluate for potential causes, such as electrolyte imbalances, myocardial ischemia or injury, and
hypoxemia. Runs of nonsustained ventricular tachycardia may be a precursor to development of sustained
ventricular tachycardia. Because the stimulus depolarizes the ventricles in a slower, abnormal way, the QRS
complex appears widened and has a bizarre shape. The QRS complex is wider than 0.12 seconds and often
wider than 0.16 seconds. A single ectopic focus produces PVC waveforms that look alike, called unifocal
PVCs. Waveforms of PVCs arising from multiple foci are not identical and are called multifocal PVCs.
DIF: Cognitive Level: Analysis REF: p. 124 | Figure 7-42B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
106
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
42. The patient is alert and talking when the nurse notices the following rhythm. The patients blood pressure is
90/44 mm Hg. The nurse should
a.
defibrillate immediately.
b.
begin basic life support.
c.
begin advanced life support.
d.
treat with intravenous amiodarone or lidocaine.
ANS: D
Ventricular tachycardia (VT) is a rapid, life-threatening dysrhythmia originating from a single ectopic focus in
the ventricles. It is characterized by at least three PVCs in a row. VT occurs at a rate greater than 100 beats per
minute, but the rate is usually around 150 beats per minute and may be up to 250 beats per minute.
Depolarization of the ventricles is abnormal and produces a widened QRS complex. The patient may or may
not have a pulse. Determine whether the patient has a pulse. If no pulse is present, provide emergent basic and
advanced life-support interventions, including defibrillation. If a pulse is present and the blood pressure is
stable, the patient can be treated with intravenous amiodarone or lidocaine.
DIF: Cognitive Level: Analysis| Cognitive Level: Application REF: p. 124-126 | Figure 7-43
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles.
TOP: Nursing Process Step: Implementation|Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
43. The nurse notes the following rhythm on the heart monitor. The patient is unresponsive and not breathing.
The nurse should
a.
treat with intravenous amiodarone or lidocaine.
b.
provide emergent basic and advanced life support.
c.
provide electrical cardioversion.
d.
ignore the rhythm because it is benign.
ANS: B
Ventricular fibrillation (VF is a chaotic rhythm characterized by a quivering of the ventricles, which results in
total loss of cardiac output and pulse. VF is a life-threatening emergency, and the more immediate the
treatment, the better the survival will be. VF produces a wavy baseline without a PQRST complex. Because a
loose lead or electrical interference can produce a waveform similar to VF, it is always important to
immediately assess the patient for pulse and consciousness. If no pulse is present, provide emergent basic and
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
107
advanced life-support interventions, including defibrillation.
DIF: Cognitive Level: Analysis| Cognitive Level: Application REF: p. 126 | Figure 7-45A
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Implementation|Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
44. Interpret the following rhythm:
a.
Idioventricular rhythm
b.
Accelerated idioventricular rhythm
c.
Ventricular tachycardia
d.
Ventricular fibrillation
ANS: A
Idioventricular rhythm is an escape rhythm that is generated by the Purkinje fibers. This rhythm emerges only
when the SA and AV nodes fail to initiate an impulse. The Purkinje fibers are capable of an intrinsic rate of 20
to 40 beats per minute. Because this last pacemaker is located in the ventricles, the QRS complex appears wide
and bizarre with a slow rate. No P waves are present. If the rate is between 40 and 100 beats per minute, this
rhythm is called accelerated idioventricular rhythm (AIVR). Ventricular tachycardia (VT) is a rapid, lifethreatening dysrhythmia originating from a single ectopic focus in the ventricles. It is characterized by at least
three PVCs in a row. VT occurs at a rate greater than 100 beats per minute, but the rate is usually around 150
beats per minute and may be up to 250 beats per minute. VF produces a wavy baseline without a PQRST
complex. Because a loose lead or electrical interference can produce a waveform similar to VF, it is always
important to immediately assess the patient for pulse and consciousness.
DIF: Cognitive Level: Analysis REF: p. 126-127 | Figure 7-46A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
45. Interpret the following rhythm:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Normal sinus rhythm
b.
Sinus rhythm with second-degree AV block
c.
Complete heart block
d.
Sinus rhythm with first-degree AV block
108
ANS: D
In first-degree block, P and QRS waves are consistent in shape. P waves are small and rounded. A P wave
precedes every QRS complex, which is followed by a T wave. PR interval is prolonged and is greater than 0.20
seconds. QRS complex and QT/QTc measurements are normal. Normal sinus rhythm (NSR) reflects normal
conduction of the sinus impulse through the atria and ventricles. Atrial and ventricular rates are the same and
range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20
seconds.
DIF: Cognitive Level: Analysis REF: p. 129 | Figure 7-49
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
46. Interpret the following rhythm:
a.
First-degree AV block
b.
Second-degree AV block Mobitz I (Wenckebach phenomenon)
c.
Second-degree AV block Mobitz II
d.
Third-degree AV block (complete heart block)
ANS: B
Also called a Mobitz I or Wenckebach phenomenon, second-degree AV block type I is represented on the ECG
as a progressive lengthening of the PR interval until there is a P wave without a QRS complex. In first-degree
AV block, a P wave precedes every QRS complex, and every P wave is followed by a QRS. Second-degree
AV block type II (Mobitz II is a more critical type of heart block that requires early recognition and
intervention. There is no progressive lengthening of the PR interval, which remains the same throughout with
the exception of the dropped beat(s. Third-degree block is often called complete heart block because no atrial
impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and ventricles
beat independently of each other because the AV node is completely blocked to the sinus impulse and it is not
conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no association
with the QRS complexes and appear throughout the QRS waveform.
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109
DIF: Cognitive Level: Analysis REF: p. 129 | Figure 7-50B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
47. Interpret the following rhythm:
a.
First-degree AV block
b.
Second-degree AV block Mobitz I (Wenckebach phenomenon)
c.
Second-degree AV block Mobitz II
d.
Third-degree AV block (complete heart block)
ANS: C
Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early
recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same
throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon,
second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until
there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex,
and every P wave is followed by a QRS. Third-degree block is often called complete heart block because no
atrial impulses are conducted through the AV node to the ventricles. In complete heart block, the atria and
ventricles beat independently of each other because the AV node is completely blocked to the sinus impulse
and it is not conducted to the ventricles. One hallmark of third-degree heart block is that the P waves have no
association with the QRS complexes and appear throughout the QRS waveform.
DIF: Cognitive Level: Analysis REF: p. 130-131 | Figure 7-51A
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
48. Interpret the following rhythm:
a.
First-degree AV block
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Second-degree AV block Mobitz I (Wenckebach phenomenon)
c.
Second-degree AV block Mobitz II
d.
Third-degree AV block (complete heart block)
110
ANS: D
Third-degree block is often called complete heart block because no atrial impulses are conducted through the
AV node to the ventricles. In complete heart block, the atria and ventricles beat independently of each other
because the AV node is completely blocked to the sinus impulse and it is not conducted to the ventricles. One
hallmark of third-degree heart block is that the P waves have no association with the QRS complexes and
appear throughout the QRS waveform.
Second-degree AV block type II (Mobitz II) is a more critical type of heart block that requires early
recognition and intervention. There is no progressive lengthening of the PR interval, which remains the same
throughout with the exception of the dropped beat(s). Also called a Mobitz I or Wenckebach phenomenon,
second-degree AV block type I is represented on the ECG as a progressive lengthening of the PR interval until
there is a P wave without a QRS complex. In first-degree AV block, a P wave precedes every QRS complex,
and every P wave is followed by a QRS.
DIF: Cognitive Level: Analysis REF: p. 131-132 | Figure 7-52B
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
49. Interpret the following rhythm:
a.
Atrial pacing
b.
Ventricular pacing
c.
Dual-chamber pacing
d.
Transcutaneous pacing
ANS: A
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers.
Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick.
This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is
commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows
for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal
cardiac cycle. However, with this patient, ventricular and AV function are normal.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
111
DIF: Cognitive Level: Knowledge REF: p. 134-135 | Figure 7-58
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
50. Interpret the following rhythm:
a.
Atrial pacing
b.
Ventricular pacing
c.
Dual-chamber pacing
d.
Transcutaneous pacing
ANS: B
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers).
Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick.
This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is
commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows
for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal
cardiac cycle. However, with this patient, ventricular and AV function are normal.
DIF: Cognitive Level: Knowledge REF: p. 134-135 | Figure 7-59
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
51. Interpret the following rhythm:
a.
Atrial pacing
b.
Ventricular pacing
c.
Dual-chamber pacing
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
112
Transcutaneous pacing
ANS: C
Pacemakers may be used to stimulate the atrium, ventricle, or both chambers (dual-chamber pacemakers).
Atrial pacing is used to mimic normal conduction and to produce atrial contraction, thus providing atrial kick.
This is the case in the scenario provided. Ventricular pacing stimulates ventricular depolarization and is
commonly used in emergency situations or when pacing is required infrequently. Dual-chamber pacing allows
for stimulation of both atria and ventricles as needed to synchronize the chambers and mimic the normal
cardiac cycle. However, with this patient, ventricular and AV function are normal.
DIF: Cognitive Level: Knowledge REF: p. 134-135 | Figure 7-60
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
52. Interpret the following rhythm:
a.
Normal pacemaker function
b.
Failure to capture.
c.
Failure to pace.
d.
Failure to sense.
ANS: C
Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it should fire. The
problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace include battery or
pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections. This is not normal
pacemaker function. When the pacemaker generates an electrical impulse (pacer spike and no depolarization
is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not followed by a P
wave (atrial pacemaker or a QRS complex (ventricular pacemaker. Common causes of failure to capture
include output (milliamperes set too low, or displacement of the pacing lead wire from the myocardium
(transvenous or epicardial leads. Other causes of failure to capture include battery failure, fracture of the
pacemaker wire, or increased pacing threshold as a result of medication or electrolyte imbalance. When the
pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is called failure
to sense. Failure to sense manifests as pacer spikes that fall too closely to the patients own rhythm, earlier than
the programmed rate. The most common cause is displacement of the pacemaker electrode wire.
DIF: Cognitive Level: Analysis REF: p. 135 | Figure 7-61B
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
113
53. Interpret the following rhythm:
a.
Normal pacemaker function.
b.
Failure to capture.
c.
Failure to pace.
d.
Failure to sense.
ANS: D
Failure to sense manifests as pacer spikes that fall too closely to the patients own rhythm, earlier than the
programmed rate. The most common cause is displacement of the pacemaker electrode wire. This is not
normal pacemaker function. When the pacemaker generates an electrical impulse (pacer spike) and no
depolarization is noted, it is described a failure to capture. On the ECG, a pacer spike is noted, but it is not
followed by a P wave (atrial pacemaker) or a QRS complex (ventricular pacemaker). Common causes of
failure to capture include output (milliamperes) set too low, or displacement of the pacing lead wire from the
myocardium (transvenous or epicardial leads). Other causes of failure to capture include battery failure,
fracture of the pacemaker wire, or increased pacing threshold as a result of medication or electrolyte
imbalance. Failure to pace or fire occurs when the pacemaker fails to initiate an electrical stimulus when it
should fire. The problem is noted by absence of pacer spikes on the rhythm strip. Causes of failure to pace
include battery or pulse generator failure, fracture or displacement of a pacemaker wire, or loose connections.
When the pacemaker does not sense the patients own cardiac rhythm and initiates an electrical impulse, it is
called failure to sense.
DIF: Cognitive Level: Analysis REF: p. 136 | Figure 7-63
OBJ: Explain the basic concepts of cardiac pacing.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The normal width of the QRS complex is which of the following? (Select all that apply.)
a.
0.06 to 0.10 seconds.
b.
0.12 to 0.20 seconds.
c.
1.5 to 2.5 small boxes.
d.
3.0 to 5.0 small boxes.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
e.
114
0.04 seconds or greater.
ANS: A, C
The waveform that initiates the QRS complex (whether it is a Q wave or an R wave) marks the beginning of
the interval. The normal width of the QRS complex is 0.06 to 0.10 seconds. This width equals 1.5 to 2.5 small
boxes. The normal PR interval is 0.12 to 0.20 seconds, three to five small boxes wide; not the QRS interval. A
pathological Q wave has a width of 0.04 seconds and a depth that is greater than one fourth of the R wave
amplitude; therefore, the QRS complex would be wider than that.
DIF: Cognitive Level: Knowledge REF: p. 106
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Which of the following are common causes of sinus tachycardia? (Select all that apply.)
a.
Hyperthyroidism
b.
Hypovolemia
c.
Hypothyroidism
d.
Heart Failure
e.
Sleep
ANS: A, B, D
Common causes of sinus tachycardia include hyperthyroidism, hypovolemia, heart failure, anemia, exercise,
use of stimulants, fever, and sympathetic response to fear or pain and anxiety. Hypothyroidism and sleep tend
to slow the heart rate.
DIF: Cognitive Level: Analysis REF: p. 112
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. Sinus bradycardia is a symptom of which of the following? (Select all that apply.)
a.
Calcium channel blocker medication
b.
Beta-blocker medication
c.
Athletic conditioning
d.
Hypothermia
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e.
115
Hyperthyroidism
ANS: A, B, C, D
Vasovagal response; medications such as digoxin or AV nodal blocking agents, including calcium channel
blockers and beta-blockers; myocardial infarction; normal physiological variant in the athlete; disease of the
sinus node; increased intracranial pressure; hypoxemia; and hypothermia may cause sinus bradycardia.
Hyperthyroidism is a cause of sinus tachycardia.
DIF: Cognitive Level: Analysis REF: pp. 112-113
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who has atrial fibrillation. Sequelae that place the patient at greater risk for
mortality/morbidity include which of the following? (Select all that apply.)
a.
Stroke
b.
Ashman beats
c.
Pulmonary emboli
d.
Prolonged PR interval
e.
Decreased cardiac output
ANS: A, C, E
One complication of atrial fibrillation is thromboembolism. The blood that collects in the atria is agitated by
fibrillation, and normal clotting is accelerated. Small thrombi, called mural thrombi, begin to form along the
walls of the atria. These clots may dislodge, resulting in pulmonary embolism or stroke. The ineffectual
contraction of the atria results in loss of atrial kick. If too many impulses conduct to the ventricles, atrial
fibrillation with rapid ventricular response may result and compromise cardiac output. Ashman beats are not
clinically significant. No recognizable or discernible P waves are present; therefore, PR interval is absent.
DIF: Cognitive Level: Analysis REF: p. 119
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. Because of the location of the AV node, the possible P waveforms that are associated with junctional
rhythms include which of the following? (Select all that apply.)
a.
No P wave
b.
Inverted P wave
c.
Shortened PR interval
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
P wave after the QRS complex
e.
Normal P wave and PR interval
116
ANS: A, B, C, D
Because of the location of the AV nodein the center of the heartimpulses generated may be conducted forward,
backward, or both. With the potential of forward, backward, or bidirectional impulse conduction, three
different P waveforms may be associated with junctional rhythms:
When the AV node impulse moves forward, P waves may be absent because the impulse enters the ventricle
first. The atria receives the wave of depolarization at the same time as the ventricles; thus, because of the larger
muscle mass of the ventricles, there is no P wave. When the AV node impulse is conducted backward, the
impulse enters the atria first. When depolarization occurs backward, an inverted P wave is created. Once the
atria have been depolarized, the impulse moves down the bundle of His and depolarizes both ventricles
normally. A short PR interval (<0.12 second) is noted. When the impulse is conducted both forward and
backward, P waves may be present after the QRS complex.
DIF: Cognitive Level: Knowledge REF: p. 120
OBJ: Interpret the basic dysrhythmias generated from the sinoatrial node, the atria, the atrioventricular node,
and the ventricles. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The patient is in third-degree heart block (complete heart block) and is symptomatic. The treatment for this
patient is which of the following? (Select all that apply.)
a.
transcutaneous pacemaker.
b.
atropine IV.
c.
temporary transvenous pacemaker.
d.
permanent pacemaker.
e.
amiodarone IV.
ANS: A, C, D
Treatments include transcutaneous or transvenous pacing and implanting a permanent pacemaker. Atropine
reduces vagal tone, but that is not a cause of complete heart block and will produce more P waves, but the P
waves will still not be associated with the QRS complexes. It is important to note that the only treatment is
pacing. Amiodarone IV is used to suppress ventricular dysrhythmia and is not used to treat third-degree heart
block.
DIF: Cognitive Level: Knowledge REF: p. 132
OBJ: Describe appropriate interventions for common dysrhythmias.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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117
Chapter 08: Hemodynamic Monitoring
MULTIPLE CHOICE
1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse
assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of
89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which
hemodynamic value requires immediate action by the nurse?
a.
Cardiac index (CI) of 1.2 L/min/m3
b.
Cardiac output (CO) of 4 L/min
c.
Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5
d.
Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5
ANS: A
A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low
cardiac output with fluid overload (bilateral crackles) requiring intervention. The remaining hemodynamic
values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm5; and the systemic vascular resistance of 1800 dynes/sec/cm-5.
DIF: Cognitive Level: Analysis REF: Table 8-1
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion
pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic
intervention?
a.
Diuretics
b.
Intravenous fluids
c.
Negative inotropic agents
d.
Vasopressors
ANS: B
Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be
indicated. Administration of diuretics would worsen the patients volume status. Negative inotropes would not
improve the patients volume status. Vasopressors will increase blood pressure but are contraindicated in a low
volume state.
DIF: Cognitive Level: Analysis REF: p. 161
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118
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications,
what is the priority nursing intervention?
a.
Apply a pressure dressing to the insertion site.
b.
Ensure all tubing connections are tightened.
c.
Obtain a portable x-ray to confirm placement.
d.
Restrain the affected extremity for 24 hours.
ANS: B
Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of
arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal.
Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed to confirm
arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is
the standard of care.
DIF: Cognitive Level: Application REF: p. 154 | Box 8-4
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion
pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to
be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear
to auscultation bilaterally. What is the priority nursing action?
a.
Increase supplemental oxygen and notify respiratory therapy.
b.
Notify the physician immediately of the assessment findings.
c.
Obtain a stat chest x-ray film to verify proper catheter placement.
d.
Zero reference and level the catheter at the phlebostatic axis.
ANS: D
A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the
accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis
and
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
119
zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis,
resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental
oxygen. Clinical manifestations do not warrant physician intervention; aberrant values should be investigated
further. An aberrant value warrants further investigation, which includes zero referencing and checking the
level as an initial measure. A chest x-ray study is not warranted at this time.
DIF: Cognitive Level: Analysis REF: p. 152 | Clinical Alert
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital
signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2
L/min, systemic vascular resistance of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates
administration of which the following therapies or medications?
a.
Blood transfusion
b.
Furosemide (Lasix)
c.
Dobutamine (Dobutrex) infusion
d.
Dopamine hydrochloride (Dopamine) infusion
ANS: A
Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss
requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume
status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are
contraindicated in a volume-depleted state.
DIF: Cognitive Level: Analysis REF: Table 8-1
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a
pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index
of 1.9 L/min/m2. Which physician order is of the highest priority?
a.
Apply 50% oxygen via venture mask.
b.
Insert an indwelling urinary catheter.
c.
Begin a dobutamine (Dobutrex) infusion.
d.
Obtain stat cardiac enzymes and troponin.
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120
ANS: C
The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output
values are low. The priority order for the nurse to implement is to begin a dobutamine (Dobutrex) infusion to
improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments are
important, but the dobutamine infusion is the most important at this time.
DIF: Cognitive Level: Analysis REF: p. 160 | Figure 8-6
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
7. The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial
line. Which assessment finding by the nurse requires immediate action?
a.
A dampened arterial line waveform
b.
Numbness and tingling in the left hand
c.
Slight bloody drainage at subclavian insertion site
d.
Slight redness at subclavian insertion site
ANS: B
Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible
neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with
arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is
not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.
DIF: Cognitive Level: Application REF: p. 154
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
8. The physician writes an order to discontinue a patients left radial arterial line. When discontinuing the
patients invasive line, what is the priority nursing action?
a.
Apply an air occlusion dressing to insertion site.
b.
Apply pressure to the insertion site for 5 minutes.
c.
Elevate the affected limb on pillows for 24 hours.
d.
Keep the patients wrist in a neutral position.
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121
ANS: B
Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure
adequate hemostasis. Application of an air occlusion dressing is not standard of care following removal of an
arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention.
Neutral wrist position is optimum while the catheter is in place and not necessary after catheter
discontinuation.
DIF: Cognitive Level: Comprehension REF: p. 155
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
9. Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper
catheter placement. The radiologist reports to the nurse: The tip of the catheter is located in the superior vena
cava. What is the best interpretation of these results by the nurse?
a.
The catheter is not positioned correctly and should be removed.
b.
The catheter position increases the risk of ventricular dysrhythmias.
c.
The distal tip of the catheter is in the appropriate position.
d.
The physician should be called to advance the catheter into the pulmonary artery.
ANS: C
X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just
above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the
superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters
are placed into great vessels of the venous system and not advanced into the pulmonary artery.
DIF: Cognitive Level: Application REF: Figure 8-16
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary
artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action?
a.
Add an additional 0.5 mL of air to the balloon and repeat the procedure.
b.
Advance the catheter with the balloon deflated and repeat the procedure.
c.
Deflate the balloon and obtain a chest x-ray study to determine line placement.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
122
Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.
ANS: C
Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary
artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid
pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location
of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery
rupture.
Advancing a pulmonary artery catheter is not within the nurses scope of practice.
Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC
should never be locked in the inflated position as rupture of the pulmonary artery may occur.
DIF: Cognitive Level: Application REF: p. 161
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC).
Which assessment finding 2 hours after insertion by the nurse warrants immediate action?
a.
Diminished breath sounds over left lung field
b.
Localized pain at catheter insertion site
c.
Measured central venous pressure of 5 mm Hg
d.
Slight bloody drainage around insertion site
ANS: A
Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a
pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of
central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate
priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at
the insertion site soon after the procedure does not require immediate action.
DIF: Cognitive Level: Application REF: Box 8-2
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving
continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is
the best nursing action?
a.
Do not document hemodynamic values until the patient can be placed in the supine position.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
123
b.
Level and zero reference the air-fluid interface of the transducer with the patient in the supine
position and record hemodynamic values.
c.
Level and zero reference the air-fluid interface of the transducer with the patients head of bed
elevated to 30 degrees and record hemodynamic values.
d.
Level and zero reference the air-fluid interface of the transducer with the patient supine in the sidelying position and record hemodynamic values.
ANS: C
Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated
pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the airfluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least
30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the
risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. Hemodynamic
values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even
though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate
unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.
DIF: Cognitive Level: Application REF: p. 152
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
13. The nurse is educating a patients family member about a pulmonary artery catheter (PAC). Which
statement by the family member best indicates understanding of the purpose of the PAC?
a.
The catheter will provide multiple sites to give intravenous fluid.
b.
The catheter will allow the physician to better manage fluid therapy.
c.
The catheter tip comes to rest inside my brothers pulmonary artery.
d.
The catheter will be in position until the heart has a chance to heal.
ANS: B
A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include
appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is
not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery,
positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of
the heart but to guide therapy.
DIF: Cognitive Level: Comprehension REF: p. 160
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
124
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is
mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the
best nursing action?
a.
Place the patient in the supine position and record the PAOP immediately after exhalation.
b.
Place the patient in the supine position and document the average PAOP obtained after three
measurements.
c.
Place the patient with the head of bed elevated 30 degrees and document the average PAOP
pressure obtained.
d.
Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the
increase in pressures during inhalation.
ANS: D
Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically
ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are
obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the
mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion
pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while
appropriate positioning is maintained.
DIF: Cognitive Level: Analysis REF: p. 150, 160
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
15. The charge nurse is supervising care for a group of patients monitored with a variety of invasive
hemodynamic devices. Which patient should the charge nurse evaluate first?
a.
A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the
past hour
b.
A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial
waveform
c.
A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of
89% on 3 L of oxygen via nasal cannula
d.
A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2
L of oxygen via nasal cannula
ANS: C
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
125
A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative
of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6
mm Hg with 40 mL of hourly urine output are acceptable assessment findings. A patient with a normal blood
pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery
pressure of 25/10 mmHg and a normal oxygen saturation does not require immediate treatment.
DIF: Cognitive Level: Analysis REF: Table 8-1
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
16. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC).
Which action by the nurse best reduces the risk of catheter- related bloodstream infection (CRBSI)?
a.
Review daily the necessity of the central venous catheter.
b.
Cleanse the insertion site daily with isopropyl alcohol.
c.
Change the pressurized tubing system and flush bag daily.
d.
Maintain a pressure of 300 mm Hg on the flush bag.
ANS: A
Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed
to guide treatment is associated with a reduction in mortality. Maintaining of the insertion site should be
guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the
number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours
reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the
integrity of the invasive line and does not reduce the risk of infection.
DIF: Cognitive Level: Application REF: p. 153
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
17. During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the
balloon with 1.5 mL of air. As the physician advances the catheter, the nurse notices premature ventricular
contractions on the monitor. What is the best action by the nurse?
a.
Deflate the balloon while slowly withdrawing the catheter.
b.
Instruct the patient to cough and deep-breathe forcefully.
c.
Inflate the catheter balloon with an additional 1 mL of air.
d.
Ensure lidocaine hydrochloride (IV) is immediately available.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
126
ANS: D
During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter
passes through the right ventricle. Treatment with lidocaine hydrochloride may be necessary to suppress the
irritated ventricle and should be readily available. Withdrawing of the catheter is not within the scope of
practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the
problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes
added may increase the risk of complications.
DIF: Cognitive Level: Application REF: p. 159
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
18. Following insertion of a pulmonary artery catheter (PAC), the physician orders the nurse to obtain a blood
sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value
is accurate?
a.
Zero referencing the transducer at the level of the phlebostatic axis following insertion
b.
Calibrating the system with a central venous blood sample and arterial blood gas value
c.
Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg
d.
Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal
stopcocks
ANS: B
To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC is
accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial
blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems.
Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a
pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring
systems.
DIF: Cognitive Level: Application REF: p. 163
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which
hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the
organs and tissues?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Arterial lactate level of 1.0 mEq/L
b.
Cardiac output of 2.5 L/min
c.
Mixed venous (SvO2 ) of 40%
d.
Cardiac index of 1.5 L/min/m2
127
ANS: A
An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the
tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits
indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.
DIF: Cognitive Level: Analysis REF: pp. 148-149
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity: Physiological Adaptation
20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood
pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and arterial oxygen
saturation (SpO2) of 90% on a 50% venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0
L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3
mm Hg. The nurse questions which of the following physicians order?
a.
Titrate supplemental oxygen to achieve a SpO2 > 94%.
b.
Infuse 500 mL 0.9% normal saline over 1 hour.
c.
Obtain arterial blood gas and serum electrolytes.
d.
Administer furosemide (Lasix) 20 mg intravenously.
ANS: D
A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 1 mm Hg along with a blood
pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of
0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is
contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen, obtaining
serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.
DIF: Cognitive Level: Analysis REF: Table 8-1
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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128
21. The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the
surgical intensive care unit. For which patient is use of this device most appropriate?
a.
A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction
b.
A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon
pump
c.
A patient with a history of atrial fibrillation having frequent episodes of paroxysmal
supraventricular tachycardia
d.
A mechanically ventilated patient admitted following repair of an acute bowel obstruction
ANS: D
Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better
predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an
acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of
monitoring.
Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions
in which pulse contour analysis systems are either inaccurate or contraindicated.
DIF: Cognitive Level: Analysis REF: p. 166
OBJ: Explain the clinical relevance and methods of measuring cardiac output.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. The physician orders a pulmonary artery occlusive (PAOP) for a patient being monitored with a pulmonary
artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform
indicated on the strip below. What are the best actions by the nurse?
Figure from Geiter H, Jr.: Swan-Ganz Catheters. Nurse411.com. http://www.nurse411.com/Swan_Ganz.asp.
Accessed April 2012.
a.
Turn the patient to the left side; obtain a stat portable chest xray.
b.
Place the patient supine; repeat zero-referencing of the system.
c.
Document the wedge pressure; continue monitoring the patient.
d.
Perform an immediate dynamic response test; obtain a chest xray.
ANS: C
After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates
the waveform has returned to a normal pulmonary artery waveform. The nurse should document the occlusive
value and continue monitoring the patient. Turning the patient to the left side, zero-referencing the system and
performing a dynamic response test are not necessary as the waveform displayed is normal.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
129
DIF: Cognitive Level: Analysis REF: p. 160
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
23. The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patients
noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an
intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the best action by
the nurse?
a.
Activate the rapid response system.
b.
Place the patient in Trendelenburg position.
c.
Assess the cuff for proper arm size.
d.
Administer 0.9% normal saline bolus.
ANS: C
Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood
pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for
noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially
higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the
rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further
assessment and troubleshooting are necessary.
DIF: Cognitive Level: Analysis REF: p. 148
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. The nurse is caring for a patient with an admitting diagnosis of congestive failure. While attempting to
obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and
tachypneic. What is the best action by the nurse?
a.
Limit the patients supine position to no more than 10 seconds.
b.
Administer anxiety medications while recording the pressure.
c.
Encourage the patient to take slow deep breaths while supine.
d.
Elevate the head of the bed 45 degrees while recording pressures.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
130
ANS: D
Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45
degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the
bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient
that becomes anxious and tachypneic when flat. Administering anxiety medications is not standard of care for
obtaining hemodynamic pressures. Encouraging slow deep breaths while supine may inappropriately alter
hemodynamic readings by altering intrathoracic pressure.
DIF: Cognitive Level: Application REF: p. 150
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk
25. The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a
pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Prior to obtaining
a cardiac output, which action is most important for the nurse to complete?
a.
Document a pulmonary artery catheter occlusion pressure.
b.
Zero reference the transducer system at the phlebostatic axis.
c.
Inflate the pulmonary artery catheter balloon with 1 mL air.
d.
Inject 10 mL of 0.9% normal saline into the proximal port.
ANS: B
To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a
patient and should be completed prior to injecting 10 mL of room temperature 0.9% normal saline. A
pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but
without zero referencing the system following movement of a patient, the obtained value may be inaccurate.
Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required prior
to obtaining a cardiac output.
DIF: Cognitive Level: Application REF: p. 152
OBJ: Analyze the conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation
26. The charge nurse is supervising the care of four critical care patients being monitored using invasive
hemodynamic modalities. Which patient should the charge nurse evaluate first?
a.
A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min
b.
A patient with a pulmonary artery systolic pressure (PAP) of 20 mm Hg
c.
A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
131
A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
ANS: A
A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of
20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.
DIF: Cognitive Level: Knowledge REF: Table 8-1
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation
27. The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line.
During the inspiratory phase of ventilation, the nurse assesses a 20 mm Hg decrease in arterial blood pressure.
What is the best interpretation of this finding by the nurse?
a.
The mechanical ventilator is malfunctioning.
b.
The patient may require fluid resuscitation.
c.
The arterial line may need to be replaced.
d.
The left limb may have reduced perfusion.
ANS: B
The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation
decreases venous return, decreasing systolic blood pressure.
A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is
indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no
evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb
may have reduced perfusion.
DIF: Cognitive Level: Comprehension REF: p. 167
OBJ: Analyze the conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation
28. Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be
slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the
nurse?
a.
Check the inflation volume of the flush system pressure bag.
b.
Disconnect the flush system from the arterial line catheter.
c.
Zero reference the transducer system at the phlebostatic axis.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
132
Reduce the number of stopcocks in the flush system tubing.
ANS: A
To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be
inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of
blood into the system tubing. Disconnecting the flush system from the arterial line is not appropriate and could
increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the
system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to
excessive blood loss.
DIF: Cognitive Level: Application REF: p. 149
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation
29. The nurse is caring for a patient with a left radial arterial line, and a pulmonary artery catheter inserted into
the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with
invasive hemodynamic monitoring lines?
a.
Document all waveform values.
b.
Limit the pressure tubing length.
c.
Zero reference the system daily.
d.
Ensure alarm limits are turned on.
ANS: D
When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in
the patients condition. Hemodyanamic values and waveforms are recorded at scheduled intervals and it is
important that the tubing not be too long; however, alarm alerts are of highest priority. The lines are zero
referenced per hospital policy, more frequently than daily.
DIF: Cognitive Level: Application REF: Box 8-4
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
30. The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored
with a pulmonary artery catheter. Which action by the nurse best ensures the safety of the patient?
a.
Ensure the transducer system is zero referenced at the level of the phlebostatic axis.
b.
Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Maintain a pressure of 300 mm Hg on the flush solution using a pressure bag.
d.
Limit the length of the noncompliant pressure tubing to a maximum 48 inches.
133
ANS: B
Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO)
measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate
solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure
bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not
influence safety.
DIF: Cognitive Level: Application REF: Box 8-9
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions?
(Select all that apply.)
a.
Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change.
b.
Inflate the balloon with air, recording the volume necessary to obtain a reading.
c.
Maintain the balloon in the inflated position for 8 hours following insertion.
d.
Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic
axis.
ANS: A, B, D
To obtain an accurate pulmonary artery occlusion pressure (PAOP, the transducer system should be zero
referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no
more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the
balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary
infarction.
DIF: Cognitive Level: Comprehension REF: p. 152 | 160-161
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
2. The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
134
nursing actions? (Select all that apply.)
a.
Compare measured pressures with other physiological parameters.
b.
Flush the central venous catheter with 20 mL of sterile saline.
c.
Inflate the balloon with 3 mL of air and record the pressure tracing.
d.
Obtain the right atrial pressure measurement during end exhalation.
e.
Zero reference the transducer system at the level of the phlebostatic axis.
ANS: A, D, E
To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero
referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained
during end exhalation, and any obtained measure should be evaluated in light of the patients physiological
parameters and physical assessment. The catheter does not need to be flushed before measurement because
continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP)
catheter.
DIF: Cognitive Level: Analysis REF: p. 156
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
3. The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter,
what are the priority nursing actions? (Select all that apply.)
a.
Allay the patients anxiety by providing information about the procedure.
b.
Ensure that a sterile field is maintained during the insertion procedure.
c.
Inflate the balloon during the procedure when indicated by the physician.
d.
Monitor the patients cardiac rhythm throughout the entire procedure.
e.
Obtain informed consent by informing the patient of procedural risks.
ANS: A, B, C, D
During insertion of a pulmonary artery catheter (PAC/Swan-Ganz, the nurse should allay the patients anxiety,
ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of
the physician to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter
passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the
physician and should occur before the procedure begins.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
135
DIF: Cognitive Level: Comprehension REF: pp. 158-160
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
4. Which nursing actions are most important for a patient with a right radial arterial line? (Select all that
apply.)
a.
Checking the circulation to the right hand every 2 hours
b.
Maintaining a pressurized flush solution to the arterial line setup
c.
Monitoring the waveform on the monitor for dampening
d.
Restraining all four extremities with soft limb restraints
ANS: A, B, C
Options A, B, and C are required to ensure proper functioning of the arterial line.
There is no need to restrain all extremities. Depending on the patients level of sedation, the right hand may
need gentle restraint.
DIF: Cognitive Level: Comprehension REF: p. 149, 154
OBJ: Describe the indications, measurement, complications, and nursing implications associated with
monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated
with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
5. Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that
apply.)
a.
Exercise
b.
Hypovolemia
c.
Myocardial infarction
d.
Shock
ANS: B, C, D
Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is
usually increased with exercise.
DIF: Cognitive Level: Knowledge REF: Box 8-8
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
136
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
137
Chapter 09: Ventilatory Assistance
MULTIPLE CHOICE
1. A patient has coronary artery bypass graft surgery and is transported to the surgical intensive care unit at
noon. He is placed on mechanical ventilation. Interpret his initial arterial blood gas levels:
pH 7.31
PaCO2 48 mm Hg
Bicarbonate 22 mEq/L
PaO2 115 mm Hg
O2 saturation 99%
a.
Normal arterial blood gas levels with a high oxygen level
b.
Partly compensated respiratory acidosis, normal oxygen
c.
Uncompensated metabolic acidosis with high oxygen levels
d.
Uncompensated respiratory acidosis; hyperoxygenated
ANS: D
The high PaO2 level reflects hyperoxygenation; the PaCO2 and pH levels show respiratory acidosis. The
respiratory acidosis is uncompensated as indicated by a pH of 7.31 (acidosis and a normal bicarbonate level.
No metabolic compensation has occurred.
DIF: Cognitive Level: Analysis REF: pp. 178-179 | Box 9-2 | Box 9-3
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The physician orders the following mechanical ventilation settings for a patient who weighs 75 kg. The
patients spontaneous respiratory rate is 22 breaths/min. What arterial blood gas abnormality may occur if the
patient continues to be tachypneic at these ventilator settings?
Settings:
Tidal volume: 600 mL (8 mL per kg
FiO2: 0.5
Respiratory rate: 14 breaths/min
Mode assist/control
Positive end-expiratory pressure: 10 cm H2O
a.
Metabolic acidosis
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
138
ANS: D
Assist/control ventilation may result in respiratory alkalosis, especially when the
patient is breathing at a high rate. Each time the patient initiates a spontaneous breathin this case 22 times per
minutethe ventilator will deliver 600 mL of volume.
DIF: Cognitive Level: Analysis REF: p. 197
OBJ: Relate complications associated with mechanical ventilation.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
3. A patients ventilator settings are adjusted to treat hypoxemia. The fraction of inspired oxygen is increased
from .60 to .70, and the positive end-expiratory pressure is increased from 10 to 15 cm H2O. Shortly after these
adjustments, the nurse notes that the patients blood pressure drops from 120/76 mm Hg to 90/60 mm Hg. What
is the most likely cause of this decrease in blood pressure?
a.
Decrease in cardiac output
b.
Hypovolemia
c.
Increase in venous return
d.
Oxygen toxicity
ANS: A
Positive end-expiratory pressure increases intrathoracic pressure and may result in decreased venous return.
Cardiac output decreases as a result, and is reflected in the lower blood pressure. It is essential to assess the
patient to identify optimal positive end-expiratory pressurethe highest amount that can be applied without
compromising cardiac output. Although hypovolemia can result in a decrease in blood pressure, there is no
indication that this patient has hypovolemia. As noted, higher levels of positive end-expiratory pressure may
cause a decrease, not an increase, in venous return. Oxygen toxicity can occur in this case secondary to the
high levels of oxygen needed to maintain gas exchange; however, oxygen toxicity is manifested in damage to
the alveoli.
DIF: Cognitive Level: Analysis REF: p. 196
OBJ: Relate complications associated with mechanical ventilation.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient with an endotracheal tube. The nurse understands that endotracheal
suctioning is needed to facilitate removal of secretions and that the procedure:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
decreases intracranial pressure.
b.
depresses the cough reflex.
c.
is done as indicated by patient assessment.
d.
is more effective if preceded by saline instillation to loosen secretions.
139
ANS: C
Suctioning is performed as indicated by patients assessment. Suctioning is associated with increases in
intracranial pressure; therefore, it is important to hyperoxygenate the patient prior to suctioning to reduce this
complication. Suctioning can stimulate the cough reflex rather than depress this reflex. Saline instillation is
associated with negative physiological outcomes and is not recommended as part of the suctioning procedure;
it does not loosen secretions, which is a common misperception.
DIF: Cognitive Level: Comprehension REF: p. 193 | Box 9-7 | Nursing Care Plan
OBJ: Discuss methods for maintaining an open airway.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. A 65-year-old patient is admitted to the progressive care unit with a diagnosis of community-acquired
pneumonia. The patient has a history of chronic obstructive pulmonary disease and diabetes. A set of arterial
blood gases obtained on admission without supplemental oxygen shows pH 7.35; PaCO2 55 mm Hg;
bicarbonate 30 mEq/L; PaO2 65 mm Hg. These blood gases reflect:
a.
hypoxemia and compensated metabolic alkalosis.
b.
hypoxemia and compensated respiratory acidosis.
c.
normal oxygenation and partly compensated metabolic alkalosis.
d.
normal oxygenation and uncompensated respiratory acidosis.
ANS: B
The PaO2 of 65 mm Hg is lower than normal range (80-100 mm Hg, indicating hypoxemia. The high PaCO2
indicates respiratory acidosis. The elevated bicarbonate indicates metabolic alkalosis. Because the pH is
normal, the underlying acid-base alteration is compensated. Given the patients history of chronic pulmonary
disease and a pH that is at the lower end of normal range, it can be determined that this patient is hypoxemic
with fully compensated respiratory acidosis.
DIF: Cognitive Level: Analysis REF: pp. 181-182 | Box 9-2 | Box 9-3
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
140
6. A patients status worsens and needs mechanical ventilation. The pulmonologist wants the patient to receive
10 breaths/min from the ventilator but wants to encourage the patient to breathe spontaneously in between the
mechanical breaths at his own tidal volume. This mode of ventilation is called:
a.
assist/control ventilation
b.
controlled ventilation
c.
intermittent mandatory ventilation
d.
positive end-expiratory pressure
ANS: C
The intermittent mandatory ventilation mode allows the patient to breathe spontaneously between breaths. The
patient will receive a preset tidal volume at a preset rate. Any additional breaths that he initiates will be at his
spontaneous tidal volume, which will likely be lower than the ventilator breaths. In assist/control ventilation,
spontaneous effort results in a preset tidal volume delivered by the ventilator. Spontaneous effort during
controlled ventilation results in patient/ventilator dyssynchrony. Positive end-expiratory pressure (PEEP) is
application of positive pressure to breaths delivered by the ventilator. PEEP is an adjunct to both intermittent
mandatory and assist/control ventilation.
DIF: Cognitive Level: Application REF: p. 198
OBJ: Describe types and modes of mechanical ventilation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A patients endotracheal tube is not secured tightly. The respiratory care practitioner assists the nurse in
taping the tube. After the tube is retaped, the nurse auscultates the patients lungs and notes that the breath
sounds over the left lung fields are absent. The nurse suspects that:
a.
the endotracheal tube is in the right mainstem bronchus.
b.
the patient has a left pneumothorax.
c.
the patient has aspirated secretions during the procedure.
d.
the stethoscope earpiece is clogged with wax.
ANS: A
The endotracheal tube can become dislodged during repositioning and is likely in the right mainstem bronchus.
It is important to reassess breath sounds after the retaping procedure. A pneumothorax would also result in
diminished or absent breath sounds; however, it is not associated with repositioning the endotracheal tube.
Aspiration may occur during the procedure but would be manifested in changes in chest x-ray, hypoxemia, etc.
The stethoscope is not a factor.
DIF: Cognitive Level: Analysis REF: p. 193 | Box 9-7 | Nursing Care Plan
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
141
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
8. A mode of pressure-targeted ventilation that provides positive pressure to decrease the workload of
spontaneous breathing through the endotracheal tube is:
a.
continuous positive airway pressure.
b.
positive end-expiratory pressure.
c.
pressure support ventilation.
d.
T-piece adapter.
ANS: C
Pressure support (PS) is a mode of ventilation in which the patients spontaneous respiratory activity is
augmented by the delivery of a preset amount of inspiratory positive pressure. Positive end-expiratory pressure
provides positive pressure at end expiration during mechanical breaths, and continuous positive airway
pressure provides positive pressure during spontaneous breaths. The T-piece adapter is used to provide oxygen
with spontaneous, unassisted breaths.
DIF: Cognitive Level: Comprehension REF: pp. 199-200
OBJ: Describe types and modes of mechanical ventilation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
9. Neuromuscular blocking agents are used in the management of some ventilated patients. Their primary
mode of action is:
a.
analgesia.
b.
anticonvulsant.
c.
paralysis.
d.
sedation.
ANS: C
Neuromuscular blocking agents cause respiratory muscle paralysis. They do not have sedative, analgesic, or
anticonvulsant effects.
DIF: Cognitive Level: Comprehension REF: pp. 212-213
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Implementation
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
142
MSC: NCLEX: Physiological Integrity
10. One of the early signs of the effect of hypoxemia on the nervous system is:
a.
cyanosis.
b.
restlessness.
c.
tachycardia.
d.
tachypnea.
ANS: B
Decreased oxygenation to the nervous system may result in restlessness and agitationearly signs of hypoxemia.
Cyanosis is a late sign. Tachycardia and tachypnea may occur, but CNS changes tend to occur earlier.
DIF: Cognitive Level: Comprehension REF: p. 179 | Box 9-1
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. The amount of effort needed to maintain a given level of ventilation is termed:
a.
compliance.
b.
resistance.
c.
tidal volume.
d.
work of breathing.
ANS: D
Work of breathing is the amount of effort needed to maintain a given level of ventilation. Compliance is a
measure of the distensibility, or stretchability, of the lung and chest wall. Resistance refers to the opposition to
the flow of gases in the airways. Tidal volume is the volume of air in a typical breath.
DIF: Cognitive Level: Comprehension REF: p. 173
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. Which of the following devices is best suited to deliver 65% oxygen to a patient who is spontaneously
breathing?
a.
Face mask with non-rebreathing reservoir
b.
Low-flow nasal cannula
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Simple face mask
d.
Venturi mask
143
ANS: A
Face masks with reservoirs (partial rebreathing and non-rebreathing reservoir masks) provide oxygen
concentration of 60% or higher. The addition of the reservoir increases the amount of oxygen available to the
patient during inspiration and allows for the delivery of concentrations of 35% to 60% (partial rebreather) or
60% to 80% (non-rebreather) depending on the flowmeter setting, the fit of the mask, and the patients
respiratory pattern. The high-flow nasal cannula, not the traditional low-flow models, can provide higher flows.
The simple face mask can deliver flows up to 60%. The Venturi mask allows better regulation of oxygen
concentration and generally does not deliver more than 60% oxygen.
DIF: Cognitive Level: Comprehension REF: pp. 183-184
OBJ: Compare commonly used oxygen delivery devices.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
13. A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a
rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate,
and his respirations decrease to 4 breaths/min. Which acid-base disturbance will likely occur?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
ANS: C
The morphine caused respiratory depression. As a result, the frequency and depth of respiration is
compromised, which can lead to respiratory acidosis.
DIF: Cognitive Level: Application REF: p. 198 | Box 9-2
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
14. A patient is being mechanically ventilated in the synchronized intermittent mandatory ventilation mode at a
rate of 4 breaths/min. His spontaneous respirations are 12 breaths/min. He receives a dose of morphine sulfate,
and his respirations decrease to 4 breaths/min. What adjustments may need to be made to the patients ventilator
settings?
a.
Add positive end-expiratory pressure (PEEP).
b.
Add pressure support.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Change to assist/control ventilation at a rate of 4 breaths/min.
d.
Increase the synchronized intermittent mandatory ventilation respiratory rate.
144
ANS: D
The morphine caused respiratory depression. As a result, the frequency and depth of respiration is
compromised, which can lead to respiratory acidosis. The respiratory rate on the mechanical ventilator needs to
be increased. The patient also may need to have naloxone administered to reverse the effects of the morphine.
PEEP is added to improve oxygenation; it does not increase the rate or depth of respirations. Pressure support
will not be effective in increasing the rate of spontaneous respiration. Changing to assist/control ventilation is
an option; however, the rate needs to be set higher than 4 breaths/min.
DIF: Cognitive Level: Analysis REF: pp. 204-207, 212 | Box 9-2
OBJ: Relate complications associated with mechanical ventilation.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
15. Current guidelines recommend the oral route for endotracheal intubation. The rationale for this
recommendation is that nasotracheal intubation is associated with a greater risk for:
a.
basilar skull fracture.
b.
cervical hyperextension.
c.
impaired ability to mouth words.
d.
sinusitis and infection.
ANS: D
Nasotracheal intubation is associated with an increased risk for sinusitis, which may contribute to ventilatorassociated infection. Nasal intubation is contraindicated in patients with basilar skull fracture. The procedure is
sometimes performed in patients with cervical spine injury; the procedure can be done without hyperextending
the neck. Patients with nasotracheal tubes are generally more comfortable and have a greater ability to mouth
words.
DIF: Cognitive Level: Comprehension REF: p. 187 | Box 9-6
OBJ: Discuss methods for maintaining an open airway.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
16. Oxygen saturation (SaO2) represents:
a.
alveolar oxygen tension.
b.
oxygen that is chemically combined with hemoglobin.
c.
oxygen that is physically dissolved in plasma.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
145
total oxygen consumption.
ANS: B
Oxygen saturation value reflects the saturation of the hemoglobin.
DIF: Cognitive Level: Knowledge REF: p. 178
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. Pulse oximetry measures:
a.
arterial blood gases.
b.
hemoglobin values.
c.
oxygen consumption.
d.
oxygen saturation.
ANS: D
Pulse oximetry measures oxygen saturation in the peripheral tissues. It does not measure arterial blood gases,
but it does estimate the PaO2 that is obtained via a blood gas analysis. It does not measure hemoglobin levels
or oxygen consumption.
DIF: Cognitive Level: Comprehension REF: p. 182
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. A PaCO2 of 48 mm Hg is associated with:
a.
hyperventilation.
b.
hypoventilation.
c.
increased absorption of O2.
d.
increased excretion of HCO3.
ANS: B
PaCO2 rises in patients with hypoventilation. Hyperventilation results in a decrease in PaCO2. PaCO2 does not
affect oxygen absorption. Increased excretion of bicarbonate would result in metabolic acidosis.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
146
DIF: Cognitive Level: Application REF: p. 180
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. The nurse notes that the patients arterial blood gas levels indicate hypoxemia. The patient is not intubated
and has a respiratory rate of 22 breaths/min. The nurses first intervention to relieve hypoxemia is to:
a.
call the physician for an emergency intubation procedure.
b.
obtain an order for bilevel positive airway pressure (BiPAP).
c.
notify the provider of values and obtain order for oxygen.
d.
suction secretions from the oropharynx.
ANS: C
Oxygen is administered to treat or prevent hypoxemia. Oxygen should be considered a first-line treatment in
cases of hypoxemia. Emergency intubation is not warranted at this time. BiPAP may be considered if
administration of supplemental oxygen does not correct the hypoxemia. There is no indication that the patient
requires suctioning.
DIF: Cognitive Level: Analysis REF: p. 183
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
20. A patient presents to the emergency department demonstrating agitation and complaining of numbness and
tingling in his fingers. His arterial blood gas levels reveal the following: pH 7.51, PaCO2 25, HCO3 25. The
nurse interprets these blood gas values as:
a.
compensated metabolic alkalosis.
b.
normal values.
c.
uncompensated respiratory acidosis.
d.
uncompensated respiratory alkalosis.
ANS: D
The low PaCO2 and high pH values show respiratory alkalosis. The bicarbonate level is normal.
DIF: Cognitive Level: Analysis REF: pp. 181-182 | Table 9-3
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation
of
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
147
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
21. Positive end-expiratory pressure (PEEP) is a mode of ventilatory assistance that produces the following
condition:
a.
Each time the patient initiates a breath, the ventilator delivers a full preset tidal volume.
b.
For each spontaneous breath taken by the patient, the tidal volume is determined by the patients
ability to generate negative pressure.
c.
The patient must have a respiratory drive, or no breaths will be delivered.
d.
There is pressure remaining in the lungs at the end of expiration that is measured in cm H2O.
ANS: D
PEEP is the addition of positive pressure into the airways during expiration. PEEP is measured in centimeters
of water.
DIF: Cognitive Level: Comprehension REF: p. 196
OBJ: Describe types and modes of mechanical ventilation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. The nurse is caring for a patient who is mechanically ventilated. As part of the nursing care, the nurse
understands that:
a.
communication with intubated patients is often difficult.
b.
controlled ventilation is the preferred mode for most patients.
c.
patients with chronic obstructive pulmonary disease wean easily from mechanical ventilation.
d.
wrist restraints are applied to all patients to avoid self-extubation.
ANS: A
Communication difficulties are common because of the artificial airway. Restraints must be determined
individually. Patients with chronic obstructive pulmonary disease often have difficulty weaning. Synchronized
intermittent mandatory ventilation and assist/control ventilation are the commonly used modes.
DIF: Cognitive Level: Application REF: p. 212 | Nursing Care Plan
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
23. A patient is having difficulty weaning from mechanical ventilation. The nurse assesses the patient for a
potential cause of this difficult weaning, which includes:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
cardiac output of 6 L/min.
b.
hemoglobin of 8 g/dL.
c.
negative sputum culture and sensitivity.
d.
white blood cell count of 8000.
148
ANS: B
The low hemoglobin level will decrease oxygen-carrying capacity and may make weaning difficult. A cardiac
output of 6 L/min is normal. A negative sputum culture indicates absence of lower respiratory infection, which
should promote rather than hinder weaning. A white blood cell count of 8000 is normal and indicates absence
of infection, which should promote rather than hinder weaning.
DIF: Cognitive Level: Analysis REF: pp. 213-215
OBJ: Explain methods for weaning patients from mechanical ventilation.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
24. A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery
with the following arterial blood gas (ABG) levels. What is the nurses interpretation of these values?
pH 7.4
PaCO2 40 mm Hg
Bicarbonate 24 mEq/L
PaO2 95 mm Hg
O2 saturation 97%
Respirations 20 breaths per minute
a.
Compensated metabolic acidosis
b.
Metabolic alkalosis
c.
Normal ABG values
d.
Respiratory acidosis
ANS: C
These are normal values. All parameters are within normal limits.
DIF: Cognitive Level: Analysis REF: p. 181 | Table 9-3
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
149
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery.
Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and
normal arterial blood gases (ABGs), and is placed on a T-piece for ventilatory weaning. During the nurses 7
PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36
breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10
premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse
suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The
nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study.
How does the nurse interpret the following blood gas levels?
pH 7.28
PaCO2 46 mm Hg
Bicarbonate 22 mEq/L
PaO2 58 mm Hg
O2 saturation 88%
a.
Hypoxemia and compensated respiratory alkalosis
b.
Hypoxemia and uncompensated respiratory acidosis
c.
Normal arterial blood gas levels
d.
Normal oxygen level and partially compensated metabolic acidosis
ANS: B
These levels show respiratory acidosis. The bicarbonate is normal; therefore, no compensation has occurred.
This patient is also hypoxemic.
DIF: Cognitive Level: Analysis REF: p. 181 | Table 9-3
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
26. A 53-year-old, 80-kg patient is admitted to the cardiac surgical intensive care unit after cardiac surgery.
Four hours after admission to the surgical intensive care unit at 4 PM, the patient has stable vital signs and
normal arterial blood gases (ABGs) and is placed on a T-piece for ventilatory weaning. During the nurses 7
PM (1900) assessment, the patient is restless, heart rate has increased to 110 beats/min, respirations are 36
breaths/min, and blood pressure is 156/98 mm Hg. The cardiac monitor shows sinus tachycardia with 10
premature ventricular contractions (PVCs) per minute. Pulmonary artery pressures are elevated. The nurse
suctions the patient and obtains pink, frothy secretions. Loud crackles are audible throughout lung fields. The
nurse notifies the physician, who orders an ABG analysis, electrolyte levels, and a portable chest x-ray study.
In communicating with the physician, which statement indicates the nurse understands what is likely occurring
with the patient?
a.
May we have an order for cardiac enzymes? This patient is exhibiting signs of a myocardial
infarction.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
My assessment indicates potential fluid overload.
c.
The patient is having frequent PVCs that are compromising the cardiac output.
d.
The patient is having a hypertensive crisis; what medications would you like to order?
150
ANS: B
The crackles, high pulmonary artery pressure, and pink, frothy sputum indicate fluid volume overload. There
are not any cues to suggest a myocardial infarction. The PVCs may be related to the surgery or hypoxemia;
however, the blood pressure indicates adequate perfusion. The blood pressure is high secondary to fluid
overload; treatment of the fluid overload will result in a decrease in blood pressure.
DIF: Cognitive Level: Analysis REF: pp. 177-178
OBJ: Describe methods for assessing the respiratory system, including physical assessment, interpretation of
arterial blood gases, and noninvasive techniques.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
27. The nurse is caring for a mechanically ventilated patient and notes the high pressure alarm sounding. The
nurse cannot quickly identify the cause of the alarm and notes the patients oxygen saturation is decreasing and
heart rate and respiratory rate are increasing. The nurses priority action is to:
a.
ask the respiratory therapist to get a new ventilator.
b.
call the rapid response team to assess the patient.
c.
continue to find the cause of the alarm and fix it.
d.
manually ventilate the patient while calling for a respiratory therapist.
ANS: D
The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not
assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting
the problem. The patient must be treated while the causes are being assessed by the nurse and respiratory
therapist. Continuing to assess for the cause without manually ventilating the patient can result in patient
compromise. The respiratory therapist, not the rapid response team, will assess and remedy the problem. A
new ventilator may be needed, but that would be determined after the respiratory therapist has assessed the
situation.
DIF: Cognitive Level: Analysis REF: pp. 203-204
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
28. The nurse is caring for a patient whose ventilator settings include 15 cm H2O of positive end-expiratory
pressure (PEEP). The nurse understands that although beneficial, PEEP may result in:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
fluid overload secondary to decreased venous return.
b.
high cardiac index secondary to more efficient ventricular function.
c.
hypoxemia secondary to prolonged positive pressure at expiration.
d.
low cardiac output secondary to increased intrathoracic pressure
151
ANS: D
Positive end-expiratory pressure, especially at higher levels, can result in a decreased cardiac output and index
secondary to increased intrathoracic pressure, which impedes venous return. Fluid overload is not an expected
finding. The cardiac index would likely decrease, not increase, along with cardiac output. PEEP is used to treat
hypoxemia; it does not cause it.
DIF: Cognitive Level: Analysis REF: p. 196
OBJ: Relate complications associated with mechanical ventilation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
29. When assessing the patient for hypoxemia, the nurse recognizes that an early sign of the effect of
hypoxemia on the cardiovascular system is:
a.
heart block.
b.
restlessness.
c.
tachycardia.
d.
tachypnea.
ANS: C
Tachycardia can occur as a compensatory mechanism to increase cardiac output and oxygenation.
Dysrhythmias may occur; however, they are not an early sign and tend to be premature ventricular
contractions. Restlessness is an early neurological sign, whereas tachypnea is an early respiratory sign.
DIF: Cognitive Level: Comprehension REF: p. 179 | Box 9-1
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
30. The nurse is caring for a mechanically ventilated patient. The physicians are considering performing a
tracheostomy because the patient is having difficulty weaning from mechanical ventilation. Related to
tracheostomy, the nurse understands which of the following?
a.
Patient outcomes are better if the tracheostomy is done within a week of intubation.
b.
Percutaneous tracheostomy can be done safely at the bedside by the respiratory therapist.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Procedures performed in the operating room are associated with fewer complications.
d.
The greatest risk after a percutaneous tracheostomy is accidental decannulation.
152
ANS: D
Optimal timing of tracheostomy is not yet known. Percutaneous procedures done at the bedside are not
associated with any higher risks than those done in the operating room. Trained physicians safely perform
percutaneous tracheostomies at the bedside. The greatest risk for percutaneous tracheostomy is accidental
decannulation because the trachea is not surgically attached.
DIF: Cognitive Level: Analysis REF: pp. 190-191
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
31. The nurse is assessing the exhaled tidal volume (EVT) in a mechanically ventilated patient. The rationale
for this assessment is to:
a.
assess for tension pneumothorax.
b.
assess the level of positive end-expiratory pressure.
c.
compare the tidal volume delivered with the tidal volume prescribed.
d.
determine the patients work of breathing.
ANS: C
The EVT is assessed to determine if the patient is receiving the tidal volume that is prescribed. Volume may be
lost because of leaks in the ventilator circuit, around the endotracheal tube cuff, or around a chest tube. The
assessment will not detect a pneumothorax and does not assess positive end-expiratory pressure or work of
breathing.
DIF: Cognitive Level: Comprehension REF: p. 197
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The nurse is caring for a mechanically ventilated patient and responds to a high inspiratory pressure alarm.
Recognizing possible causes for the alarm, the nurse assesses for which of the following? (Select all that
apply.)
a.
Coughing or attempting to talk
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Disconnection from the ventilator
c.
Kinks in the ventilator tubing
d.
Need for suctioning
153
ANS: A, C, D
Coughing, kinks, and mucus in the airway can cause the inspiratory pressure to increase; ventilator disconnects
result in low-volume alarms. A disconnection from the ventilator would result in a low exhaled volume alarm,
not a high-pressure alarm.
DIF: Cognitive Level: Analysis REF: pp. 203-204 | Table 9-4
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
2. Select all of the factors that may predispose the patient to respiratory acidosis.
a.
Anxiety and fear
b.
Central nervous system depression
c.
Diabetic ketoacidosis
d.
Nasogastric suctioning
e.
Overdose of sedatives
ANS: B, E
Central nervous system depression and drug overdose may result in hypoventilation and cause respiratory
acidosis. Anxiety is a cause of hyperventilation and respiratory alkalosis. Diabetic ketoacidosis is a cause of
metabolic acidosis. Nasogastric suctioning is a cause of metabolic alkalosis.
DIF: Cognitive Level: Comprehension REF: p. 180 | Box 9-2
OBJ: Review the anatomy and physiology of the respiratory system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is assisting with endotracheal intubation and understands correct placement of the endotracheal
tube in the trachea would be identified by which of the following? (Select all that apply.)
a.
Auscultation of air over the epigastrium
b.
Equal bilateral breath sounds upon auscultation
c.
Position above the carina verified by chest x-ray
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
154
Positive detection of carbon dioxide (CO2) through CO2 detector devices
ANS: B, C, D
The position of the tube is assessed after intubation through auscultation of breath sounds, carbon dioxide
testing, and chest x-ray. Auscultation of air over the epigastrium indicates placement in the esophagus rather
than the trachea.
DIF: Cognitive Level: Analysis REF: p. 190
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment
COMPLETION
1. The nurse is caring for a mechanically ventilated patient and is charting outside the patients room when the
ventilator alarm sounds. What is the priority order for the nurse to complete these actions: _______________,
_______________, _______________, _______________? (Put a comma and space between each answer
choice.)
A. Check quickly for possible causes of the alarm that can be fixed.
B. After troubleshooting, connect back to mechanical ventilator and reassess patient.
C. Go to patients bedside.
D. Manually ventilate the patient while getting respiratory therapist.
ANS:
C, A, D, B
The nurse must quickly assess the patient and determine possible causes of the alarm. If the cause is not
assessed within seconds, the nurse must manually ventilate the patient and secure assistance in troubleshooting
the problem. Once the problem has been corrected, the patient must be reassessed.
DIF: Cognitive Level: Analysis REF: pp. 203-204
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. The nurse is assisting with endotracheal intubation of the patient and recognizes that the procedure will be
done in what order: _______________, _______________, _______________, _______________,
_______________? (Put a comma and space between each answer choice.)
A. Assess balloon on endotracheal tube for symmetry and leaks.
B. Assess lung fields for bilateral expansion.
C. Inflate balloon of endotracheal tube.
D. Insert endotracheal tube with laryngoscope and blade.
E. Suction oropharynx.
ANS:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
155
A, E, D, C, B
Intubation is done systematically by the physician, therapist, or anesthetist. Equipment is gathered and assessed
(e.g., balloon/cuff on endotracheal tube). The patient is hyperoxygenated and secretions are suctioned from the
oropharynx to visualize the vocal cords. The tube is inserted, and the balloon is inflated once the tube is in
place. The position of the tube is assessed after intubation through auscultation of breath sounds, carbon
dioxide testing, and chest x-ray.
DIF: Cognitive Level: Analysis REF: pp. 188-189
OBJ: Formulate a plan of care for the mechanically ventilated patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
156
Chapter 10: Rapid Response Teams and Code Management
MULTIPLE CHOICE
1. The nurse chooses which method and concentration of oxygen administration until intubation is established
in a patient who has sustained a cardiopulmonary arrest?
a.
Bag-valve-mask at FiO2 of 100%
b.
Bag-valve-mask at FiO2 of 50%
c.
Mouth-to-mask ventilation with supplemental oxygen
d.
Non-rebreather mask at FiO2 of 100%
ANS: A
Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal
tube. During resuscitation efforts, 100% oxygen is administered.
DIF: Cognitive Level: Application REF: p. 238 | Table 10-4
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital
setting?
a.
Automatic external defibrillator
b.
Carbon dioxide detector
c.
Pocket mask
d.
Transcutaneous pacemaker
ANS: A
Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external
defibrillators are recommended to be placed in a variety of public settings where they may be used by
laypersons.
DIF: Cognitive Level: Comprehension REF: p. 232
OBJ: Identify equipment used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
157
3. When doing manual ventilations during a code, the nurse would administer ventilations following which
guideline?
a.
Approximately 8 to 10 breaths per minute
b.
During the fifth chest compression
c.
Every 3 seconds or 20 times per minute
d.
While compressions are stopped
ANS: A
Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.
DIF: Cognitive Level: Application REF: p. 227
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction.
Suddenly his monitor alarms and the screen shows a flat line. What action should the nurse take first?
a.
Administer epinephrine by intravenous push.
b.
Begin chest compressions.
c.
Check patient for unresponsiveness.
d.
Defibrillate at 360 J.
ANS: C
The first intervention is to assess unresponsiveness.
DIF: Cognitive Level: Application REF: p. 226
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. During a code, the nurse would place paddles for anterior defibrillation in what locations?
a.
Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line
b.
Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line
d.
Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line
158
ANS: C
Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive
electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or
adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.
DIF: Cognitive Level: Application REF: p. 231
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the
ECG complex?
a.
P
b.
R
c.
S
d.
T
ANS: B
During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent
the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock
is delivered on the T wave.
DIF: Cognitive Level: Comprehension REF: pp. 232-233
OBJ: Identify equipment used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D where
D refers to:
a.
defibrillate.
b.
differential diagnosis.
c.
diltiazem intravenous push.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
159
do not resuscitate.
ANS: B
The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support
(ACLS) secondary survey involves the performance of more in-depth assessments and interventions.
Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a
specific therapy can be initiated.
DIF: Cognitive Level: Application REF: p. 226
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
8. The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which
medication that has a short half-life and is recommended to treat symptomatic SVT?
a.
Adenosine
b.
Amiodarone
c.
Diltiazem
d.
Procainamide
ANS: A
Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias.
Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is
administered rapidly.
DIF: Cognitive Level: Application REF: p. 239 | Table 10-4
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
9. The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what
is the next action to take?
a.
Administer amiodarone.
b.
Administer lidocaine.
c.
Assess rhythm and pulse.
d.
Prepare for transcutaneous pacing.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
160
ANS: C
Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.
DIF: Cognitive Level: Analysis REF: p. 229
OBJ: Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
10. The patients monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular
contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which
drug?
a.
Atropine 0.5 to 1 mg intravenous push
b.
Dopamine dripcontinuous infusion
c.
Lidocaine 1 mg/kg intravenous push
d.
Transcutaneous pacemaker
ANS: A
This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer
atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is not indicated in second-degree
atrioventricular (AV) block type II or third-degree AV block.
DIF: Cognitive Level: Analysis REF: p. 238 | Table 10-4
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
11. The monitor technician notifies the nurse stat that the patient has a rapid, chaotic rhythm that looks like
ventricular tachycardia. What is the nurses first action?
a.
Call a code overhead.
b.
Check the patient immediately.
c.
Go to the nurses station and look at the rhythm strip.
d.
Take the crash cart to the room.
ANS: B
The first intervention in this situation is to assess unresponsiveness by checking the patient.
DIF: Cognitive Level: Analysis REF: Table 10-3
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
161
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker?
a.
Asystole
b.
Bradycardia (heart rate 40 beats/min) normotensive and alert
c.
Bradycardia (heart rate 50 beats/min) with hypotension and syncope
d.
Supraventricular tachycardia (heart rate 150 beats/min), hypotensive
ANS: C
Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic
bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine.
This patient is symptomatic.
DIF: Cognitive Level: Application REF: p. 234
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. A 74-year-old patient is admitted to the coronary care unit with an inferior wall myocardial infarction and
develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The
nurse knows to prepare to administer which drug?
a.
Amiodarone
b.
Atropine
c.
Lidocaine
d.
Magnesium
ANS: B
Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with
symptomatic bradycardia.
DIF: Cognitive Level: Analysis REF: p. 236, 238 | Table 10-4
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Adenosine
b.
Atropine
c.
Lidocaine
d.
Magnesium
162
ANS: C
Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity.
DIF: Cognitive Level: Analysis REF: p. 239 | Table 10-4
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be
inserted. What is the most appropriate nursing intervention?
a.
Apply conductive gel to the skin.
b.
Provide adequate sedation and analgesia.
c.
Recheck leads to make sure that the rhythm is asystole.
d.
Set the milliamperes to 2 mA below the capture level.
ANS: B
The alert patient who requires transcutaneous pacing may experience some discomfort. Because the skeletal
muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or
thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be
indicated.
DIF: Cognitive Level: Analysis REF: p. 234
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
16. The nurse needs to evaluate arterial blood gases before the administration of which drug?
a.
Calcium chloride
b.
Magnesium sulfate
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Potassium
d.
Sodium bicarbonate
163
ANS: D
Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial
blood gas analysis or laboratory measurement.
DIF: Cognitive Level: Analysis REF: p. 240 | Table 10-4
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
17. During a code situation, the nurse would prepare to use which preferred intravenous fluid?
a.
5% Dextrose in 0.45 normal saline
b.
5% Dextrose in water
c.
Dopamine infusion
d.
Normal saline
ANS: D
Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular
volume better than infusions containing dextrose.
DIF: Cognitive Level: Comprehension REF: p. 228
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. A 90-year-old nursing home patient is admitted to the critical care unit with a severe case of pneumonia.
No living will or designation of healthcare surrogate is noted on the chart. In the event this patient needs
intubation and/or cardiopulmonary resuscitation, what should be the nurses action?
a.
Activate the code team, but initiate a slow code.
b.
Call the nursing home to determine the patients or familys wishes.
c.
Code the patient for 5 minutes and then cease efforts.
d.
Initiate intubation and/or cardiopulmonary resuscitation efforts.
ANS: D
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
164
In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must
be initiated if indicated.
DIF: Cognitive Level: Analysis REF: p. 220
OBJ: Identify psychosocial, legal, and ethical issues related to code management.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
19. A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient is
complaining of dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left
side and a tracheal shift. What would be the most likely diagnosis?
a.
Pericardial tamponade
b.
Symptomatic bradycardia
c.
Tension pneumothorax
d.
Unstable tachycardia
ANS: C
A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the
pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest
pain, tachypnea, tachycardia, and jugular venous distention.
DIF: Cognitive Level: Analysis REF: p. 228
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
20. The patient has pulseless electrical activity (PEA). The doctor decides that the cause of the PEA is
pericardial tamponade. What is the most appropriate treatment for pericardial tamponade?
a.
Atropine
b.
Chest tube placement
c.
Pericardiocentesis
d.
Transcutaneous pacemaker
ANS: C
Pericardiocentesis, or needle aspiration of pericardial fluid, is performed to alleviate the pressure around the
heart.
DIF: Cognitive Level: Comprehension REF: p. 229
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
165
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
21. What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote
better neurological recovery?
a.
Hypothermia decreases the metabolic rate by 7% for each decrease of 1 C.
b.
Lower body temperatures are beneficial in patients with low blood pressure.
c.
Temperatures of 40 C may reduce neurological impairment.
d.
The lower body temperature leads to decreased oxygen delivery.
ANS: A
Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1 C in temperature; decreased
metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32o C to
34o C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.
DIF: Cognitive Level: Analysis REF: p. 244
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
22. The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are
noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the
following?
a.
Obtain a 12-lead electrocardiogram (ECG).
b.
Call for a pacemaker interrogation.
c.
Palpate the pulse.
d.
Run a 2-minute monitor strip for analysis.
ANS: C
The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a
pacemaker spike that indicates that the pacemaker is initiating electrical activity. The spike is followed by a
broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.
DIF: Cognitive Level: Analysis REF: p. 234
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
166
MULTIPLE RESPONSE
1. A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon
further assessment, it is noted that she is hypotensive. The appropriate treatment for her hypotension may
include:(Select all that apply.)
a.
adenosine.
b.
dopamine infusion.
c.
magnesium.
d.
normal saline infusion.
e.
sodium bicarbonate.
ANS: B, D
The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been
corrected.
DIF: Cognitive Level: Application REF: p. 240
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
implications. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent
premature ventricular contractions. Upon assessment, you note that she is lethargic and has complained of
dizziness for the past 12 hours. Which of the following are acceptable treatments for symptomatic bradycardia?
(Select all that apply.)
a.
Atropine
b.
Epinephrine
c.
Lidocaine
d.
Transcutaneous pacemaker
ANS: A, B, D
Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia.
Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine is
considered as well. Lidocaine is contraindicated in bradycardia because it can depress conduction, which
would be detrimental with a heart rate of 39 beats/min.
DIF: Cognitive Level: Analysis REF: p. 234, 238 | Table 10-4
OBJ: Identify medications used in code management, including use, action, side effects, and nursing
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
167
implications. TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
3. Ventricular fibrillation should initially be treated by which of the following? (Select all that apply.)
a.
Administration of amiodarone, followed by defibrillation at 360 J
b.
Atropine 1 mg, followed by defibrillation at 200 J
c.
Defibrillation at 200 J with biphasic defibrillation
d.
Defibrillation at 360 J with monophasic defibrillation
ANS: C, D
If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for
terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is
available, use an initial shock of 360 J and use 360 J for subsequent shocks.
DIF: Cognitive Level: Comprehension REF: p. 228
OBJ: Discuss treatment of special problems that can occur during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Which code drugs can be given safely through an endotracheal tube? (Select all that apply.)
a.
Adenosine
b.
Atropine
c.
Epinephrine
d.
Vasopressin
ANS: B, C, D
Medications that can be administered through the endotracheal tube until IV access is established are atropine,
epinephrine, lidocaine, and vasopressin.
DIF: Cognitive Level: Comprehension REF: p. 228 | Table 10-4
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
5. Which of the following statements about defibrillation are correct? (Select all that apply.)
a.
Early defibrillation (if warranted) is recommended before other actions.
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b.
It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used.
c.
It is not necessary to synchronize the defibrillation shocks.
d.
Paddles/patches can be placed anteriorly and posteriorly on the chest.
ANS: A, C, D
Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of
survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed
during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used
most often; however, the alternative method is anteroposterior placement.
DIF: Cognitive Level: Application REF: pp. 224-225 | 229
OBJ: Differentiate basic and advanced life-support measures used during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. Post-resuscitation goals include which of the following? (Select all that apply.)
a.
Control dysrhythmias
b.
Maintain airway
c.
Maintain blood pressure
d.
Wean off oxygen
ANS: A, B, C
Post-resuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance,
oxygenation, and control of dysrhythmias.
DIF: Cognitive Level: Application REF: p. 242
OBJ: Describe care of patients after resuscitation.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
7. Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply.)
a.
Medication administration times
b.
Defibrillation times, joules, outcomes
c.
Rhythm strips of cardiac rhythm(s) noted
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169
Signatures of recorder and other personnel
ANS: A, B, C, D
Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the
patients response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation
and defibrillation (and the energy used) must be documented, along with the patients response. The time and
sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be
accurately recorded. Rhythm strips are recorded to document events and response to treatment. Signatures of
those involved in the code effort, including the recorder, are essential.
DIF: Cognitive Level: Analysis REF: pp. 240-241
OBJ: Identify information to be documented during a code.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
8. Benefits of having the family present during resuscitation include which of the following? (Select all that
apply.)
a.
Facilitates the grief process
b.
Letting family sees that everything is being done
c.
Sustaining patient-family relationships
d.
Allows the staff easy access to ask for organ transplant
e.
Provides a sense of closure
ANS: A, B, C, E
Families who have been present during a code describe the benefits as knowing that everything possible was
being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family
relationships, providing a sense of closure on a life shared together, and facilitating the grief process.
DIF: Cognitive Level: Analysis REF: pp. 243-244
OBJ: Identify psychosocial, legal, and ethical issues related to code management.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
9. The nurse should call the rapid response EMS for which patients? (Select all that apply.)
a.
53-year-old with pneumonia and severe respiratory distress
b.
17-year-old with apnea following a head injury
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c.
24-year-old experiencing a severe asthmatic attack with stridor
d.
73-year-old patient with bradycardia of 40 beats per minute
e.
52-year-old patient with no palpable pulse
170
ANS: A, C, D
Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patients clinical
condition before a cardiopulmonary arrest occurs.
DIF: Cognitive Level: Analysis REF: pp. 220-221
OBJ: Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 11: Organ Donation
MULTIPLE CHOICE
1. The nurse is working for a hospital that holds an agreement with a local organ procurement organization
(OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the
family about withdrawing life support. Which statement by the nurse best describes requirements that must be
met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?
a.
I need to notify TransLife (OPO) of my patients impending death.
b.
I will contact the physician to obtain informed consent for organ donation.
c.
The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead.
d.
I need the physician to evaluate my patients suitability for organ donation.
ANS: A
Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending
death. It is the responsibility of the organ procurement organization, not the physician, to obtain family consent
for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ
procurement organization must occur prior to death, not after the patient has been pronounced dead.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
2. The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patients organs.
Which assessment finding requires immediate action by the nurse?
a.
Morning serum blood glucose of 128 mg/dL
b.
pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L
c.
Pulmonary artery temperature of 97.8 F
d.
Central venous pressure of 8 mm Hg
ANS: B
Donor management, focuses on maintaining hemodynamic stability and normal
laboratory parameters. Care of the patient is under the direction of the OPO coordinator working
collaboratively with the physician and critical care nurses. Standardized order sets are usually used, and they
focus on preserving organ function and viability.Immediate action is required for an arterial blood gas value of
pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L which indicates metabolic acidosis. All other values are within
normal limits.
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DIF: Cognitive Level: Analysis REF: Box 11-2
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
3. The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse
notify the organ procurement organization to evaluate for possible organ donation?
a.
A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on
electroencephalogram
b.
A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke
c.
A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale
score of 7
d.
A 53-year-old diabetic male with a history of unstable angina status post resuscitation
ANS: A
A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be
notified. There are no indications of impending death in any of the other patient scenarios.
DIF: Cognitive Level: Application REF: Box 11-2 | Box 11-3
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
4. The transplant clinic coordinator is evaluating relatives of a patient with end-stage renal disease, whose
blood type is A positive, for suitability as a living donor for kidney transplantation. Which family member best
qualifies for evaluation?
a.
A 65-year-old brother with a history of hypertension; blood type A positive
b.
A 35-year-old female with a history of food allergies; blood type O negative
c.
A 14-year-old son, otherwise healthy with no history; blood type B negative
d.
A 70-year-old mother, with a history of sinus infections; blood type A positive
ANS: B
To qualify as a living donor, an individual must be free from hypertension, diabetes, cancer, kidney disease,
and heart disease and generally between 18 and 60 years of age. A 35-year-old female with a history of food
allergies; blood type O negative (universal donor best qualifies for evaluation. The brother and mother,
although blood-type compatible, are outside of acceptable age ranges for living donation. The minor son does
not qualify based on blood type.
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DIF: Cognitive Level: Application REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Adaptation
5. The nurse is caring for a patient who is being evaluated clinically for brain death by a physician. Which
assessment findings by the nurse support brain death?
a.
Absence of a corneal reflex
b.
Unequal, reactive pupils
c.
Withdrawal from painful stimuli
d.
Core temperature of 100.8 F
ANS: A
Absence of a corneal reflex indicates altered brainstem activity and is a component used in the clinical
evaluation of brain death. Reactive pupils, withdrawal reaction to painful stimuli, and the ability to maintain
core temperature indicate brainstem activity.
DIF: Cognitive Level: Comprehension REF: Table 11-3
OBJ: Describe clinical triggers associated with brain death.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
6. The nurse is providing preoperative care to a patient who will receive a transplant. The patient has high
panel reactive antibodies (PRA). As part of induction therapy for this patient, the nurse understands which
medication to be of priority for administration in the operating room?
a.
Alemtuzumab (Campath)
b.
Tacrolimus (Prograf)
c.
Sirolimus (Rapamune)
d.
Cyclosporine (Neoral)
ANS: A
Alemtuzumab (Campath) is a monoclonal antibody used as an induction agent in patients that are at high
immunological risk. Tacrolimus (Prograf), sirolimus (Rapamune), and cyclosporine (Neoral) are all
immunosuppressive agents used as part of ongoing maintenance therapy.
DIF: Cognitive Level: Comprehension REF: Table 11-5
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
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TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
7. The nurse is caring for a mechanically ventilated patient following bilateral lung transplantation. When
planning the care of this patient, what is the priority nursing intervention?
a.
Thirty-degree elevation of head of bed
b.
Endotracheal suctioning as needed
c.
Frequent side to side repositioning
d.
Sequential compression stockings
ANS: B
Denervation of the lung that occurs during lung transplantation causes changes in mucus production and ciliary
movement. As a result, to promote the drainage of secretions and prevent mucus plugging, endotracheal and
oral suctioning should be a priority of nursing care in the postoperative lung transplant patient. Head of bed
elevation, side to side repositioning, and application of sequential compression stockings are appropriate
nursing interventions, but they are not the priority intervention.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
8. A family member approaches the nurse caring for their gravely ill son and states, We want to donate our
sons organs. What is the best action by the nurse?
a.
Arrange a multidisciplinary meeting with physicians.
b.
Consult the hospitals ethics committee for a ruling.
c.
Notify the organ procurement organization (OPO).
d.
Obtain family consent to withdraw life support.
ANS: C
It is the ultimate responsibility of the organ procurement organization to approach the family and obtain
consent for organ donation. The best action by the nurse is to notify the OPO. Arranging a multidisciplinary
meeting with physicians and consulting the hospitals ethics committee are not appropriate actions in this
scenario. Informed consent to withdraw life support is provided by the physician.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Implementation
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MSC: NCLEX: Safe and Effective Care Environment
9. The nurse is caring for a patient in the critical care unit who, after being declared brain dead, is being
managed by the OPO transplant coordinator. Thirty minutes into the shift, assessment by the nurse includes a
blood pressure 75/50 mm Hg, heart rate 85 beats/min, and respiratory rate 12 breaths/min via assist/control
ventilation. The oxygen saturation (SpO2) is 99% and core temperature 93.8 F. Which physician order should
the nurse implement first?
a.
Apply forced air warming device to keep temperature > 96.8
b.
Obtain basic metabolic panel every 4 hours until surgery
c.
Begin phenylephrine (Neo-Synephrine) for systolic BP < 90 mm Hg
d.
Draw arterial blood gas every 4 hours until surgery
ANS: C
Hemodynamic stability is a priority in donor management. Following brain death, loss of autoregulation results
in intense vasodilation. To maintain perfusion to the vital organs, the priority action is to begin a phenylephrine
(Neo-Synephrine) infusion to get systolic BP > 90 mm Hg. Maintaining normothermia is the next priority.
Obtaining laboratory tests and arterial blood gasses is a part of donor management but not the priority in this
scenario.
DIF: Cognitive Level: Application REF: Table 11-2
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Planning
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
10. The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being
cared for in the unit. Which patient assessed by the charge nurse requires immediate action?
a.
Renal transplant recipient, 1 day post op with a 3/10 pain level
b.
Lung transplant recipient, 1 day post op with a productive cough
c.
Heart transplant recipient, 1 day post op with a cardiac output of 4 L/min
d.
Liver transplant recipient, 12 hours post op with a serum glucose of 58 mg/dL
ANS: D
Hypoglycemia may indicate a poorly functioning liver and requires immediate action. Postoperative pain level
of 3/10 in a renal transplant patient, a lung transplant patient with a productive cough, and a heart transplant
recipient with a cardiac output of 4 L/min are normal or expected findings requiring no immediate action.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Evaluation
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MSC:NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse is caring for a renal transplant recipient in the post-anesthesia care unit. Blood pressure is 125/70
mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3
L/min of oxygen via nasal cannula, temperature is 97.8 F, and the central venous pressure (CVP/RAP) is 2 mm
Hg. What is the best action by the nurse?
a.
Administer fluid replacement therapy; monitor intake and output closely.
b.
Increase supplemental oxygen to 100% non-rebreather mask; notify physician.
c.
Apply thermal warming blanket; administer all fluids through warming device.
d.
Assess the patient for pain; administer pain medications as ordered.
ANS: A
Fluid replacement therapy is a priority in a postoperative renal transplant patient with a CVP of 2 mm Hg and
elevated heart rate. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is
normothermic; application of active warming measures is not indicated. Although pain assessment is an
important part of postoperative nursing care, it is not the priority in this scenario.
DIF: Cognitive Level: Analysis REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Evaluation
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
12. The nurse is caring for a postoperative renal transplant recipient in the critical care unit. After seeing
minimal urine output in the catheter for most of the day, the patient expresses concern to the nurse. What is the
best response by the nurse?
a.
Your kidney has unfortunately failed and will be removed.
b.
It can take a few days for your kidney to start working
c.
You are experiencing an acute rejection episode.
d.
You will have to undergo daily hemodialysis treatments.
ANS: B
There are many factors that can delay normal functioning of a transplanted renal graft (e.g., prolonged cold
times, altered perfusion states during surgery. It can take a few days for the transplant to function optimally.
Low urine output alone is not the sole indicator of kidney failure or an acute rejection episode. Hemodialysis
treatments are not routine in the presence of low urine output following a renal transplant.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Evaluation
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MSC:NCLEX: Physiological Integrity: Physiological Adaptation
13. The nurse is providing discharge instructions to a renal transplant recipient. The patient has a follow-up
appointment the next day for routine post-transplant laboratory bloodwork, including trough levels of antirejection medications.Which instruction describes what the patient should do regarding the anti-rejection
medications the next day?
a.
Take your morning dose of medications at midnight with sips of water.
b.
Take your morning dose of medications after labs have been drawn.
c.
Skip your morning dose of medications and then resume your evening doses.
d.
Hold all doses of your medications the day you have labs drawn.
ANS: B
Medication trough levels are used to guide dosing. The patient should not take his morning dose of
medications until labs have been drawn so that an accurate trough level is obtained. Transplant medication is
administered at regular dosing intervals (e.g. every 12 hours) to maintain therapeutic drug levels and intervals
should not be independently adjusted. Medication should not be skipped when lab is drawn. The patient
should be instructed to take the medication immediately after lab work has been drawn. Medication is not to
be held for an entire day as doing so places the patient at risk for rejection.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Evaluation
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
14. The nurse is caring for a patient following a bilateral lung transplant. When planning postoperative care of
the patient, priority is placed on pulmonary hygiene. Which statement provides the best explanation for this
priority?
a.
Immunosuppressant medications reduce the bodys ability to fight infections.
b.
During the early postoperative period, atelectasis decreases oxygenation.
c.
Pulmonary hygiene reduces the risk of early primary graft dysfunction.
d.
Loss of cough reflex results in decreased ability to remove secretions effectively.
ANS: D
Nerves of the autonomic nervous system are severed during lung transplant surgery. This results in denervation
of the lung and loss of the cough reflex. Loss of this reflex places the patient at greater risk for infection
because of the potential inability to clear secretions effectively. Although immunosuppressant medications
reduce the bodys ability to fight infections, this is a general explanation for all increased risk of infection in
transplant recipients. Atelectasis decreases oxygenation. The primary reason for pulmonary hygiene is to
expectorate secretions. Primary graft dysfunction is caused by ischemia, surgical trauma, or denervation and is
similar to acute respiratory distress syndrome.
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DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Planning
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
15. While following up on a postoperative renal transplant recipient, the nurse discovers that the donor tested
positive for cytomegalovirus (CMV). What is the priority action by the nurse?
a.
Notify the OPO transplant coordinator.
b.
Verify results with the lab technician.
c.
Repeat all pre-procedure viral studies.
d.
Continue to monitor for signs of rejection.
ANS: A
It is mandatory to report any donor-derived infections to the organ procurement organization (OPO). The
priority action is to notify the transplant coordinator. Verifying results with the lab technician, if indicated,
would be the responsibility of the transplant coordinator. Repeating viral studies and continuing to monitor for
signs of rejection are appropriate actions but not the immediate priority.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16. The transplant clinic nurse is conducting patient education on the importance of follow-up health screening
activities important in detecting complications associated with long-term immunosuppressant therapy. Which
statement is most important for the nurse to include in the discussion?
a.
Application of sunscreen may cause a reaction.
b.
Avoid sun exposure during peak hours of the day.
c.
Melanoma is the most common type of cancer.
d.
Skin examinations should occur every 5 years.
ANS: B
The nurse should instruct the patient to avoid sun exposure during peak hours of the day. Application of
sunscreen is a priority to reduce the risk of sunburn and subsequent skin cancer. The most common type of
skin cancer is squamous cell cancer. Skin examinations should be conducted annually.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
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Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse obtains initial vital signs on a patient 2 weeks posttransplant who presents for follow-up
monitoring to the outpatient transplant clinic. Which assessment finding by the nurse requires immediate
action?
a.
Blood pressure of 100/60 mm Hg
b.
Serum creatinine of 1.5 mg/dL
c.
Hemoglobin of 9.2 gm/dL
d.
Tenderness over graft site
ANS: D
Tenderness over the graft site may be indicative of acute rejection in a renal transplant recipient 2 weeks
posttransplant. Blood pressure, serum creatinine, and hemoglobin values are all within acceptable ranges and
do not require immediate action.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
18. The transplant clinic social worker is completing a social history on a patient with end-stage renal disease
who is being evaluated for transplant. Which statement by the patient warrants further action?
a.
I only smoke marijuana on an occasional basis.
b.
I have two sisters who live within two hours of me.
c.
I have attended all of my scheduled dialysis sessions.
d.
My mothers side of the family has a history of cancer.
ANS: A
Current recreational drug use is a contraindication to transplantation. Family support is critical during
posttransplant care. Adherence to dialysis indicates likely success in adhering to future treatment plans. A
patient history of active or recent malignancy is a contraindication to transplantation.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
19. The transplant clinic nurse is educating a patient about the renal criteria that must be met in order to be
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placed on the transplant waiting list. Which statement by the patient best indicates an understanding of the
criteria?
a.
I qualify if my glomerular filtration rate is less than 20 mL per minute.
b.
I will not qualify until I have to go on regular hemodialysis treatments.
c.
My blood type does not have to be a match with the donor blood type.
d.
The national waiting list is based on the ability to pay for medications.
ANS: A
Candidates are placed on the UNOS national waiting list once they become dialysis dependent or have a
glomerular filtration rate of less than 20 mL/minute if not on dialysis. ABO compatibility is necessary for
successful renal transplantation. A point system is used to rank candidates to determine who will receive a
kidney when a donor becomes available.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
20. The nurse is educating a renal transplant patient about his immunosuppressant medication therapy. Which
statement by the patient best indicates an appropriate understanding?
a.
I will be gradually weaned off my medications during my lifetime.
b.
After 6 months, I will be down to taking one medication for life.
c.
My doctors may try to stop my steroids soon after my transplant.
d.
I will only need to take my mediations every other day for life.
ANS: C
Transplant programs vary in the immunosuppressant medications that are prescribed; some programs withdraw
steroids after a predetermined amount of time. Transplant recipients will be on immunosuppressant
medications for life taking, at minimum, two medicationsa calcineurin inhibitor or mTOR inhibitor and an
antimetabolite. Medications are taken at regular daily prescribed intervals to maintain therapeutic blood levels.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
21. The nurse is preparing to admit a patient with heart failure who has been listed on the UNOS transplant list
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as status 1A. What is the best understanding of this classification by the nurse?
a.
The patient can be managed at home with a left ventricular assist device.
b.
Hospitalization is required with mechanical support and vasoactive infusions.
c.
The patient has advanced heart failure and is being managed with medication.
d.
An advanced heart failure patient not successfully managed on medications.
ANS: B
Status 1A is the most urgent status assigned to advanced heart failure awaiting transplantation. Status 1A
patients are expected to die within a week without transplant. Status 1B patients are less urgent and can be
managed at home with a left ventricular assist device. A patient with advanced heart failure being managed
with medications is being managed appropriately. An advanced heart failure patient not successfully managed
on medications has the option of listing for a heart transplant.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
22. The nurse is providing postoperative education to a transplant patients family. When asked about detecting
rejection, which answer by the nurse is most appropriate?
a.
Endomyocardial biopsies will be performed weekly for the first six weeks after surgery.
b.
Increased shortness of breath most likely indicates immediate, acute rejection of the heart.
c.
Biopsies of the heart are done every 6 months after the day of the transplant surgery.
d.
As time passes, the more biopsies that are performed, the more reliable the results become.
ANS: A
The traditional method of rejection surveillance in a heart transplant recipient is through endometrial biopsies
performed weekly during the first six weeks posttransplant. Shortness of breath can be a symptom of rejection,
but only in combination with other symptoms. Rejection is confirmed through biopsy. Over time, with frequent
biopsies, cardiac tissue becomes scarred, making detection of rejection impossible.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Planning
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
23. The transplant clinic nurse is conducting a pretransplant education session for patients being evaluated for
liver transplantation. Which statement by the nurse provides the best explanation of the numeric system used to
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182
classify the severity of a patients liver disease?
a.
A score is calculated based upon kidney function, clotting time, and bilirubin levels.
b.
A score is calculated that ranges between 6 and 40, with the lower score being more serious.
c.
There are currently no exceptions to the MELD score calculation for severity of disease.
d.
The calculated score represents the patients risk of death within 1 year of diagnosis.
ANS: A
The Model for End-Stage Liver Disease (MELD) score uses the patients serum creatinine, international
normalized ratio (INR) for prothrombin time, and serum bilirubin to predict survival. Calculated MELD scores
range between 6 and 40, with higher scores directly associated with the patients risk of death in 3 months.
Patients with an acute onset of liver disease and a life expectancy of hours to a few days are the only exception
to the use of a calculated MELD score. The MELD score measures the severity of liver disease.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
24. Which statement best represents appropriate donor-to-recipient criteria for liver transplantation?
a.
Blood type and HLA tissue type
b.
HLA tissue type and body type
c.
Body type and body size
d.
Blood type and donor history
ANS: C
Blood type and body size are the two criteria necessary for matching a donor liver to a recipient. HLA tissue
typing is not used because it has not been known to affect outcomes. Donors are carefully screen for infectious
diseases and carcinomas during the process, but blood type and body type are the essential matching criteria.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
25. The nurse assesses morning lab results for a postoperative day 1 liver transplant recipient. Lab results noted
by the nurse include aspartate transaminase (AST 365 U/L; alanine aminotransferase (ALT 400 U/L; and
serum glucose of 85 mg/dL. What is the best action by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Notify the physician of liver enzyme results.
b.
Treat hypoglycemia with 50 mL 5% dextrose.
c.
Repeat the liver enzyme results in 4 hours.
d.
Prepare to administer IV insulin infusion.
183
ANS: A
Laboratory values should be trended, but the nurse should notify the physician of the elevated liver enzyme
results, as significantly elevated results could indicate hepatic artery thrombosis. Glucose of 85 mg/dL is
considered within normal limits by most laboratories and would not require treatment with glucose or insulin
to normalize. Repeating the enzyme results in 4 hours would be appropriate, but it is not the immediate
priority.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Evaluation
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
26. The transplant clinic nurse is educating a group of transplant recipients on health promotion and
maintenance. What is the priority statement by the nurse?
a.
Adhere to all future scheduled appointments with the clinic.
b.
Obtain annual vaccinations for pneumonia from your physician.
c.
Report all routine lab results to your primary care physician.
d.
Notify the transplant clinic of all future hospital admissions.
ANS: B
To protect against viruses that would be detrimental to a transplant recipient, it is most important for transplant
patients to consult with their clinic providers to obtain the appropriate vaccinations. Adherence to future
scheduled appointments, reporting lab results, and notifying the clinic of all future hospitalizations are part of
long-term care, but appropriate vaccinations are essential to the health of the patient.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Discuss complications associated with the long-term management of solid organ transplant
recipients.TOP: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
27. A renal transplant recipient presents to the outpatient transplant clinic with blood glucose values for the
past 3 days exceeding 250 mg/dL. The patient takes prednisone 5 mg daily and tacrolimus (Prograf 2 mg
twice daily. Hemoglobin A1C level drawn the day of the clinic appointment was 8.5%. What is the best
interpretation of this finding by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
The patient is at increased risk for infection.
b.
The patient has developed posttransplant diabetes.
c.
Temporary elevations in blood sugars are normal.
d.
Discontinuation of steroids will normalize values.
184
ANS: B
A patient taking steroids and calcineurin inhibitors is at risk for the development of posttransplant diabetes as a
complication of long-term medication therapy. Although the lab values in isolation do not indicate infection,
blood sugars must be normalized to promote healing. Hemoglobin A1C levels indicate the level of blood sugar
control over the past 2 to 3 months. Findings should not be considered temporary. Although steroids can
elevate blood sugar values, discontinuation of steroid therapy may not be feasible in all transplant recipients.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss complications associated with the long-term management of solid organ transplant
recipients.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
28. The postanesthesia care unit receives handoff communication from the CRNA indicating that the renal
transplant recipient received induction therapy in the operating room with antithymocyte globulin (ATG).
What is the best understanding of the administration of this drug by the nurse?
a.
The drug is administered for recipients of CMV-positive donor organs.
b.
Administration of the drug decreases initial postoperative rejection rates.
c.
Antiproliferative agents are recommended for routine induction therapy.
d.
Antithymocyte globulin (ATG) is given as a single dose in the OR.
ANS: B
Administration of antiproliferative agents such as antithymocyte globulin (ATG has been shown to decrease
rejection rates in the initial postoperative period. Antiviral agents are administered if CMV donor status is
positive. Antiproliferative agents are recommended as first choice for induction therapy in recipients at high
immunological risk. ATG is given in the operating room as well as for several days postoperative.
DIF: Cognitive Level: Comprehension REF: Table 11-5
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
29. The nurse is preparing to administer a renal transplant recipients first dose of mycophenolate mofetil
(CellCept. Prior to administering the medication, the nurse appropriately reviews drug formulary information.
What is the best understanding of this medication by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
It is a calcineurin inhibitor used for induction therapy.
b.
It is an antimetabolite used for maintenance therapy.
c.
It is a polyclonal antibody used for maintenance therapy.
d.
It is an mTOR inhibitor used for maintenance therapy.
185
ANS: C
Mycophenolate mofetil (CellCept) is an antimetabolite that inhibits T lymphocytes. CellCept is used for
maintenance immunosuppression therapy.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Discuss immunosuppression of the solid organ transplant recipient.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
30. A patient presents to the outpatient transplant clinic stating, I would like to donate one of my kidneys.
What is the best response by the nurse?
a.
To be a living donor, you must be related to the recipient.
b.
You must be over the age of 30 to be a living donor.
c.
Living donor donation is coordinated by UNOS.
d.
Let us orient you to the process required to become a donor.
ANS: D
An altruistic living donor is an individual who makes a decision to donate an organ or part of an organ to a
stranger. The nurse can help the patient navigate the donation process. Living donors may be related or
unrelated to the potential recipient. In general, living donors are usually between the ages of 18 and 60 years.
All transplant centers coordinate the living donation process.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
31. Which clinical scenario best represents hyperacute rejection?
a.
A cardiac transplant patient with a 3-month history of shortness of breath
b.
A lung transplant patient with small pustules that follow a dermatome
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
A liver transplant patient with several small lumps under the skin
d.
An implanted renal transplant that, upon reperfusion, becomes cyanotic
186
ANS: D
A hyperacute rejection occurs within hours or days of the transplanted organ. An implanted renal transplant
that becomes cyanotic upon reperfusion represents a hyperacute rejection. A cardiac transplant patient with a
3-month history of shortness of breath represents an acute rejection. Small pustules that follow a dermatome
most likely represent herpes zoster. Several small lumps under the skin may indicate squamous cell carcinoma.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Discuss complications associated with the long-term management of solid organ transplant
recipients.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Psychosocial Integrity: Reduction of Risk
32. Which statement best describes the lung allocation score (LAS) used to prioritize lung transplant
recipients?
a.
The LAS is based on lab values, diagnostic tests, and medical diagnosis.
b.
Lungs from children and adolescents are offered to adults first.
c.
The LAS is limited to candidates under the age of 65 years.
d.
The score was developed to estimate 5-year survival rates.
ANS: A
The LAS is based on lab values, diagnostic tests, and medical diagnosis; candidates with higher LASs have
higher priority than those with lower scores. Lungs from children and adults are offered to pediatric and
adolescent candidates first. The LAS is used for all patients who are listed on the organ donor registry. The
LAS was developed to estimate the change of first-year survival after transplantation.
DIF: Cognitive Level: Knowledge REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Assessment
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
33. The nurse is caring for a renal transplant recipient in the postanesthesia care unit. Handoff communication
from the OR included a reported output of 500 mL following anastomosis of the renal vessels and reperfusion.
One hour after the transplant recipient was admitted to the PACU, the RN notes no urine output. Which
physician order should the nurse implement first?
a.
Administer 20 mg furosemide intravenous (IV) every 4 hours as needed for urine output < 30
mL/hr.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Administer a 500-mL bolus of 0.9% normal saline intravenously over 2 hours.
c.
Irrigate the indwelling urinary catheter gently with 30 mL 0.9% normal saline.
d.
Provide maintenance IV fluids of D5 NS to infuse at 100 mL/hr.
187
ANS: C
Surgical complications following renal transplantation include ureteral obstruction. The nurse should gently
irrigate the Foley catheter to determine patency. Furosemide administration should not occur until catheter
obstruction has been ruled out. Administration of a fluid bolus should not occur until catheter obstruction has
been ruled out. Maintenance fluids administration should be a part of the plan of care but is not the priority in
this scenario.
DIF: Cognitive Level: Application REF: Chap 11
OBJ: Describe the postsurgical nursing and medical management of solid organ transplant procedures.TOP:
Nursing Process Step: Implementation
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
34. The nurse is caring for a renal transplant patient admitted with an acute rejection episode. The patient asks
the nurse how the doctors will know if the kidney has been rejected. What is the best response by the nurse?
a.
Your admission lab results will determine if your kidney is being rejected.
b.
A procedure called a renal biopsy will be the best way to confirm rejection.
c.
Monitoring over the next few days will determine if your kidney is failing.
d.
An ultrasound of your kidney will determine if your kidney has failed.
ANS: B
Renal biopsy confirms the presence of rejection. Admission lab results will provide information related to the
current functional level of the kidney but will not confirm rejection. Monitoring the patient will not confirm
the presence of rejection. An ultrasound of the kidney will determine if there is blood flow to the kidney but
will not provide information at the cellular level.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss complications associated with the long-term management of solid organ transplant
recipients.TOP: Nursing Process Step: Planning
MSC:NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The family of a critically ill patient has asked to discuss organ donation with the patients nurse. When
preparing to answer the familys questions, the nurse understands which concern(s most often influence a
familys decision to donate? (Select all that apply.)
a.
Donor disfigurement influences on funeral care
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Fear of inferior medical care provided to donor
c.
Age and location of all possible organ recipients
d.
Concern that donated organs will not be used
e.
Fear that the potential donor may not be deceased
f.
Concern over financial costs associated with donation
188
ANS: A, B, E, F
Common fears and concerns that can influence a familys decision to donate include fear of disfigurement of
the donor, fear of inferior medical care being provided to the donor in order to hasten the process, fear that the
donor may not really be deceased, and concern that the family of the donor will assume the financial burden
associated with the donation. The number of individuals awaiting transplant along with the current UNOS
registry system ensures all procured organs will be transplanted. The age and location of recipients are not
disclosed by the OPO.
DIF: Cognitive Level: Comprehension REF: Chap 11
OBJ: Discuss processes associated with organ donation.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment: Management of Care
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
189
Chapter 12: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
MULTIPLE CHOICE
1. The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial
pulses but is unable to auscultate a blood pressure. What is the best nursing action?
a.
Assess the blood pressure by Doppler.
b.
Estimate the systolic pressure as 60 mm Hg.
c.
Obtain an electronic blood pressure monitor.
d.
Record the blood pressure as not assessable.
ANS: A
Auscultated blood pressures in shock may be significantly inaccurate due to vasoconstriction. If blood pressure
is not audible, the approximate value can be assessed by palpation or ultrasound. If brachial pulses are
palpable, the approximate measure of systolic blood pressure is 80 mm Hg. This action has the potential to
delay further assessment of a compromised patient in shock. Documenting a blood pressure as not assessable is
not appropriate without further attempts using different modalities.
DIF: Cognitive Level: Application REF: p. 258
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
2. The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe
sepsis. One hour later, which laboratory result requires immediate nursing action?
a.
Creatinine 1.0 mg/dL
b.
Lactate 6 mmol/L
c.
Potassium 3.8 mEq/L
d.
Sodium 140 mEq/L
ANS: B
Lactate level has been used as an indicator of decreased oxygen delivery to the cells, adequacy of resuscitation
in shock, and as an outcome predictor. All other listed values are within normal limits and do not require
additional follow-up.
DIF: Cognitive Level: Application REF: p. 259 | Laboratory Alert
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
190
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
3. The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed
therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which
physiological parameters would be most important for the nurse to assess?
a.
Breath sounds and capillary refill
b.
Blood pressure and oral temperature
c.
Oral temperature and capillary refill
d.
Right atrial pressure and urine output
ANS: D
Early goal-directed therapy includes administration of IV fluids to keep central venous pressure at 8 mm Hg or
greater. Combined with urine output, fluid therapy effectiveness can be adequately assessed. Evaluation of
breath sounds assists with determining fluid overload in a patient but does not evaluate the effectiveness of
fluid therapy. Capillary refill provides a quick assessment of the patients overall cardiovascular status, but this
assessment is not reliable in a patient who is hypothermic or has peripheral circulatory problems. Evaluation of
oral temperature does not assess the effectiveness of fluid therapy in patients in shock. Evaluation of oral
temperature does not assess the effectiveness of fluid therapy in patients in shock. Capillary refill provides a
quick assessment of the patients overall cardiovascular status, but this assessment is not reliable in a patient
who is hypothermic or has peripheral circulatory problems.
DIF: Cognitive Level: Application REF: p. 282
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours
postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50
mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr;
chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
a.
The assessed values are within normal limits.
b.
The patient is at risk for developing cardiogenic shock.
c.
The patient is at risk for developing fluid volume overload.
d.
The patient is at risk for developing hypovolemic shock.
ANS: D
Vital signs and hemodynamic values assessed collectively include classic signs and symptoms of hypovolemia.
Both urine output and chest drainage values are high, contributing to the hypovolemia. Assessed values are not
within normal limits.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
191
A cardiac output of 4 L/min is not indicative of cardiogenic shock. The patient is at risk for hypovolemia, not
volume overload, as evidenced by excessive hourly chest drainage and urine output.
DIF: Cognitive Level: Analysis REF: Table 12-5
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
5. A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of
110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates
administering which therapeutic intervention?
a.
Human albumin infusion
b.
Hypotonic saline solution
c.
Lactated Ringers bolus
d.
Packed red blood cells
ANS: C
The patient is experiencing symptoms of hypovolemic shock. Isotonic crystalloids, such as normal saline and
lactated Ringers solutions, are the priority intervention. Albumin and plasma protein fraction (Plasmanate) are
naturally occurring colloid solutions that are infused when the volume loss is caused by a loss of plasma rather
than blood, such as in burns, peritonitis, and bowel obstruction. Hypotonic solutions rapidly leave the
intravascular space, causing interstitial and intracellular edema and are not used for fluid resuscitation. There is
no evidence to support a transfusion in the given scenario.
DIF: Cognitive Level: Analysis REF: Table 12-5
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
6. The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and
flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess?
a.
High pulmonary artery occlusive pressure and high cardiac output
b.
High systemic vascular resistance and low cardiac output
c.
Low pulmonary artery occlusive pressure and low cardiac output
d.
Low systemic vascular resistance and high cardiac output
ANS: D
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
192
As a consequence of the massive vasodilation associated with septic shock, in the early stages, cardiac output is
high with low systemic vascular resistance. In septic shock, pulmonary artery occlusion pressure is not
elevated. In the early stages of septic shock, systemic vascular resistance is low and cardiac output is high. In
the early stages of septic shock, cardiac output is high.
DIF: Cognitive Level: Knowledge REF: Table 12-5
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood
pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102 F, and a
right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry
out first?
a.
Acetaminophen suppository
b.
Blood cultures from two sites
c.
IV antibiotic administration
d.
Isotonic fluid challenge
ANS: D
Early goal-directed therapy in severe sepsis includes administration of IV fluids to keep RAP/CVP at 8 mm Hg
or greater (but not greater than 15 mm Hg) and heart rate less than 110 beats/min. Fluid resuscitation to restore
perfusion is the immediate priority. Broad-spectrum antibiotics are recommended within the first hour;
however, volume resuscitation is the priority in this scenario.
DIF: Cognitive Level: Analysis REF: p. 270
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
8. Which patient being cared for in the emergency department is most at risk for developing hypovolemic
shock?
a.
A patient admitted with abdominal pain and an elevated white blood cell count
b.
A patient with a temperature of 102 F and a general dermal rash
c.
A patient with a 2-day history of nausea, vomiting, and diarrhea
d.
A patient with slight rectal bleeding from inflamed hemorrhoids
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
193
ANS: C
Excessive external loss of fluid may occur through the gastrointestinal tract via vomiting and diarrhea, which
may lead to hypovolemia. There is no evidence to support significant fluid loss in the remaining patient
scenarios.
DIF: Cognitive Level: Comprehension REF: p. 270
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
9. The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a
pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac
index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention?
a.
Dobutamine (Dobutrex)
b.
Furosemide (Lasix)
c.
Phenylephrine (Neo-Synephrine)
d.
Sodium nitroprusside (Nipride)
ANS: A
Positive inotropic agents (e.g., dobutamine) are given to increase the contractile force of the heart. As
contractility increases, cardiac output and index increase and improve tissue perfusion. Administration of
furosemide will assist only in managing fluid volume overload. Phenylephrine administration enhances
vasoconstriction, which may increase afterload and further reduce cardiac output. Sodium nitroprusside is
given to reduce afterload. There is no evidence to support a need for afterload reduction in this scenario.
DIF: Cognitive Level: Analysis REF: Table 12-4
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
10. Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips,
hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg,
heart rate 130 beats/min, and respirations 36 breaths/min. What is the priority intervention?
a.
Diphenhydramine (Benadryl) 50 mg intravenously
b.
Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously
c.
Methylprednisolone (Solu-Medrol) 125 mg intravenously
d.
Ranitidine (Zantac) 50 mg intravenously
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
194
ANS: B
The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0.5 mg (3
to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine (Benadryl) will help block
histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids,
such as methylprednisolone (Solu-Medrol), are used to reduce inflammation, but epinephrine is the drug of
choice for anaphylaxis with hypotension. Ranitidine (Zantac) will help block histamine release, but
epinephrine is the drug of choice for anaphylaxis with hypotension.
DIF: Cognitive Level: Analysis REF: Table 12-5
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse
assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields.
Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse
most likely to assess?
a.
High pulmonary artery diastolic pressure and low cardiac output
b.
Low pulmonary artery occlusive pressure and low cardiac output
c.
Low systemic vascular resistance and high cardiac output
d.
Normal cardiac output and low systemic vascular resistance
ANS: A
In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery
pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary
circulation and the right side of the heart.
Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and
cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in
cardiogenic shock.
DIF: Cognitive Level: Analysis REF: p. 275
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. During the initial stages of shock, what are the physiological effects of decreased cardiac output?
a.
Arterial vasodilation
b.
High urine output
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Increased parasympathetic stimulation
d.
Increased sympathetic stimulation
195
ANS: D
A reduction in blood pressure leads to an increase in catecholamine release, resulting in an increase in heart
rate and contractility to improve cardiac output. Decreased cardiac output leads to arterial vasoconstriction in
an effort to increase blood pressure. Low urine output results, as decreased cardiac output reduces blood flow
to the kidneys. There is an increase in sympathetic stimulation in response to a decrease in cardiac output.
DIF: Cognitive Level: Knowledge REF: p. 258
OBJ: Correlate the four classifications of shock to their pathophysiology.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. While monitoring a patient for signs of shock, the nurse understands which system assessment to be of
priority?
a.
Central nervous system
b.
Gastrointestinal system
c.
Renal system
d.
Respiratory system
ANS: A
The central nervous system experiences decreased perfusion first. The patient will have central nervous system
changes early during the course of shock, such as changes in the level of consciousness. Although the
gastrointestinal, renal, and respiratory systems also experience changes during shock, changes in the central
nervous system provide the earliest indication of decreased perfusion.
DIF: Cognitive Level: Knowledge REF: p. 257
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump
(IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to
explain the IABP?
a.
The action of the machine will improve blood supply to the damaged heart.
b.
The machine will beat for the damaged heart with every beat until it heals.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
The machine will help cleanse the blood of impurities that might damage the heart.
d.
The machine will remain in place until the patient is ready for a heart transplant.
196
ANS: A
The IABP improves coronary artery perfusion, reduces afterload, and improves perfusion to vital organs. An
IABP acts through counterpulsation, augmenting the pumping action of the heart, displacing blood to improve
both forward and backward blood flow. It does not beat for the damaged heart. An IABP does not filter blood
impurities. An IABP is designed as a temporary therapy for use when pharmacological interventions alone are
not effective. It is indicated for short-term use, not as a bridge to transplant.
DIF: Cognitive Level: Comprehension REF: p. 275
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
15. The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic
shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate
response to therapy?
a.
Cardiac index (CI) of 2.5 L/min/m2
b.
Pulmonary artery diastolic pressure of 26 mm Hg
c.
Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg
d.
Systemic vascular resistance (SVR) of 1600 dynes/sec/cm-5
ANS: A
Desired outcomes for a patient in cardiogenic shock with an IABP include decreased SVR, diminished
symptoms of myocardial ischemia (chest pain, ST-segment elevation), increased stroke volume, and increased
cardiac output and cardiac index. A cardiac index of 2.5 L/min is within normal limits. All other values are
high and would not indicate an appropriate response to therapy.
DIF: Cognitive Level: Comprehension REF: p. 275
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
16. The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury following a diving
accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26
breaths/min. The patients skin is warm and flushed. What is the best interpretation of these findings by the
nurse?
a.
The patient is developing neurogenic shock.
b.
The patient is experiencing an allergic reaction.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
The patient most likely has an elevated temperature.
d.
The vital signs are normal for this patient.
197
ANS: A
The most profound feature of neurogenic shock is bradycardia with hypotension from the decreased
sympathetic activity. There is no evidence to support an allergic reaction in this scenario. Hypothermia, not an
elevated temperature, can develop from uncontrolled heat loss associated with vasodilation in neurogenic
shock. Vital signs are not normal given the clinical situation.
DIF: Cognitive Level: Analysis REF: pp. 276-277
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. The nurse is caring for a patient in spinal shock. Vital signs include blood pressure 100/70 mm Hg, heart
rate 70 beats/min, respirations 24 breaths/min, oxygen saturation 95% on room air, and an oral temperature of
96.8 F. Which intervention is most important for the nurse to include in the patients plan of care?
a.
Administration of atropine sulfate (Atropine)
b.
Application of 100% oxygen via facemask
c.
Application of slow rewarming measures
d.
Infusion of IV phenylephrine (Neo-Synephrine)
ANS: C
Hypothermia can develop in neurogenic shock from uncontrolled heat loss; therefore, a patient should be
rewarmed slowly to avoid further vasodilation. In shock, a drop in systolic blood pressure to less than 90 mm
Hg is considered hypotensive. Atropine is used for symptomatic bradycardia. The patients oxygen saturation is
95% on room air with an adequate respiratory rate. The application of 100% oxygen via facemask is not
indicated. The patients heart rate is adequate to support a normal blood pressure.
DIF: Cognitive Level: Application REF: p. 277
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
18. The nurse has just completed administration of a 1000-L bolus of 0.9% normal saline. The nurse assesses
the patient to be slightly confused, with a mean arterial blood pressure (MAP of 50 mm Hg, a heart rate of 110
beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP of 3 mm Hg.
What is the best interpretation of these results by the nurse?
a.
Patient response to therapy is appropriate.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Additional interventions are indicated.
c.
More time is needed to assess response.
d.
Values are normal for the patient condition.
198
ANS: B
Assessed vital signs and hemodynamic values indicate decreased circulating volume. The patient has not
responded appropriately to therapy aimed at increasing circulating volume. Additional intervention is needed
because response to therapy is not appropriate, values are abnormal, and timely intervention is critical for a
patient with low circulating blood volume.
DIF: Cognitive Level: Analysis REF: p. 262
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include
blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101 F and
oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0
g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the
nurse to include in the patients plan of care?
a.
Insertion of an 18-gauge peripheral intravenous line
b.
Application of cushioned heel protectors
c.
Implementation of fall precautions
d.
Implementation of universal precautions
ANS: A
Given the patients diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume
is a priority and can be accomplished following insertion of an appropriate gauge IV (18 to facilitate blood
and fluid administration. Universal precautions, fall precautions, and application of heel protectors are
appropriate interventions but are not the immediate priority.
DIF: Cognitive Level: Analysis REF: p. 262
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
20. The nurse is starting to administer a unit of packed red blood cells (PRBCs to a patient admitted in
hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150
beats/min, respirations 42 breaths/min, and temperature 100.6 F. What is the best action by the nurse?
a.
Administer blood transfusion over at least 4 hours.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Notify the physician of the elevated temperature.
c.
Titrate rate of blood administration to patient response.
d.
Notify the physician of the patients heart rate.
199
ANS: C
Given the acute nature of the patients blood loss, the nurse should titrate the rate of the blood transfusion to an
improvement in the patients blood pressure. Administering the transfusion over 4 hours can lead to a prolonged
state of hypoperfusion and end-organ damage. The heart rate will normalize as circulating blood volume is
restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.
DIF: Cognitive Level: Analysis REF: p. 264
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of
105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on
45% supplemental oxygen via Venturi mask, and a temperature of 102 F. The physician orders stat
administration of an antibiotic. Which additional physician order should the nurse complete first?
a.
Blood cultures
b.
Chest x-ray
c.
Foley insertion
d.
Serum electrolytes
ANS: A
Timely identification of the causative organism through blood cultures and the initiation of appropriate
antibiotics following obtaining blood cultures improve the survival of patients with sepsis or septic shock. A
chest x-ray, Foley insertion, and measurement of serum electrolytes may be included in the plan of care but are
not the priority in this scenario.
DIF: Cognitive Level: Analysis REF: p. 282
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
22. The nurse is caring for a patient admitted to the critical care unit 48 hours ago with a diagnosis of severe
sepsis. As part of this patients care plan, what intervention is most important for the nurse to discuss with the
multidisciplinary care team?
a.
Frequent turning
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Monitoring intake and output
c.
Enteral feedings
d.
Pain management
200
ANS: C
Initiation of enteral feedings within 24 to 48 hours of admission is critical in reducing the risk of infection by
assisting in maintaining the integrity of the intestinal mucosa. Monitoring intake and output, frequent turning,
and pain management are important aspects of care but are not a critical priority during the first 24 to 48 hours
following admission.
DIF: Cognitive Level: Analysis REF: p. 268
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
23. The nurse is administering both crystalloid and colloid intravenous fluids as part of fluid resuscitation in a
patient admitted in severe sepsis. What findings assessed by the nurse indicate an appropriate response to
therapy?
a.
Normal body temperature
b.
Balanced intake and output
c.
Adequate pain management
d.
Urine output of 0.5 mL/kg/hr
ANS: D
Adequate urine output of at least 0.5 mL/ kg/hr indicates adequate perfusion to the kidneys following
administration of fluid to enhance circulating blood volume. Normal body temperature and adequate pain
management are not assessment findings indicating an adequate response to fluid therapy. During fluid
resuscitation in severe sepsis, intake and output will not be balanced as circulating fluid volume deficit is
restored.
DIF: Cognitive Level: Comprehension REF: p. 268
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Adaptation
24. The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a
blood pressure of 90/50 mm Hg, heart rate 125 beats/min, respirations 32 breaths/min, central venous pressure
(CVP/RAP of 3 mm Hg, and urine output of 5 mL during the past hour. Following physician rounds, the nurse
reviews the orders and questions which order?
a.
Administer acetaminophen (Tylenol) 650-mg suppository prn every 6 hours for pain.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Titrate dopamine (Intropin) intravenously for blood pressure < 90 mm Hg systolic.
c.
Complete neurological assessment every 4 hours for the next 24 hours.
d.
Administer furosemide (Lasix) 20 mg IV every 4 hours for a CVP > 20 mm Hg.
201
ANS: B
Vasoconstrictive agents should not be administered for hypotension in the presence of circulation fluid volume
deficit. The nurse should question the use of the dopamine (Intropin) infusion. All other listed orders are
appropriate and have potential for use in the treatment of a hypovolemic shock.
DIF: Cognitive Level: Analysis REF: Table 12-4
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
25. The nurse is administering intravenous norepinephrine (Levophed) at 5 mcg/kg/min via a 20-gauge
peripheral intravenous (IV) catheter. What assessment finding requires immediate action by the nurse?
a.
Blood pressure 100/60 mm Hg
b.
Swelling at the IV site
c.
Heart rate of 110 beats/min
d.
Central venous pressure (CVP) of 8 mm Hg
ANS: B
Swelling at the IV site is indicative of infiltration. Infusion of norepinephrine (Levophed through an infiltrated
IV site can lead to tissue necrosis and requires immediate intervention by the nurse. A blood pressure of
100/60 mm Hg, heart rate of 110 beats/min, and a CVP of 8 mm Hg are adequate and do not require immediate
intervention.
DIF: Cognitive Level: Comprehension REF: Table 12-4
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
26. The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values
assessed by the nurse include a cardiac index (CI of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic
vascular resistance (SVR of 2200 dynes/sec/cm-5. Upon review of physician orders, which order is most
appropriate for the nurse to initiate?
a.
Furosemide (Lasix) 20 mg intravenous (IV) every 4 hours as needed for CVP > 20 mm Hg
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
202
b.
Nitroglycerin infusion titrated at a rate of 5-10 mcg/min as needed for chest pain
c.
Dobutamine (Dobutrex) infusion at a rate of 2-20 mcg/kg/min as needed for CI < 2 L/min/m2
d.
Dopamine (Intropin) infusion at a rate of 5-10 mcg/kg/min to maintain a systolic BP of at least 90
mm Hg
ANS: B
The patient is complaining of chest pain and has an elevated systemic vascular resistance (SVR). To reduce
afterload, ease the workload of the heart, and dilate the coronary arteries, improving oxygenation to the heart
muscle, initiation of a nitroglycerin infusion is most appropriate. Assessment data do not support the initiation
of other listed physician order options.
DIF: Cognitive Level: Analysis REF: Table 12-4
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central
venous catheter (CVC). What action by the nurse best protects against the development of a central
lineassociated bloodstream infection (CLABSI)?
a.
Documentation of insertion date
b.
Elevation of the head of the bed
c.
Assessment for weaning readiness
d.
Appropriate sedation management
ANS: A
Interventions that have been associated with a reduction in CLABSI include timely removal of unnecessary
central lines. Documentation of the line insertion date will assist in monitoring this measure. Elevation of the
head of the bed, assessment for weaning readiness, and appropriate sedation management are appropriate
interventions to reduce the risk of ventilator-acquired pneumonia.
DIF: Cognitive Level: Application REF: p. 282
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
28. The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the
patient to be tachypneic, with a respiratory rate of 32 breaths/min. Arterial blood gas values assessed on
admission are pH 7.50, CO2 28 mm Hg, HCO3 26. Which diagnostic study result reviewed by the nurse
indicates progression of the shock state?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
pH 7.40, CO2 40, HCO3 24
b.
pH 7.45, CO2 45, HCO3 26
c.
pH 7.35, CO2 40, HCO3 22
d.
pH 7.30, CO2 45, HCO3 18
203
ANS: D
As shock progresses along the continuum, acidosis ensues, caused by metabolic acidosis, hypoxia, and
anaerobic metabolism. A pH 7.30, CO2 45 mm Hg, HCO3 18 indicates metabolic acidosis and progression to a
late stage of shock. All other listed arterial blood gas values are within normal limits.
DIF: Cognitive Level: Application REF: p. 260
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
29. The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hours, the
patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To
prevent complications, what is the priority nursing intervention?
a.
Administer pain medication.
b.
Turn patient every 2 hours.
c.
Assess core body temperature.
d.
Apply bilateral heel protectors.
ANS: C
Hypothermia is anticipated during the rapid infusion of fluids or blood products. Assessment of core body
temperature is a priority. While administration of pain management, repositioning the patient every 2 hours,
and application of heel protectors should be part of the patient care, given the rapid transfusion of blood
products, these interventions are not the priority in this scenario.
DIF: Cognitive Level: Application REF: pp. 267-268
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
30. The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine
(Dobutrex. The physicians order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5
L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6
L/min/m2. What is the best action by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Obtain a stat serum potassium level.
b.
Order a stat 12-lead electrocardiogram.
c.
Reduce the rate of dobutamine (Dobutrex).
d.
Assess the patients hourly urine output.
204
ANS: C
Dobutamine (Dobutrex) is used to stimulate contractility and heart rate while causing vasodilation in low
cardiac output states improving overall cardiac performance. The patients cardiac index is well above normal
limits, so the rate of infusion of the medication should be reduced so as not to overstimulate the heart. There is
no evidence to support the need for a serum potassium or 12-lead electrocardiogram. Assessment of hourly
urine output is important in the care of the patient in cardiogenic shock, but it is not a priority in this scenario.
DIF: Cognitive Level: Analysis REF: p. 265
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
31. After receiving a handoff report from the night shift, the nurse completes the morning assessment of a
patient with severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min,
respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature
101.5 F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the past hour. The nurse
initiates which active physician order first?
a.
Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm
Hg.
b.
Increase supplemental oxygen therapy to maintain SpO2 greater than 94%.
c.
Administer 40 mg furosemide (Lasix) intravenous as needed if the urine output is less than 30
mL/hr.
d.
Administer acetaminophen (Tylenol) 650-mg suppository per rectum as needed to treat
temperature > 101 F.
ANS: A
Fluid volume resuscitation is the priority in patients with severe sepsis to maintain circulating blood volume
and end-organ perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the
patients CVP of 2 mm Hg and hourly urine output of 10 mL/hr. There is no evidence to support the need to
increase supplemental oxygen. Administration of furosemide (Lasix in the presence of a fluid volume deficit
is contraindicated.
DIF: Cognitive Level: Analysis REF: p. 262
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Assessment
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
205
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
32. The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer
solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of
28%. What is the best interpretation of these findings by the nurse?
a.
Blood transfusion with packed red blood cells is required.
b.
Hemoglobin and hematocrit results indicate hemodilution.
c.
Fluid resuscitation has resulted in fluid volume overload.
d.
Fluid resuscitation has resulted in third spacing of fluid.
ANS: B
Fluid resuscitation with large volumes of crystalloid results in hemodilution of red blood cells and plasma
proteins. Hemoglobin and hematocrit results indicate hemodilution. Given the clinical scenario, there is no
evidence to support the need for a blood transfusion and no evidence of fluid overload. Although
administration of large volumes of crystalloid can result in hemodilution of plasma proteins leading to third
spacing of fluid, this fact does not support the hemoglobin and hematocrit results.
DIF: Cognitive Level: Comprehension REF: p. 260
OBJ: Develop an individualized plan of care that includes nursing diagnosis, expected outcomes, nursing
interventions, and rationales. TOP: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
1. Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock, the nurse assesses a
drop in the patients blood pressure to 60/40 mm Hg, heart rate 135 beats/min, respirations 40 breaths/min, and
a temperature of 102 F. The nurse notes the new onset of hematuria in the patients Foley catheter. What are the
priority nursing actions? (Select all that apply.)
a.
Administer acetaminophen (Tylenol).
b.
Document the patients response.
c.
Increase the rate of transfusion.
d.
Notify the blood bank.
e.
Notify the physician.
f.
Stop the transfusion.
ANS: B, D, E, F
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
206
In the event of a reaction, the transfusion is stopped, the patient is assessed, and both the physician and
laboratory are notified. All transfusion equipment (bag, tubing, and remaining solutions) and any blood or
urine specimens obtained are sent to the laboratory according to hospital policy. The events of the reaction,
interventions used, and patient response to treatment are documented. Acetaminophen is not warranted in the
immediate recognition and treatment of a transfusion reaction. The infusion must be stopped. Increasing the
infusion further increases the likelihood of worsening the transfusion reaction.
DIF: Cognitive Level: Analysis REF: p. 278
OBJ: Describe management strategies for each classification of shock.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment
findings best assess tissue perfusion in a patient in shock? (Select all that apply.)
a.
Blood pressure
b.
Heart rate
c.
Level of consciousness
d.
Pupil response
e.
Respirations
f.
Urine output
ANS: A, C, F
The level of consciousness assesses cerebral perfusion, urine output assesses renal perfusion, and blood
pressure is a general indicator of systemic perfusion. Heart rate is not an indicator of perfusion. Pupillary
response does not assess perfusion. Respirations do not assess perfusion.
DIF: Cognitive Level: Analysis REF: p. 257 | Clinical Alert
OBJ: Relate assessment findings to the classification and stage of shock.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
207
Chapter 13: Cardiovascular Alterations
MULTIPLE CHOICE
1. The patient is admitted with a suspected acute myocardial infarction (MI). In assessing the 12-lead
electrocardiogram (ECG) changes, which findings would indicate to the nurse that the patient is in the process
of an evolving Q wave myocardial infarction(MI)?
a.
ST-segment elevation on ECG and elevated CPK-MB or troponin levels
b.
Depressed ST-segment on ECG and elevated total CPK
c.
Depressed ST-segment on ECG and normal cardiac enzymes
d.
Q wave on ECG with normal enzymes and troponin levels
ANS: A
ST segment elevation and elevated cardiac enzymes are seen in Q wave MI.
DIF: Cognitive Level: Analysis REF: p. 302, 311 | Table 12-6
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize
complications of cardiac and vascular patients.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is assessing a patient with left-sided heart failure. Which symptom would the nurse expect to
find?
a.
Dependent edema
b.
Distended neck veins
c.
Dyspnea and crackles
d.
Nausea and vomiting
ANS: C
In left-sided heart failure, signs and symptoms are related to pulmonary congestion. Dependent edema and
distended neck veins are related to right-sided heart failure.
DIF: Cognitive Level: Analysis REF: pp. 326-327 | Box 12-11 | Box 12-12
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. A patient is admitted with an acute myocardial infarction (AMI). The nurse knows that an angiotensinconverting enzymes (ACE) inhibitor should be started within 24 hours to reduce the incidence of which
process?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Myocardial stunning
b.
Hibernating myocardium
c.
Myocardial remodeling
d.
Tachycardia
208
ANS: C
Myocardial remodeling is a process mediated by angiotensin II, aldosterone, catecholamine, adenosine, and
inflammatory cytokines, which causes myocyte hypertrophy and loss of contractile function in the areas of the
heart distant from the site of infarctions. ACE inhibitors reduce the incidence of remodeling.
DIF: Cognitive Level: Analysis REF: p. 317
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. A patient presents to the emergency department (ED) with chest pain that he has had for the past 2 hours. He
is nauseous and diaphoretic, and his skin is dusky in color. The electrocardiogram shows ST elevation in leads
II, III, and aVF. Which therapeutic intervention would the nurse question?
a.
Emergent pacemaker insertion
b.
Emergent percutaneous coronary intervention
c.
Emergent thrombolytic therapy
d.
Immediate coronary artery bypass graft surgery
ANS: A
The goals of management of AMI are to dissolve the lesion that is occluding the coronary artery and to
increase blood flow to the myocardium. Options include emergent percutaneous intervention, such as
angioplasty, emergent coronary artery bypass graft surgery, or thrombolytic therapy if the patient has been
symptomatic for less than 6 hours. No data in this scenario warrant insertion of a pacemaker.
DIF: Cognitive Level: Analysis REF: pp. 319-322
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological
mechanism present is most likely which of the following?
a.
Complete occlusion of a coronary artery
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Fatty streak within the intima of a coronary artery
c.
Partial occlusion of a coronary artery with a thrombus
d.
Vasospasm of a coronary artery
209
ANS: C
In unstable angina, some blood continues to flow through the affected coronary artery; however, flow is
diminished related to partial occlusion. The pain in unstable angina is more severe, may occur at rest, and
requires more frequent nitrate therapy.
DIF: Cognitive Level: Analysis REF: p. 305
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated?
a.
ACE inhibitors and diuretics
b.
Morphine sulfate and oxygen
c.
Nitroglycerin, oxygen, and beta-blockers
d.
Statins, bile acid, and nicotinic acid
ANS: C
Conservative intervention for the patient experiencing angina includes nitrates, beta-blockers, and oxygen.
DIF: Cognitive Level: Analysis REF: p. 306-309 | Table 12-5
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
7. A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease.
Which study best identifies valvular function and measures the size of the cardiac chambers?
a.
12-lead electrocardiogram
b.
Cardiac catheterization
c.
Echocardiogram
d.
Electrophysiology study
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
210
ANS: C
Echocardiography is a noninvasive, acoustic imaging procedure and involves the use of ultrasound to visualize
the cardiac structures and the motion and function of cardiac valves and chambers.
DIF: Cognitive Level: Comprehension REF: p. 300, 328
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for
the patient?
a.
Bile acid resins
b.
Nicotinic acid
c.
Nitroglycerin
d.
Statins
ANS: D
The statins have been found to lower low-density lipoproteins (LDLs) more than other types of lipid-lowering
drugs.
DIF: Cognitive Level: Comprehension REF: p. 302
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
9. The patient is admitted with an acute myocardial infarction (AMI). Three days later the nurse is concerned
that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle
rupture?
a.
Gallop rhythm
b.
Murmur
c.
S1 heart sound
d.
S3 heart sound
ANS: B
The presence of a new murmur warrants special attention, particularly in a patient with an AMI. A papillary
muscle may have ruptured, causing the valve to close incorrectly, which can be indicative of severe damage
and impending complications.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
211
DIF: Cognitive Level: Analysis REF: p. 295
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize
complications of cardiac and vascular patients.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
10. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which
process?
a.
Coronary artery spasm.
b.
Decreased blood flow (ischemia).
c.
Death of cardiac muscle from lack of oxygen (tissue necrosis).
d.
Sporadic decrease in oxygen to the heart (transient oxygen imbalance).
ANS: C
Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply
from the occlusion of a coronary artery and its branches.
DIF: Cognitive Level: Analysis REF: p. 310
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Diagnosis MSC: NCLEX: Physiological Integrity
11. A 72-year-old woman is brought to the ED by her family. The family states that shes just not herself. Her
respirations are slightly labored, and her heart monitor shows sinus tachycardia (rate 110 beats/min) with
frequent premature ventricular contractions (PVCs). She denies any chest pain, jaw pain, back discomfort, or
nausea. Her troponin levels are elevated, and her 12-lead electrocardiogram (ECG) shows elevated ST
segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with
which diagnosis?
a.
Hypokalemia
b.
NonQ wave MI
c.
Silent myocardial infarction
d.
Unstable angina
ANS: C
Some individuals may have ischemic episodes without knowing it, thereby having a silent infarction. These
can occur with no presenting signs or symptoms. Asymptomatic or nontraditional symptoms are more common
in elderly persons, in women, and in diabetic patients.
DIF: Cognitive Level: Analysis REF: p. 311
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
212
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder
and back that started about 12 hours ago. The patient delayed coming to the ED since he was hoping the pain
would go away. The patients 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and
CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention.
Thrombolysis is one possible treatment. Based on these data, the nurse understands that?
a.
The patient is not a candidate for thrombolysis.
b.
The patients history makes him a good candidate for thrombolysis.
c.
Thrombolysis is appropriate for a candidate having a nonQ wave MI.
d.
Thrombolysis should be started immediately.
ANS: A
To be eligible for thrombolysis, the patient must be symptomatic for less than 6 hours.
DIF: Cognitive Level: Analysis REF: p. 312
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13. The patient presents to the ED with severe chest discomfort. He is taken for cardiac catheterization and
angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely
followed?
a.
Coronary artery bypass graft surgery
b.
Intracoronary stent placement
c.
Percutaneous transluminal coronary angioplasty (PTCA)
d.
Transmyocardial revascularization
ANS: A
Coronary artery bypass graft surgery is indicated for significant left main coronary occlusion (>50%.
DIF: Cognitive Level: Analysis REF: p. 319
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
213
14. The patient is admitted with recurrent supraventricular tachycardia that the cardiologist believes to be
related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be
planned for this patient?
a.
Implantable cardioverter-defibrillator placement
b.
Permanent pacemaker insertion
c.
Radiofrequency catheter ablation
d.
Temporary transvenous pacemaker placement
ANS: C
Radiofrequency catheter ablation is a method of interrupting a supraventricular tachycardia, a dysrhythmia
caused by a reentry circuit, and an abnormal conduction pathway.
DIF: Cognitive Level: Analysis REF: p. 322
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
15. The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down
both arms, as well as numbness in his left arm. While taking the patients vital signs, the nurse notices a 30point discrepancy in systolic blood pressure between the right and left arm. Based on these findings, the nurse
should:
a.
contact the physician and report the cardiac enzyme results.
b.
contact the physician and prepare the patient for thrombolytic therapy.
c.
contact the physician immediately and begin prepping the patient for surgery.
d.
give the patient aspirin and heparin.
ANS: C
These symptoms indicate the possibility of acute aortic dissection. Symptoms often mimic those of AMI or
pulmonary embolism. Aortic dissection is a surgical emergency. Signs and symptoms include chest pain and
arm paresthesia.
DIF: Cognitive Level: Analysis REF: p. 340
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize
complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
214
16. A patient is admitted to the emergency department with clinical indications of an acute myocardial
infarction. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary
intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of
this patient?
a.
Administer thrombolytic therapy unless contraindicated
b.
Diurese aggressively and monitor daily weight
c.
Keep oxygen saturation levels at least 88%
d.
Maintain heart rate above 100 beats/min
ANS: A
Medical treatment of AMI is aimed at relieving pain, providing adequate oxygenation to the myocardium,
preventing platelet aggregation, and restoring blood flow to the myocardium through thrombolytic therapy or
acute interventional therapy such as angioplasty. Since interventional cardiology is not available, thrombolytic
therapy is indicated. Oxygen saturation should be maintained at higher levels to ensure adequate oxygenation
to the heart muscle. An elevated heart rate increases oxygen demands and should be avoided. Diuresis is not
indicated with this scenario.
DIF: Cognitive Level: Analysis REF: pp. 312-313
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse
will be sure to verify whether the patient has taken medications prior to admission for:
a.
Erectile dysfunction
b.
Prostate enlargement
c.
Asthma
d.
Peripheral vascular disease
ANS: A
A history of the patients use of sildenafil citrate (Viagra or similar medications taken for erectile dysfunction
is necessary to know when considering NTG administration. These medications potentiate the hypotensive
effects of nitrates; thus, concurrent use is contraindicated. It is also important to determine whether the patient
has any food or drug allergies.
DIF: Cognitive Level: Analysis REF: p. 298
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
215
18. Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the
patient anything to eat or drink?
a.
Barium swallow
b.
Transesophageal echocardiogram
c.
MUGA scan
d.
Stress test
ANS: B
In transesophageal echocardiography, an ultrasound probe is fitted on the end of a flexible gastroscope, which
is inserted into the posterior pharynx and advanced into the esophagus. After the procedure, the patient is
unable to eat until the gag reflex returns.
DIF: Cognitive Level: Application REF: p. 300
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. A patient was admitted in terminal heart failure and is not eligible for transplant. The family wants
everything possible done to maintain life. Which procedure might be offered to the patient for this condition to
increase the patients quality of life?
a.
Intraaortic balloon pump (IABP)
b.
Left ventricular assist device (LVAD)
c.
Nothing, because the patient is in terminal heart failure
d.
Nothing additional; medical management is the only option
ANS: B
LVADs are capable of partial to complete circulatory support for short- to long-term use. At present, the
LVAD is therapy for patients with terminal heart failure. It would provide better management than medical
therapy alone. The IABP is for short-term management of acute heart failure.
DIF: Cognitive Level: Analysis REF: p. 332
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
20. The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would
anticipate that the drug of choice would be
a.
Dopamine
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Dobutamine
c.
Adenosine
d.
Atropine
216
ANS: C
If a patient is unable physically to perform the exercise, a pharmacological stress test can be done. Adenosine
is preferred over dobutamine because of its short duration of action and because reversal agents are not needed.
DIF: Cognitive Level: Analysis REF: p. 299
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21. The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later
they ask the nurse what the patient did wrong to cause this condition. The nurse explains:
a.
This is a result of a high-cholesterol diet and poor exercise habits.
b.
The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac
rehabilitation they will work with the patient to strengthen his heart through special exercises.
c.
This is an inherited condition. You should give serious consideration to having family members
screened for it.
d.
This is a result of clot formation in the blood vessels in the heart. We will need to use medications
to reduce the risk of further clotting.
ANS: C
Hypertrophic cardiomyopathy is a genetically inherited disease that affects the myocardial sarcomere.
DIF: Cognitive Level: Comprehension REF: p. 326
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The patients wife is feeling overwhelmed and tells the nurse that she doesnt know if she can manage to
cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The
nurse tells her:
a.
It will be worth it to have him healthy, wont it?
b.
The low-cholesterol diet is one from which everyone can benefit.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
As long as you change at least a few things in the diet, it will be okay.
d.
You can go on the diet with him, and then just let the children eat whatever they want.
217
ANS: B
Some cardiologists advocate a reduction of the low-density lipoprotein goal to the 50 to 70 mg/dL range for
everyone, not only those with a known cardiovascular disease.
DIF: Cognitive Level: Analysis REF: p. 297
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize
complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
23. Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery?
a.
Right coronary artery
b.
Left coronary artery
c.
Circumflex
d.
Left main coronary artery
ANS: D
Stenosis of the left mainstem artery is considered unacceptable for percutaneous intervention.
DIF: Cognitive Level: Comprehension REF: p. 318
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
24. Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease?
a.
I had a heart attack because I work too hard and it puts too much strain on my heart.
b.
The pain in my chest gets worse each time it happens. I think that there is more damage to my
heart vessels as time goes on.
c.
If I change my diet and exercise more, I should get over this and be healthy.
d.
What kind of pills can you give me to get me over this and back to my lifestyle?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
218
ANS: B
Coronary heart disease is a progressive atherosclerotic disorder of the coronary arteries that results in
narrowing or complete occlusion.
DIF: Cognitive Level: Analysis REF: pp. 305-306
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity
25. The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurses
responsibilities is to monitor the patient for which common postoperative dysrhythmia?
a.
Second degree heart block
b.
Atrial fibrillation or flutter
c.
Ventricular ectopy
d.
Premature junctional contractions
ANS: B
Atrial fibrillation and flutter are dysrhythmias common after cardiac surgery.
DIF: Cognitive Level: Analysis REF: p. 322
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
26. An essential aspect of teaching that may prevent recurrence of heart failure is:
a.
notifying the physician if a 2-lb weight gain occurs in 24 hours.
b.
compliance with diuretic therapy.
c.
taking nitroglycerin if chest pain occurs.
d.
assessment of an apical pulse.
ANS: B
Reduction or cessation of diuretics usually results in sodium and water retention, which may precipitate heart
failure.
DIF: Cognitive Level: Application REF: p. 330
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
219
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
27. The patients wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the
patient will be healthy again. The nurse explains:
a.
The operation will remove all of the plaque, and if your husband exercises and diets he will be free
of cardiac problems.
b.
The surgery will remove all the buildup, but it will reaccumulate and he will probably need this
surgery again this time next year.
c.
The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your
husband will need to diet and exercise carefully to avoid further cardiac risk.
d.
The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked
relief of your husbands symptoms.
ANS: C
A successful angioplasty procedure is one in which the stenosis is reduced to less than 50% of the vessel lumen
diameter, although most clinicians aim for less than 20% final diameter stenosis.
DIF: Cognitive Level: Application REF: p. 318
OBJ: Discuss the nursing care responsibilities related to the cardiac and vascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
28. The patients wife is confused about the scheduling of a stent insertion. She says that she thought the
angioplasty was surgery to fix her husbands heart problem. The nurse explains to her:
a.
The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel.
b.
The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open
and prevent it from closing again.
c.
This procedure is being done instead of using clot-dissolving medication to help keep the heart
vessel open.
d.
The stent will remove any clots that are in the vessel and protect the heart muscle from damage.
ANS: B
Stents are inserted to optimize the results of other treatments for acute vessel closure (percutaneous
transluminal coronary angioplasty, atherectomy, fibrinolytics) and to prevent restenosis.
DIF: Cognitive Level: Comprehension REF: p. 319
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
220
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
29. The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants
further assessment and intervention by the critical care 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 a cause for concern. Severe lower back pain and ecchymoses
are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies must be
discontinued, and volume expanders or coagulation factors, or both, are administered.
DIF: Cognitive Level: Analysis REF: p. 315
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. The patient has been in chronic heart failure for the past 10 years. He has been treated with beta-blockers
and angiotensin-converting enzyme inhibitors as well as diuretics. His symptoms have recently worsened, and
he presents to the ED with severe shortness of breath and crackles throughout his lung fields. His respirations
are labored and arterial blood gases show that he is at risk for respiratory failure. Which of the following
therapies may be used for acute, short-term management of the patient? (Select all that apply).
a.
Dobutamine
b.
Intraaortic balloon pump
c.
Nesiritide (Natrecor)
d.
Ventricular assist device
ANS: A, B, C
This patient is showing signs and symptoms of an acute exacerbation of heart failure. Dobutamine and
nesiritide are medications administered for acute short-term management; mechanical assist with an intraaortic
balloon pump also may be warranted.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
221
DIF: Cognitive Level: Analysis REF: pp. 333-335 | Table 12-13
OBJ: Compare and contrast pharmacological, operative, and electrical treatment modalities used in treatment
of cardiac disease. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. Identify the priority interventions for managing symptoms of an acute myocardial infarction (AMI) in the
ED. (Select all that apply).
a.
Administration of morphine
b.
Administration of nitroglycerin (NTG)
c.
Dopamine infusion
d.
Oxygen therapy
ANS: A, B, D
The initial pain of AMI is treated with morphine sulfate administered intravenously. NTG may be given to
reduce the ischemic pain of AMI. NTG increases coronary perfusion because of its vasodilatory effects.
Oxygen administration is important for assisting the myocardial tissue to continue its pumping activity and for
repairing the damaged tissue around the site of the infarct.
DIF: Cognitive Level: Analysis REF: pp. 312-315
OBJ: Develop a research-related care plan for the acutely ill cardiovascular patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. Which statements are true regarding the symptoms of an AMI? (Select all that apply.)
a.
Dysrhythmias are common occurrences.
b.
Men have more atypical symptoms than women.
c.
Midsternal chest pain is a common presenting symptom.
d.
Some patients are asymptomatic.
ANS: A, C, D
Chest pain is a common presenting symptom in AMI. Dysrhythmias are commonly seen in AMI. Some
individuals may have ischemic episodes without knowing it, thereby having a silent infarction. Women are
more likely to have atypical signs and symptoms, such as shortness of breath, nausea and vomiting, and back
or jaw pain.
DIF: Cognitive Level: Analysis REF: p. 331
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
222
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. Acute myocardial infarction (AMI) can be classified as which of the following? (Select all that apply.)
a.
Angina
b.
Nonischemic
c.
NonQ wave
d.
Q wave
ANS: C, D
AMI can be classified as Q wave or nonQ wave.
DIF: Cognitive Level: Knowledge REF: p. 312 | Table 12-7
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. A patient is admitted with an acute myocardial infarction (AMI). The nurse monitors for which potential
complications? (Select all that apply.)
a.
Cardiac dysrhythmias
b.
Heart failure
c.
Pericarditis
d.
Ventricular rupture
ANS: A, B, C, D
All are potential complications of AMI.
DIF: Cognitive Level: Analysis REF: pp. 312-315
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The patients husband tells the nurse, We didnt think she was having a heart attack because the pain was in
her neck and back. The nurse explains: (Select all that apply.)
a.
Pain can occur anywhere in the chest, neck, arms, or back. Dont hesitate to call the emergency
medical services if you think its a heart attack.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
For many people chest pain from a heart attack occurs in the center of the chest, behind the
breastbone.
c.
The sooner the patient can get medical help, the less damage is likely to occur in case of a heart
attack.
d.
You need to make sure its a heart attack before you call the emergency response personnel.
223
ANS: A, B, C
Angina may occur anywhere in the chest, neck, arms, or back, but the most commonly described is pain or
pressure behind the sternum. The pain often radiates to the left arm but can also radiate down both arms and to
the back, the shoulder, the jaw, and/or the neck.
DIF: Cognitive Level: Analysis REF: p. 311
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
7. Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.)
a.
Jugular venous distention
b.
Peripheral edema
c.
Crackles audible in the lungs
d.
Weak peripheral pulses
ANS: A, B
Rationale: Jugular venous distention, liver tenderness, hepatomegaly, and peripheral edema are signs of right
ventricular failure.
DIF: Cognitive Level: Analysis REF: p. 325
OBJ: Contrast the pathological cause and effect mechanisms that produce acute cardiac disturbances.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. Which nursing interventions would be appropriate after angioplasty? (Select all that apply.)
a.
Elevate the head of the bed by 45 degrees for 6 hours
b.
Assess pedal pulses on the involved limb every 15 minutes for 2 hours
c.
Monitor the vascular hemostatic device for signs of bleeding
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
224
Instruct the patient bend his/her knee every 15 minutes while the sheath is in place
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.
DIF: Cognitive Level: Analysis REF: pp. 318-319
OBJ: Identify specific nursing interventions designed to prevent secondary occurrences or to minimize
complications of cardiac and vascular patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
225
Chapter 14: Nervous System Alterations
MULTIPLE CHOICE
1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the
nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and
temperature of 100.5. The patient is lethargic, responds to voice but falls asleep readily when not stimulated.
Which nursing action is most important to include in this patients plan of care?
a.
Frequent neurological assessments
b.
Side to side position changes
c.
Range of motion to extremities
d.
Frequent oropharyngeal suctioning
ANS: A
Nurses complete neurological assessments based on ordered frequency and the severity of the patients
condition. The newly admitted patient has an altered neurological status so frequent neurological assessments
are most important to include in the patients plan of care. Side to side position changes, range of motion
exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patients plan of
care but in the setting of increased intracranial pressure should not be regularly performed unless indicated.
DIF: Cognitive Level: Application REF: p. 365 | Nursing Care Plan
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90
mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
a.
54 mm Hg
b.
72 mm Hg
c.
90 mm Hg
d.
126 mm Hg
ANS: C
CPP = MAP ICP. In this case, CPP = 108 mm Hg 18 mm Hg = 90 mm Hg. All other calculated responses are
incorrect.
DIF: Cognitive Level: Comprehension REF: pp. 360-361
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
226
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP
of 85 mm Hg. What is the best interpretation by the nurse?
a.
Both pressures are high.
b.
Both pressures are low.
c.
ICP is high; CPP is normal.
d.
ICP is high; CPP is low.
ANS: C
The ICP is above the normal level of 15 mm Hg. The CPP is within the normal range.
All other listed responses are incorrect.
DIF: Cognitive Level: Comprehension REF: p. 361
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs
to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and
reposition the patient to the left side. What is the best action by the nurse?
a.
Hyperoxygenate during endotracheal suctioning.
b.
Elevate the patients head of the bed 30 degrees.
c.
Apply bilateral heel protectors after repositioning.
d.
Provide rest periods between nursing interventions.
ANS: D
Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing
nursing care activities to allow for rest between activities. All other nursing actions are a part of the patients
plan of care; however, spacing out interventions is the priority.
DIF: Cognitive Level: Application REF: p. 365
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patients
left naris. What is the best nursing action?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Have the patient blow the nose until clear.
b.
Insert bilateral cotton nasal packing.
c.
Place a nasal drip pad under the nose.
d.
Suction the left nares until the drainage clears.
227
ANS: C
In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small
bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow
their nose because that action may further aggravate the dural tear. Suction catheters should be inserted
through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.
DIF: Cognitive Level: Application REF: p. 374
OBJ: Describe the nursing and medical management of patients with skull fractures.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the
scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15.
One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?
a.
Stimulate the patient hourly.
b.
Continue to monitor the patient.
c.
Elevate the head of the bed.
d.
Notify the physician immediately.
ANS: D
These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive
deterioration. The physician must be notified of this neurological emergency so appropriate interventions can
be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying
stimulation as necessary to assess neurological response are appropriate interventions, notification of the
physician is a priority given the severity in change of neurological status.
DIF: Cognitive Level: Analysis REF: p. 376
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the
administration of mannitol (Osmitrol, which assessment finding by the nurse requires further action?
a.
ICP of 10 mm Hg
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
CPP of 70 mm Hg
c.
GCS score of 5
d.
CVP of 2 mm Hg
228
ANS: D
Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output.
An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum
indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral
perfusion, further action on the part of the nurse is necessary.
DIF: Cognitive Level: Application REF: p. 370
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values
indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?
a.
Altered cerebral spinal fluid production and reabsorption
b.
Decreased cerebral blood volume due to vessel constriction
c.
Increased cerebral blood volume due to vessel dilation
d.
No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
ANS: C
Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.
Cerebral vessels dilate when CO2 levels increase, increasing cerebral blood volume. To compensate for
increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the
effect of hypercarbia (elevated PaCO2 on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would
cause cerebral vasodilation and increased cerebral blood volume.
DIF: Cognitive Level: Knowledge REF: p. 366
OBJ: Describe the pathophysiology of increased intracranial pressure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital
signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10
breaths/min, oxygen saturation (SpO2 94% on oxygen at 3 L per nasal cannula. What is the priority nursing
action?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Monitor the patients airway patency.
b.
Elevate the head of the patients bed.
c.
Increase supplemental oxygen delivery.
d.
Support bony prominences with padding.
229
ANS: A
A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined
with the GSC score of 3, the nurse must focus on maintaining the patients airway. There is no evidence to
support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in
increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the
head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep
coma; however, airway patency is the immediate priority.
DIF: Cognitive Level: Application REF: pp. 355-356
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically
ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction
catheter. What is the best interpretation by the nurse?
a.
The patient is exhibiting extension posturing.
b.
The patient is exhibiting flexion posturing.
c.
The patient is exhibiting purposeful movement.
d.
The patient is withdrawing to stimulation.
ANS: C
This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.
Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists.
Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet.
Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.
DIF: Cognitive Level: Comprehension REF: p. 366
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient admitted to the ED following a fall from a 10-foot ladder. Upon admission,
the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising
behind the left ear and straw-colored drainage from the left nare. What is the most appropriate nursing action?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Insert bilateral ear plugs.
b.
Monitor airway patency.
c.
Maintain neutral head position.
d.
Apply a small nasal drip pad.
230
ANS: D
Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may
be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal
drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral
position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of
care.
DIF: Cognitive Level: Application REF: p. 374
OBJ: Describe the nursing and medical management of patients with skull fractures.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood
pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102 F. To
reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing
action(s)?
a.
Ensure adequate periods of rest between nursing interventions.
b.
Insert an oral airway and monitor respiratory rate and depth.
c.
Maintain neutral head alignment and avoid extreme hip flexion.
d.
Reduce ambient room temperature and administer antipyretics.
ANS: D
In this scenario, the patients temperature is elevated, which increases metabolic demands. Increases in
metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP.
Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated.
While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions
are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.
DIF: Cognitive Level: Application REF: p. 369
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse
arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Assist the patient to the floor and provide soft head support.
b.
Insert a nasogastric tube and connect to continuous wall suction.
c.
Open the patients mouth and insert a padded tongue blade.
d.
Restrain the patients extremities until the seizure subsides.
231
ANS: A
To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be
assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure
activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should
not be carried out during tonic-clonic activity; most likely the patients jaws will be clenched shut. Forceful
insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not
standard of care.
DIF: Cognitive Level: Application REF: p. 387
OBJ: Describe the pathophysiology and management for status epilepticus.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which
arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of
injury?
a.
pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg
b.
pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg
c.
pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg
d.
pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
ANS: C
Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and
ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both.
PaCO2 values greater than normal (35-45 can lead to cerebral vasodilatation and further increase cerebral
blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction
and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.
DIF: Cognitive Level: Comprehension REF: Nursing Care Plan: Spinal Cord Injury
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
232
injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart
rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4
hours. What is the best action by the nurse?
a.
Administer acetaminophen as ordered for the headache.
b.
Assess for a kinked urinary catheter and assess for bowel impaction.
c.
Encourage the patient to take slow, deep breaths.
d.
Notify the physician of the patients blood pressure.
ANS: B
Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system can be
triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder
distention. Other causes that should be ruled out prior to pharmacological intervention include fecal impaction.
Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus
on identifying the underlying cause. Slow deep breathes will not correct the underlying problem. Assessing for
underlying causes of autonomic dysreflexia should precede contacting the physician.
DIF: Cognitive Level: Application REF: Box 13-5
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided
weakness. What is the priority nursing action?
a.
Assess for the presence of a headache.
b.
Assess the patients general orientation.
c.
Determine the patients drug allergies.
d.
Determine the time of symptom onset.
ANS: D
Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the
onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and
general orientation, are a part of a complete neurological assessment and should be performed, time of onset of
symptoms is critical to the type of treatment.
DIF: Cognitive Level: Application REF: p. 379
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. Which patient being cared for in the emergency department should the charge nurse evaluate first?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
A patient with a complete spinal injury at the C5 dermatome level
b.
A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula
c.
An alert patient with a subdural bleed who is complaining of a headache
d.
An ischemic stroke patient with a blood pressure of 190/100 mm Hg
233
ANS: A
A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed
immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The
patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic
stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.
DIF: Cognitive Level: Analysis REF: pp. 393-394
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What
is the priority nursing action?
a.
Keep the neck in the hyperextended position.
b.
Maintain proper head and neck alignment.
c.
Prepare for immediate endotracheal intubation.
d.
Remove cervical collar upon arrival to the ED.
ANS: B
Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury.
Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation
is not indicated with a suspected cervical spine injury unless the patients airway is compromised. The use of
assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.
DIF: Cognitive Level: Comprehension REF: p. 392
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The
patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority
nursing action?
a.
Maintain body temperature.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Monitor blood pressure.
c.
Pad all bony prominences.
d.
Use proper hand washing.
234
ANS: B
Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood
pressure is a priority.
DIF: Cognitive Level: Comprehension REF: pp. 393-394
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
20. The physician has opted to treat a patient with a complete spinal cord injury with glucocorticoids. The
physician orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/min for 23
hours. What is the total 24-hour dose for the 70-kg patient?
a.
2478 mg
b.
5000 mg
c.
10,794 mg
d.
12,750 mg
ANS: C
The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a
continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg 70 kg) + (5.4 mg 70 kg) 23 hours =
10,794 mg.
DIF: Cognitive Level: Comprehension REF: Table 13-9
OBJ: Describe nursing and medical management of patients with a spinal cord injury.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
21. The nurse receives a patient from the emergency department following a closed head injury. After insertion
of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52
beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via
Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which physician
order should the nurse institute first?
a.
Mannitol 1 g intravenous
b.
Portable chest x-ray
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Seizure precautions
d.
Ancef 1 g intravenous
235
ANS: A
The patients GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure
precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention
to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however,
antibiotic therapy is not the priority in this scenario.
DIF: Cognitive Level: Analysis REF: Table 13-9
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm
for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with
a blood pressure 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation
(SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5 F. Which physician order should
the nurse institute first?
a.
Blood cultures (2 specimens) for temperature > 101 F
b.
Acetaminophen (Tylenol) 650 mg per rectum
c.
500 mL albumin infusion intravenously
d.
Decadron 20 mg intravenous push every 4 hours
ANS: C
Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm
has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with
500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and
ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to
include in the plan of care but are not priorities in this scenario.
DIF: Cognitive Level: Analysis REF: p. 384
OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine (Cardene
infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the
infusion at 5 mg/hr, the nurse assesses the patients blood pressure to be 160/90 mm Hg. What is the best action
by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Stop the infusion for 5 minutes.
b.
Increase the dose by 2.5 mg/hr.
c.
Notify the physician of the BP.
d.
Begin weaning the infusion.
236
ANS: B
Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured.
Following infusion, the patients blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr
is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching
the desired blood pressure. Notifying the physician of the blood pressure is not indicated until the upper limits
of the infusion are reached without achieving the desired blood pressure.
DIF: Cognitive Level: Analysis REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
24. The nurse is preparing to administer a routine dose of phenytoin (Dilantin). The physician orders phenytoin
(Dilantin) 500 mg intravenous every 6 hours. What is the best action by the nurse?
a.
Administer over 2 minutes.
b.
Administer with 0.9% normal saline intravenous.
c.
Contact the physician.
d.
Assess cardiac rhythm.
ANS: C
The ordered dose is an inappropriate maintenance dose. The nurse should contact the physician. Administering
the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia
are normal administration guidelines for normal dose parameters.
DIF: Cognitive Level: Application REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
25. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs
assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36
breaths/min, oxygen saturation (SpO2 96% on 100% supplemental oxygen by non-rebreather mask. After
establishing an intravenous (IV) line, which order by the physician should the nurse implement first?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Obtain stat serum electrolytes.
b.
Administer lorazepam (Ativan).
c.
Obtain stat portable chest x-ray.
d.
Administer phenytoin (Dilantin).
237
ANS: B
The nurse should administer lorazepam (Ativan) as ordered; lorazepam (Ativan) is the first-line medication for
the treatment of status epilepticus. Phenytoin (Dilantin) is administered only when lorazepam fails to stop
seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest xrays are appropriate orders but not the priority in this scenario.
DIF: Cognitive Level: Application REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
26. The physician orders fosphenytoin (Cerebyx), 1.5 g intravenous (IV) loading dose for a 75-kg patient in
status epilepticus. What is the most important action by the nurse?
a.
Contact the admitting physician.
b.
Administer drug over 10 minutes.
c.
Mix medication with 0.9% normal saline.
d.
Administer via central line.
ANS: B
The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE]
over 1 full minute. The drug dose ordered is appropriate for the patients weight. Fosphenytoin (Cerebyx does
not have to be administered with normal saline or via a central line.
DIF: Cognitive Level: Application REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
27. The nurse is to administer 100 mg phenytoin (Dilantin intravenous (IV. Vital signs assessed by the nurse
include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen
saturation (SpO2 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the
best action by the nurse?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Administer over 2 minutes.
b.
Administer over 5 minutes.
c.
Mix medication with 0.9% normal saline.
d.
Administer via central line.
238
ANS: B
In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast.
Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent
complications related to this scenario. Administering the medications via central line will not prevent
complications related to this scenario.
DIF: Cognitive Level: Application REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
28. The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus. To
prevent patient complications, what is the best action by the nurse?
a.
Ensure patency of intravenous (IV) line.
b.
Mix drug with 0.9% normal saline.
c.
Evaluate serum K+ level.
d.
Obtain an IV infusion pump.
ANS: A
Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue
necrosis. Mixing the drug with normal saline prevents crystallization of the medication and would be noticed
prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin
(Dilantin ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.
DIF: Cognitive Level: Comprehension REF: Table 13-9
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological and Parenteral Therapies
29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the
aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory
rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
239
Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the physician orders,
which order is of the highest priority?
a.
Lasix 20 mg intravenous push as needed
b.
500 mL albumin intravenous infusion
c.
Decadron 10 mg intravenous push
d.
Dilantin 50 mg intravenous push
ANS: B
To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate
of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low
volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the
priority medications.
DIF: Cognitive Level: Application REF: p. 384
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
30. After receiving the hand-off report from the day shift charge nurse, which patient should the evening
charge nurse assess first?
a.
A patient with meningitis complaining of photophobia
b.
A mechanically ventilated patient with a GCS of 6
c.
A patient with bacterial meningitis on droplet precautions
d.
A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104 F
ANS: D
The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104 F as this is an
abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated
has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis
and droplet precautions are appropriate for a patient with bacterial meningitis.
DIF: Cognitive Level: Analysis REF: Nursing Care Plan: Traumatic Brain Injury
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
240
31. The nurse has just received a patient from the emergency department with an admitting diagnosis of
bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by
the nurse?
a.
Implement droplet precautions upon admission.
b.
Wash hands thoroughly before leaving the room.
c.
Scrub the hub of all central line ports prior to use.
d.
Dispose of all bloody dressings in biohazard bags.
ANS: A
Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of
antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of
injection ports are practices that help reduce the risk of infection, but added precautions are necessary for
preventing the spread of bacterial meningitis. Disposing all bloody dressings in biohazard bags is a standard
universal precaution and is not specific to bacterial meningitis.
DIF: Cognitive Level: Comprehension REF: p. 388
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Planning
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs
assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30
breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5 F.
What is the priority nursing action?
a.
Elevate the head of the bed 30 degrees.
b.
Keep lights dim at all times.
c.
Implement seizure precautions.
d.
Maintain bedrest at all times.
ANS: C
Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid
(CSF in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral
irritation such photophobia and seizures. In addition, the patient is at increased risk for seizures because of a
high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent
injury. Elevating the head of the bead, keeping the lights dim, and maintaining bedrest are all appropriate
nursing interventions but are not the priorities in this scenario.
DIF: Cognitive Level: Application REF: p. 388
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
241
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The
nurse understands which principles and/or components to be essential when implementing ICP monitoring?
(Select all that apply.)
a.
Use of a heparin flush solution
b.
Manually flushing the device prn
c.
Recording ICP as a mean value
d.
Use of a pressurized flush system
e.
Zero referencing the transducer system
ANS: C, E
Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is
recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro.
Manually flushing the device may result in an increase in ICP.
DIF: Cognitive Level: Knowledge REF: p. 362
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. In an unconscious patient, eye movements are tested by the oculocephalic response. Which statements
regarding the testing of this reflex are true? (Select all that apply.)
a.
Dolls eyes absent indicate a disruption in normal brainstem processing.
b.
Dolls eyes present indicate brainstem activity.
c.
Eye movement in the opposite direction as the head when turned indicates an intact reflex.
d.
Eye movement in the same direction as the head when turned indicates an intact reflex.
e.
Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex.
f.
Presence of cervical injuries is a contraindication to the assessment of this reflex.
ANS: A, B, C, E, F
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
242
In unconscious patients with stable cervical spine, assess oculocephalic reflex (dolls eye): turn the patients
head quickly from side to side while holding the eyes open. Note movement of eyes. The dolls eye reflex is
present if the eyes move bilaterally in the opposite direction of the head movement.
DIF: Cognitive Level: Comprehension REF: pp. 393-396
OBJ: Complete an assessment on a critically ill patient with nervous system injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided
weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed.
Which actions are most important to include in the patients plan of care? (Select all that apply.)
a.
Make frequent neurological assessments.
b.
Maintain CO2 level at 50 mm Hg.
c.
Maintain MAP less than 130 mm Hg.
d.
Prepare for thrombolytic administration.
e.
Restrain affected limb to prevent injury.
ANS: A, C
The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood
pressure 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg.
Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time
of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within
normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits
thrombolytic therapy. Restraints should be avoided.
DIF: Cognitive Level: Analysis REF: pp. 382-383
OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
243
Chapter 15: Acute Respiratory Failure
MULTIPLE CHOICE
1. The nurse is caring for a patient with acute respiratory failure and identifies Risk for Ineffective Airway
Clearance as a nursing diagnosis. A nursing intervention relevant to this diagnosis is:
a.
Elevate head of bed to 30 degrees.
b.
Obtain order for venous thromboembolism prophylaxis.
c.
Provide adequate sedation.
d.
Reposition patient every 2 hours.
ANS: D
Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention
to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility.
Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained
secretions.
DIF: Cognitive Level: Analysis REF: Nursing Care Plan
OBJ: Formulate a plan of care for the patient with acute respiratory failure.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
2. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following
symptoms?
a.
Decreasing PaO2 levels despite increased FiO2 administration
b.
Elevated alveolar surfactant levels
c.
Increased lung compliance with increased FiO2 administration
d.
Respiratory acidosis associated with hyperventilation
ANS: A
Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in
ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory
alkalosis.
DIF: Cognitive Level: Comprehension REF: p. 410
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find
which
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
acid-base alteration?
a.
Hyperventilation and respiratory acidosis
b.
Hypoventilation and respiratory acidosis
c.
Hypoventilation and respiratory alkalosis
d.
Respiratory acidosis and normal oxygen levels
ANS: B
Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and
respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not
hyperventilation. Hypoxemia is expected secondary to depressed respirations.
DIF: Cognitive Level: Analysis REF: p. 401
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. Intrapulmonary shunting refers to:
a.
alveoli that are not perfused.
b.
blood that is shunted from the left side of the heart to the right and causes heart failure.
c.
blood that is shunted from the right side of the heart to the left without oxygenation.
d.
shunting of blood supply to only one lung.
ANS: C
Shunting refers to blood that is not oxygenated in the lungs.
DIF: Cognitive Level: Comprehension REF: p. 401
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. When fluid is present in the alveoli:
a.
alveoli collapse and atelectasis occurs.
b.
diffusion of oxygen and carbon dioxide is impaired.
c.
hypoventilation occurs.
244
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
245
the patient is in heart failure.
ANS: B
Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in
the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress
syndrome.
DIF: Cognitive Level: Comprehension REF: p. 408
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. In assessing a patient, the nurse understands that an early sign of hypoxemia is:
a.
clubbing of nail beds
b.
cyanosis
c.
hypotension
d.
restlessness
ANS: D
Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a
sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure,
not hypotension, may be seen early in hypoxemia.
DIF: Cognitive Level: Comprehension REF: p. 403
OBJ: Describe methods for assessing the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. The basic underlying pathophysiology of acute respiratory distress syndrome results from:
a.
a decrease in the number of white blood cells available.
b.
damage to the right mainstem bronchus.
c.
damage to the type II pneumocytes, which produce surfactant.
d.
decreased capillary permeability.
ANS: C
Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability,
and noncardiogenic pulmonary edema.
DIF: Cognitive Level: Comprehension REF: p. 408 | Figure 14-2
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
246
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite
mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite
sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the
physician of this assessment and anticipates an order for:
a.
continuous lateral rotation therapy.
b.
guided imagery.
c.
neuromuscular blockade.
d.
prone positioning.
ANS: C
Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided
imagery is an excellent non-pharmacological approach to manage anxiety; however, the non-traditional mode
of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment
for refractory hypoxemia but not indicated until the neuromuscular blockade has been tried.
DIF: Cognitive Level: Analysis REF: p. 412
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
9. A patient presents to the emergency department in acute respiratory failure secondary to communityacquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates
which treatment to facilitate ventilation?
a.
Emergency tracheostomy and mechanical ventilation
b.
Mechanical ventilation via an endotracheal tube
c.
Noninvasive positive-pressure ventilation (NPPV)
d.
Oxygen at 100% via bag-valve-mask device
ANS: C
Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive
pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive
pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bagvalve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that
exists. Emergency tracheostomy is not indicated, as there is an indication of an obstructed airway.
DIF: Cognitive Level: Analysis REF: p. 404
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
247
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
10. Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired
gas exchange seen in severe exacerbation of asthma?
a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis
ANS: C
Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which
causes respiratory acidosis.
DIF: Cognitive Level: Comprehension REF: p. 401
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. An acute exacerbation of asthma is treated with which of the following?
a.
Corticosteroids and theophylline by mouth
b.
Inhaled bronchodilators and intravenous corticosteroids
c.
Prone positioning or continuous lateral rotation
d.
Sedation and inhaled bronchodilators
ANS: B
Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma;
they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous
lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is
not recommended.
DIF: Cognitive Level: Comprehension REF: p. 404
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part
of the discharge teaching, the nurse instructs:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
248
a.
If you get the pneumococcal vaccine, youll never get pneumonia again.
b.
It is important for you to get an annual influenza shot to reduce your risk of pneumonia.
c.
Stay away from cold, drafty places because that increases your risk of pneumonia when you get
home.
d.
Since you have been treated for pneumonia, you now have immunity from getting it in the future.
ANS: B
The influenza vaccine reduces the risk of pneumonia by over a half. The pneumococcal vaccine is important
but only protects against pneumococcal infection. Cold, drafty environments will not cause infection.
Immunity for pneumonia does not occur as a result of getting it.
DIF: Cognitive Level: Analysis REF: p. 419
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the
patient to prevent exacerbation by:
a.
obtaining an appointment for follow-up pulmonary function studies 1 week after discharge.
b.
limiting activity until patient is able to climb two flights of stairs.
c.
taking all asthma medications as prescribed.
d.
taking medications on a prn basis according to symptoms.
ANS: C
Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
Follow-up studies will be determined by the physician. Activity is based on the patients activity tolerance and
is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a
prn basis.
DIF: Cognitive Level: Analysis REF: pp. 416-417
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD. Which
assessment would be a cue to the patient developing postoperative pneumonia?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Bradycardia
b.
Change in sputum characteristics
c.
Hypoventilation and respiratory acidosis
d.
Pursed-lip breathing
249
ANS: B
Change in the character of sputum may signal the development of a respiratory infection in the patient with
COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue,
malaise, confusion, fever, and sleeping difficulties.
DIF: Cognitive Level: Analysis REF: p. 413
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the
most common cause of a pulmonary embolus is:
a.
amniotic fluid embolus.
b.
deep vein thrombosis from lower extremities.
c.
fat embolus from a long bone fracture.
d.
vegetation that dislodges from an infected central venous catheter.
ANS: B
The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less
common causes.
DIF: Cognitive Level: Comprehension REF: p. 423
OBJ: Describe methods for assessing the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops
a plan of care for prevention to include which of the following?
a.
Antiseptic oral care
b.
Bed rest with head of bed elevated
c.
Coughing and deep breathing
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
250
Mobility
ANS: D
Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and
coughing and deep breathing assist in preventing pneumonia.
DIF: Cognitive Level: Application REF: p. 424 | Box 14-7
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
17. Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary
embolus (PE)?
a.
PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk
factors for VTE.
b.
Bradycardia and hyperventilation are classic symptoms of PE.
c.
Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE.
d.
Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.
ANS: A
PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for
VTE. Dyspnea, hemoptysis, and chest pain have been called the classic signs and symptoms for PE, but the
three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not
classic signs of PE. Most critically ill patients are at high risk for VTE and all should receive prophylaxis.
DIF: Cognitive Level: Analysis REF: p. 424
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient:
a.
Im going to contact the pharmacist to see if you can take this medication by mouth.
b.
This injection is being given to prevent blood clots from forming.
c.
This medication will dissolve any blood clots you might get.
d.
You should not be receiving this medication. I will contact the physician to get it stopped.
ANS: B
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
251
Lovenox, or lowmolecular weight heparin, is recommended for patients at high risk for PE. This patient is at
high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots
from forming but does not dissolve them.
DIF: Cognitive Level: Application REF: p. 424 | Box 14-7
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. A definitive diagnosis of pulmonary embolism can be made by:
a.
arterial blood gas (ABG) analysis.
b.
chest x-ray examination.
c.
pulmonary angiogram.
d.
ventilation-perfusion scanning.
ANS: C
The angiogram is the only test that can confirm pulmonary embolism. ABG would only indicate hypoxemia
and/or acid-base abnormalities. A chest x-ray study is nonconclusive. A ventilation-perfusion scan is
nonconclusive.
DIF: Cognitive Level: Comprehension REF: p. 424 | Box 14-7
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is:
a.
administration of two aspirin tablets every 4 hours.
b.
infusion of thrombolytics.
c.
insertion of a vena cava filter.
d.
subcutaneous heparin administration every 12 hours.
ANS: C
A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin
is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is
administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at
high risk for VTE.
DIF: Cognitive Level: Application REF: p. 424 | Box 14-7
OBJ: Discuss medical management of the patient with ARF.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
252
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
21. Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary
artery?
a.
Aspirin
b.
Embolectomy
c.
Heparin
d.
Thrombolytics
ANS: D
Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin
will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An
embolectomy is a surgical procedure to remove the clot. Heparin will prevent further clot formation, but it will
not dissolve the clot.
DIF: Cognitive Level: Comprehension REF: p. 425
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory
distress syndrome (ARDS)?
a.
Increased oxygen saturation via pulse oximetry
b.
Increased peak inspiratory pressure on the ventilator
c.
Normal chest radiograph with enlarged cardiac structures
d.
PaO2/FiO2 ratio > 300
ANS: B
Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in
ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio less than 200 is a
criterion.
DIF: Cognitive Level: Application REF: pp. 408-410 | Table 14-1
OBJ: Describe methods for assessing the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
253
23. The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).
a.
46.8; meets criteria for ARDS
b.
130; meets criteria for ARDS
c.
468; normal lung function
d.
Not enough data to compute the ratio
ANS: B
78/0.60 = 130, which meets the criteria for ARDS.
DIF: Cognitive Level: Analysis REF: pp. 408-410 | Table 14-1
OBJ: Describe methods for assessing the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
24. The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is:
a.
cardiac output of 10 L/min and low systemic vascular resistance.
b.
PAOP of 10 mm Hg and PaO2 of 55.
c.
PAOP of 20 mm Hg and cardiac output of 3 L/min.
d.
PAOP of 5 mm Hg and high systemic vascular resistance.
ANS: B
A normal PAOP with hypoxemia is an expected assessment finding in ARDS. Cardiac output of 10 L/min and
low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3
L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are
expected findings in hypovolemic shock.
DIF: Cognitive Level: Analysis REF: pp. 408-410 | Table 14-1
OBJ: Describe methods for assessing the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress
syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?
a.
Management and protection of the airway
b.
Prevention of gastric aspiration
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Prevention of skin breakdown and nerve damage
d.
Psychological support to patient and family
254
ANS: A
All are important, but protection of the airway is the most important intervention if the patient is placed in the
prone position.
DIF: Cognitive Level: Comprehension REF: p. 412
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
26. During rounds, the physician alerts the team that proning is being considered for a patient with acute
respiratory distress syndrome. The nurse understands that proning is:
a.
an optional treatment if the PaO2/FiO2 ratio is less 100.
b.
less of a risk for skin breakdown because the patient is face down.
c.
possible with minimal help from co-workers.
d.
used to provide continuous lateral rotational turning.
ANS: A
Proning is considered if the PaO2/FiO2 ratio is low. The patient is not responding to treatment, and all options
should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the
risk is in the dependent areas such as the face. Proning is a labor-intensive procedure, and the nurse needs help
from team members to ensure a safe turn, including protecting the airway. Continuous lateral rotation is a
therapy done in the supine position with a specialized bed.
DIF: Cognitive Level: Application REF: p. 412
OBJ: Discuss medical management of the patient with acute respiratory failure.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
27. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related
to damage to the:
a.
alveolar-capillary membrane.
b.
left ventricle.
c.
mainstem bronchus.
d.
trachea.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
255
ANS: A
Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other
responses apply.
DIF: Cognitive Level: Comprehension REF: p. 401
OBJ: Describe the pathophysiology of ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Identify diagnostic criteria for ARDS. (Select all that apply.)
a.
Bilateral infiltrates on chest x-ray study
b.
Decreased cardiac output
c.
PaO2/ FiO2 ratio of less than 200
d.
Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
ANS: A, C
Diagnostic criteria for ARDS include bilateral infiltrates, or white out, on chest x-ray study and a low
PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with
cardiac causes. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with
cardiac causes.
DIF: Cognitive Level: Comprehension REF: pp. 407-408
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Which of the following statements is true regarding oral care for the prevention of ventilator-associated
pneumonia (VAP)? (Select all that apply.)
a.
Tooth brushing is performed every 2 hours for the greatest effect.
b.
Implementing a comprehensive oral care program is an intervention for preventing VAP.
c.
Oral care protocols should include oral suctioning and brushing teeth.
d.
Protocols that include chlorhexidine gluconate have been effective in preventing VAP.
ANS: B, C, D
A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
256
teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have
undergone cardiac surgery.
DIF: Cognitive Level: Application REF: p. 422 | Box 14-4 | Box 14-5
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
3. Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the
treatment of ARDS? (Select all that apply.)
a.
Increase functional residual capacity
b.
Prevent collapse of unstable alveoli
c.
Improve arterial oxygenation
d.
Open collapsed alveoli
ANS: A, B, C, D
Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed
alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation.
DIF: Cognitive Level: Comprehension REF: p. 410, 412
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Which of the following are components of the Institute for Healthcare Improvements (IHIs) ventilator
bundle? (Select all that apply.)
a.
Interrupt sedation each day to assess readiness to extubate.
b.
Maintain head of bed at least 30 degrees elevation.
c.
Provide deep vein thrombosis prophylaxis.
d.
Provide prophylaxis for peptic ulcer disease.
e.
Swab the mouth with foam swabs every 2 hours.
ANS: A, B, C, D
Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently
been added to the IHI bundle. Swabbing alone provides comfort care.
DIF: Cognitive Level: Application REF: p. 422 | Box 14-4 | Box 14-5
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
257
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all
that apply.)
a.
Graduated compression stockings
b.
Heparin or lowmolecular weight heparin for patients at risk
c.
Sequential compression devices
d.
Strict bed rest
ANS: A, B, C
Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for
DVT. Physical activity can also reduce the risk; bed rest increases the risk.
DIF: Cognitive Level: Comprehension REF: p. 425
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent
ventilator-associated pneumonia include which of the following? (Select all that apply.)
a.
Drain condensate from the ventilator tubing away from the patient.
b.
Elevate the head of the bed 30 to 45 degrees.
c.
Instill normal saline as part of the suctioning procedure.
d.
Perform regular oral care with chlorhexidine.
ANS: A, B, D
Condensate should be drained away from the patient to avoid drainage back into the patients airway.
Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care,
with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended
as part of the suctioning procedure, and it may increase the risk for infection.
DIF: Cognitive Level: Comprehension REF: p. 422 | Box 14-4 | Box 14-5
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
258
7. The nurse is caring for a patient in acute respiratory failure and understands that the patient should be
positioned: (Select all that apply.)
a.
high Fowlers.
b.
side lying with head of bed elevated.
c.
sitting in a chair.
d.
supine with the bed flat.
ANS: A, B, C
Patients in respiratory distress are unable to tolerate a flat position. High Fowlers is appropriate. Side lying
with head of bed elevated, sitting in a chair, and high Fowlers position are all appropriate ways to position the
patient to facilitate gas exchange and comfort.
DIF: Cognitive Level: Comprehension REF: pp. 403-405
OBJ: Formulate a plan of care for the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of
the following? (Select all that apply.)
a.
Airway clearance therapies
b.
Antibiotic therapy
c.
Nutritional support
d.
Tracheostomy
ANS: A, B, C
The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional
support. A tracheostomy is not a standard treatment for CF.
DIF: Cognitive Level: Application REF: p. 427
OBJ: Discuss medical management of the patient with ARF.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
OTHER
1. In the following picture of the alveolar-capillary membrane, select what is being demonstrated.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
A normal alveolar-capillary unit
b.
Hypoventilation with increased PaCO
c.
Shunting
d.
Ventilation/perfusion mismatch
ANS:
C - shunting
DIF: Cognitive Level: Comprehension REF: Figure 14-1
OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: N/A
MSC: NCLEX: Physiologic Integrity
259
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
260
Chapter 16: Acute Kidney Injury
MULTIPLE CHOICE
1. With sudden cessation of renal function, all body systems are affected by the inability to maintain fluid and
electrolyte balance and eliminate metabolic waste. In critically ill patients, renal dysfunction:
a.
is a very rare problem.
b.
affects nearly two thirds of patients.
c.
has a low mortality once renal replacement therapy has been initiated.
d.
has little effect on morbidity, mortality, or quality of life.
ANS: B
The kidney is the primary regulator of the bodys internal environment. With sudden cessation of renal
function, all body systems are affected by the inability to maintain fluid and electrolyte balance and eliminate
metabolic waste. Renal dysfunction is a common problem in critically ill patients with nearly two thirds of
patients experiencing some degree of renal dysfunction. The most severe cases requiring renal replacement
therapy have a reported mortality of 50% to 60%. Acute kidney injury that progresses to chronic renal failure
is associated with increased morbidity, mortality and reduced quality of life.
DIF: Cognitive Level: Comprehension REF: p. 432
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the
patients urinalysis results. The nurse should become concerned when
a.
creatinine levels in the urine are similar to blood levels of creatinine.
b.
sodium and chloride are found in the urine.
c.
urine uric acid levels have the same values as serum levels.
d.
red blood cells and albumin are found in the urine.
ANS: D
Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and
phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those
in plasma. Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular
membrane. Their presence in urine may indicate glomerular damage.
DIF: Cognitive Level: Comprehension REF: p. 433
OBJ: Review the anatomy and physiology of the renal system.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
261
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. A normal glomerular filtration rate is:
a.
less than 80 mL/min.
b.
80 to 125 mL/min
c.
125 to 180 mL/min
d.
more than 189 mL/min
ANS: B
At a normal glomerular filtration rate (GFR) of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate.
As the filtrate passes through the various components of the nephrons tubules, 99% is reabsorbed into the
peritubular capillaries or vasa recta.
DIF: Cognitive Level: Knowledge REF: p. 434
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. A normal urine output is considered to be:
a.
80 to 125 mL/min.
b.
180 L/day.
c.
80 mL/min.
d.
1 to 2 L/day.
ANS: D
At a normal glomerular filtration rate (GFR of 80 to 125 mL/min, the kidneys produce 180 L/day of filtrate.
As the filtrate passes through the various components of the nephrons tubules, 99% is reabsorbed into the
peritubular capillaries or vasa recta. Eventually, the remaining filtrate (1% of the original 180 L/day is
excreted as urine, for an average urine output of 1 to 2 L/day.
DIF: Cognitive Level: Knowledge REF: p. 434
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. Renin plays a role in blood pressure regulation by:
a.
activating the renin-angiotensin-aldosterone cascade.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
suppressing angiotensin production.
c.
decreasing sodium reabsorption.
d.
inhibiting aldosterone release.
262
ANS: A
Specialized cells in the afferent and efferent arterioles and the distal tubule are collectively known as the
juxtaglomerular apparatus. These cells are responsible for the production of a hormone called renin, which
plays a role in blood pressure regulation. Renin is released whenever blood flow through the afferent and
efferent arterioles decreases. A decrease in the sodium ion concentration of the blood flowing past the
specialized cells (e.g., in hypovolemia) also stimulates the release of renin. Renin activates the reninangiotensin-aldosterone cascade, which ultimately results in angiotensin II production. Angiotensin II causes
vasoconstriction and release of aldosterone from the adrenal glands, thereby raising blood pressure and flow
and increasing sodium and water reabsorption in the distal tubule and collecting ducts.
DIF: Cognitive Level: Knowledge REF: p. 434
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse is caring for an elderly patient who was admitted with renal insufficiency. The nurse realizes that
with advance age often comes declining renal function. An expected laboratory finding for this patient may be:
a.
an increased glomerular filtration rate (GFR).
b.
a normal serum creatinine level.
c.
increased ability to excrete drugs.
d.
hypokalemia.
ANS: B
The most important renal physiological change that occurs with aging is a decrease in the GFR. After age 40,
renal blood flow gradually diminishes at a rate of 10% per decade. With advancing age, there is also a decrease
in renal mass, the number of glomeruli and peritubular density. Serum creatinine levels may remain the same
in the elderly patient, even with a declining GFR, because of decreased muscle mass and hence decreased
creatinine production. Tubular changes include a diminished ability to excrete drugs, including radiocontrast
dyes used in diagnostic testing, which necessitates a decrease in drug dosing to avoid nephrotoxicity. Many
medications, including antibiotics, require dose adjustments as kidney function declines. Age-related changes
in renin and aldosterone levels also occur, which can lead to fluid and electrolyte abnormalities. Renin levels
are decreased by 30% to 50% in the elderly, resulting in less angiotensin II production and lower aldosterone
levels. Together these can cause an increased risk of hyperkalemia. The aging kidney is also slower to correct
an increase in acids, causing a prolonged metabolic acidosis and the subsequent shifting of potassium out of
cells and worsening hyperkalemia.
DIF: Cognitive Level: Comprehension REF: p. 435
OBJ: Review the anatomy and physiology of the renal system.
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TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. The term used to describe an increase in blood urea nitrogen (BUN) and serum creatinine is:
a.
oliguria.
b.
azotemia.
c.
acute kidney injury.
d.
prerenal disease.
ANS: B
Azotemia refers to increases in blood urea nitrogen and serum creatinine. Oliguria is defined as urine output
less than 0.5 mL/kg/hr. Elevation of BUN and creatinine can be the result of acute kidney injury or chronic
kidney diseases. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal.
DIF: Cognitive Level: Knowledge REF: p. 435
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The most common cause of acute kidney injury in critically ill patients is:
a.
sepsis.
b.
fluid overload.
c.
medications.
d.
hemodynamic instability.
ANS: A
The etiology of AKI in critically ill patients is often multifactorial and develops from a combination of
hypovolemia, sepsis, medications, and hemodynamic instability. Sepsis is the most common cause of AKI.
DIF: Cognitive Level: Knowledge REF: p. 436
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the
patients urine output has been less than 20 mL/hour for the past 2 hours. It is 0200 in the morning. The patients
blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per
minute with a blood pressure of 120/80 mm Hg. The nurse should:
a.
contact the provider and expect an order for a normal saline bolus.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
wait until 0900 when the provider makes rounds to report the assessment findings.
c.
continue to evaluate urine output for 2 more hours.
d.
ignore the urine output, as this is most likely postrenal in origin.
264
ANS: A
Most prerenal causes of AKI are related to intravascular volume depletion, decreased cardiac output, renal
vasoconstriction, or pharmacological agents that impair autoregulation and GFR (Box 15-2).8 These conditions
reduce the glomerular perfusion and the GFR, and the kidneys are hypoperfused. For example, major
abdominal surgery can cause hypoperfusion of the kidney as a result of blood loss during surgery or as a result
of excess vomiting or nasogastric suction during the postoperative period. The body attempts to normalize
renal perfusion by reabsorbing sodium and water. If adequate blood flow is restored to the kidney, normal renal
function resumes. Most forms of prerenal AKI can be reversed by treating the cause.
DIF: Cognitive Level: Analysis REF: p. 436
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. Acute kidney injury from post renal etiology is caused by:
a.
obstruction of the flow of urine.
b.
conditions that interfere with renal perfusion.
c.
hypovolemia or decreased cardiac output.
d.
conditions that act directly on functioning kidney tissue.
ANS: A
Acute kidney injury resulting from obstruction of the flow of urine is classified as postrenal or obstructive
renal injury. Conditions that result in AKI by interfering with renal perfusion are classified as prerenal and
include hypovolemia and decreased cardiac output. Conditions that produce AKI by directly acting on
functioning kidney tissue are classified as intrarenal.
DIF: Cognitive Level: Knowledge REF: pp. 436-437
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. Conditions that produce acute kidney injury by directly acting on functioning kidney tissue are classified as
intrarenal. The most common intrarenal condition is:
a.
prolonged ischemia.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
exposure to nephrotoxic substances.
c.
acute tubular necrosis (ATN).
d.
hypotension for several hours.
265
ANS: C
The most common intrarenal condition is ATN. This condition may occur after prolonged ischemia (prerenal),
exposure to nephrotoxic substances, or a combination of these. Some patients have ATN after only several
minutes of hypotension or hypovolemia, whereas others can tolerate hours of renal ischemia without having
any apparent tubular damage.
DIF: Cognitive Level: Knowledge REF: p. 437
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure.
To detect signs of contrast-induced kidney injury, the nurse should:
a.
not be concerned unless urine output decreases.
b.
evaluate the patients serum creatinine for up to 72 hours after the procedure.
c.
obtain an order for a renal ultrasound.
d.
evaluate the patients post void residual volume to detect intrarenal injury.
ANS: B
Contrast- induced kidney injury is diagnosed by an increase in serum creatinine of 25%, or 0.5 mg/dL, within
48 to 72 hours following the administration of contrast. Urine output usually remains normal. The renal
ultrasound and postvoid residual assessment are not warranted.
DIF: Cognitive Level: Analysis REF: p. 438
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. The nurse is caring for a patient with acute kidney injury who is being treated with hemodialysis. The
patient asks if he will need dialysis for the rest of his life. Which of the following would be the best response?
a.
Unfortunately, kidney injury is not reversible; it is permanent.
b.
Kidney function usually returns within 2 weeks.
c.
You will know for sure if you start urinating a lot all at once.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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266
recovery is possible, but it may take several months.
ANS: D
Renal dysfunction is potentially reversible during the initiation phase. This phase spans several hours to 2
days, during which time the normal renal processes begin to deteriorate, but actual intrinsic renal damage has
not yet occurred. During the maintenance phase, intrinsic renal damage is established, and the GFR stabilizes
at approximately 5 to 10 mL/min. This phase usually lasts 8 to 14 days, but it may last up to 11 months. The
longer a patient remains in this stage, the slower the recovery and the greater the chance of permanent renal
damage will be. The recovery phase is the period during which the renal tissue recovers and repairs itself. A
gradual increase in urine output and an improvement in laboratory values occur. Recovery may take as long as
4 to 6 months.
DIF: Cognitive Level: Comprehension REF: pp. 439-440
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. Which of the following patients is at the greatest risk of developing acute kidney injury? A patient who:
a.
has been on aminoglycosides for the past 6 days.
b.
has a history of controlled hypertension with a blood pressure of 138/88 mm Hg.
c.
was discharged 2 weeks earlier after aminoglycoside therapy of 2 weeks.
d.
has a history of fluid overload as a result of heart failure.
ANS: C
Acute kidney injury can be caused by aminoglycoside nephrotoxicity, especially prolonged use of the drug
(more than 10 days). Symptoms of acute kidney injury are usually seen about 1 to 2 weeks after exposure.
Because of this delay, the patient must be questioned about any recent medical therapy for which an
aminoglycoside may have been prescribed. The blood pressure of 138/88 mm Hg controlled by medication
would not cause acute kidney injury, nor would fluid overload from exacerbation of heart failure.
DIF: Cognitive Level: Analysis REF: p. 440
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. The patient has elevated blood urea nitrogen (BUN) and serum creatinine levels with a normal
BUN/creatinine ratio. These levels most likely indicate:
a.
increased nitrogen intake.
b.
acute kidney injury, such as acute tubular necrosis (ATN).
c.
hypovolemia.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
267
fluid resuscitation.
ANS: B
A normal BUN/creatinine ratio is present in ATN. In ATN, there is actual injury to the renal tubules and a
rapid decline in the GFR; hence, BUN and creatinine levels both rise proportionally as a result of increased
reabsorption and decreased clearance. Hypovolemia would result in prerenal condition, which usually
increases the BUN/creatinine ratio.
DIF: Cognitive Level: Comprehension REF: p. 442
OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of
laboratory values and radiological diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. The patients serum creatinine level is 0.7 mg/dL. The expected BUN level should be:
a.
1-2 mg/dL.
b.
7-14 mg/dL.
c.
10-20 mg/dL.
d.
20-30 mg/dL.
ANS: B
The normal BUN/creatinine ratio is 10:1 to 20:1. Therefore, the expected range for this creatinine level would
be 7 to 14 mg/dL.
DIF: Cognitive Level: Analysis REF: p. 442
OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of
laboratory values and radiological diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. In determining the glomerular filtration rate (GFR) or creatinine clearance, a 24-hour urine is obtained. If a
reliable 24-hour urine collection is not possible,
a.
it is not possible to determine the GFR.
b.
the BUN may be used to determine renal function.
c.
an elevated BUN/creatinine ratio can be used.
d.
a standardized formula may be used to calculate GFR.
ANS: D
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Historically, timed 24-hour urine collections have been used to evaluate GFR or creatinine clearance. If a
reliable 24-hour urine collection is not possible, the Cockcroft and Gault formula may be used to determine the
creatinine clearance from a serum creatinine value. The BUN level is not a reliable indicator of kidney function
because the rate of protein metabolism is not constant. An increased BUN/creatinine ratio is typically noted
with prerenal conditions, but does not provide an estimate of GFR.
DIF: Cognitive Level: Comprehension REF: p. 442
OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of
laboratory values and radiological diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. In calculating the glomerular filtration rate (GFR) results for women, the creatinine clearance is usually:
a.
the same as for men.
b.
greater than that for men.
c.
multiplied by 0.85.
d.
multiplied by 1.15.
ANS: C
For women, the calculated result is multiplied by 0.85 to account for the smaller muscle mass as compared to
men.
DIF: Cognitive Level: Knowledge REF: p. 442
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary
output. The patients urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines
that the patient has:
a.
acute kidney injury from a prerenal condition.
b.
acute kidney injury from postrenal obstruction.
c.
intrarenal disease, probably acute tubular necrosis.
d.
a urinary tract infection.
ANS: C
Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of
acute kidney injury. Coarse, muddy brown granular casts are classic findings in ATN. Microscopic hematuria
and a small amount of protein also may be seen. In prerenal conditions, the urine typically has no cells but may
contain hyaline casts. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from
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the obstruction. Bacteria would be present in a urinary tract infection.
DIF: Cognitive Level: Analysis REF: p. 442
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. The patient is complaining of severe flank pain when he tries to urinate. His urinalysis shows sediment and
crystals along with a few bacteria. Using this information along with the clinical picture, the nurse realizes that
the patients condition is:
a.
prerenal.
b.
postrenal.
c.
intrarenal.
d.
not renal related.
ANS: B
Analysis of urinary sediment and electrolyte levels is helpful in distinguishing among the various causes of
acute kidney injury. Postrenal conditions may present with stones, crystals, sediment, bacteria, and clots from
the obstruction. Coarse, muddy brown granular casts are classic findings in ATN (intrarenal), along with
microscopic hematuria and a small amount of protein. In prerenal conditions, the urine typically has no cells
but may contain hyaline casts. The flank pain and urinalysis definitely indicate a renal condition.
DIF: Cognitive Level: Analysis REF: pp. 436-437
OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of
laboratory values and radiological diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
21. The patient is a new postoperative patient. She weighs 75 kg. The nurse expects the minimal acceptable
urine output to be:
a.
less than 30 mL/hour.
b.
37 mL/hour.
c.
80 mL/hour.
d.
150 mL/hour.
ANS: B
Normal urine output is 0.5 to 1 mL/kg of body weight each hour.
DIF: Cognitive Level: Comprehension REF: p. 447
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270
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. Daily weights are being recorded for the patient. His urine output has been less than his intravenous and
oral intake. His weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this
corresponds to a(n):
a.
fluid retention of 1.5 liters.
b.
fluid loss of 1.5 liters.
c.
equal intake and output due to insensible losses.
d.
fluid loss of 0.5 liters.
ANS: A
A 1-kg gain in body weight is equal to a 1000-mL fluid gain. This patient has gained 1.5 kg, or 1.5 liters of
fluid.
DIF: Cognitive Level: Analysis REF: p. 446
OBJ: Describe the pathophysiology and systemic manifestations of acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
23. The patient is admitted to the unit with the diagnosis of rhabdomyolysis. The patient is started on
intravenous (IV) fluids and IV mannitol. Because mannitol is an osmotic diuretic, the nurse should:
a.
assess the patients hearing.
b.
assess the patients lungs.
c.
decrease IV fluids once the diuretic has been administered.
d.
give extra doses prior to giving radiological contrast agents.
ANS: B
Mannitol, an osmotic diuretic often used in acute kidney injury caused by rhabdomyolysis, increases plasma
volume. Patients may be at risk for the development of pulmonary edema due to the rapid expansion of
intravascular volume triggered by mannitol. Hearing is assessed with administration of loop diuretics, such as
furosemide, which have been associated with deafness. Aggressive fluid administration is required in
rhabdomyolysis. Diuretics may increase the risk of acute kidney injury from volume depletion when they are
given before procedures requiring radiological contrast agents or if the patient is hypovolemic. Adequate
hydration prior to administration of diuretics is essential.
DIF: Cognitive Level: Application REF: p. 448
OBJ: Describe the medical management of the patient with acute kidney injury.
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TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
24. The patient gets hemodialysis 3 days a week. He is 74 inches tall and weighs 100 kg. In planning the care
for this patient, the nurse recommends:
a.
2500 to 3500 kcal diet per day.
b.
protein intake less than 50 grams per day.
c.
potassium intake of 10 mEq per day.
d.
fluid intake of less than 500 mL per day.
ANS: A
Nutritional recommendations include the following: caloric intake of 25 to 35 kcal/kg of ideal body weight per
day (2500-3500 kcal) and protein intake of no less than 0.8 g/kg body weight. Patients who are extremely
catabolic should receive 1.5 to 2 g/kg of ideal body weight per day, 75% to 80% of which contains all the
required essential amino acids; sodium intake of 0.5 to 1.0 g/day; potassium intake of 20 to 50 mEq/day;
calcium intake of 800 to 1200 mg/day; fluid intake equal to the volume of the patients urine output plus an
additional 600 to 1000 mL/day.
DIF: Cognitive Level: Application REF: p. 449
OBJ: Develop a plan of care for the patient with acute kidney injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
25. The patients potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces
plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?
a.
Kayexalate
b.
Kayexalate with sorbitol
c.
Regular insulin
d.
Calcium gluconate
ANS: A
Only dialysis and administration of cation exchange resins (sodium polystyrene sulfonate [Kayexalate]
actually reduce plasma potassium levels and total body potassium content in a patient with renal dysfunction.
In the past, sorbitol has been combined with sodium polystyrene sulfonate powder (Kayexalate for
administration. The concomitant use of sorbitol with Kayexalate has been implicated in cases of colonic
intestinal necrosis; therefore, this combination is not recommended. Other treatments, such as administration of
regular insulin and calcium gluconate only protect the patient for a short time until dialysis or cation exchange
resins can be instituted.
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DIF: Cognitive Level: Knowledge REF: p. 449
OBJ: Describe the medical management of the patient with acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
26. The patient is diagnosed with acute kidney injury and has been getting dialysis 3 days per week. The
patient complains of general malaise and is tachypneic. An arterial blood gas is ordered and shows that the
patients pH is 7.19, with a PCO2 of 30 mm Hg and a bicarbonate level of 13 mEq/L. The nurse prepares to:
a.
administer morphine to slow the respiratory rate.
b.
prepare for intubation and mechanical ventilation.
c.
administer intravenous sodium bicarbonate.
d.
cancel tomorrows dialysis session.
ANS: C
Metabolic acidosis is the primary acid-base imbalance seen in acute kidney injury. Treatment of metabolic
acidosis depends on its severity. Patients with a serum bicarbonate level of less than 15 mEq/L and a pH of less
than 7.20 are usually treated with intravenous sodium bicarbonate. The goal of treatment is to raise the pH to a
value greater than 7.20. Rapid correction of the acidosis should be avoided, because tetany may occur as a
result of hypocalcemia. Renal replacement therapies also may correct metabolic acidosis because it removes
excess hydrogen ions and bicarbonate is added to the dialysate and replacement solutions; therefore, dialysis
would not be cancelled. The tachypnea is a compensatory mechanism for the metabolic acidosis, and
treatments to decrease the respiratory rate are not indicated. Treatment is aimed at correcting the metabolic
acidosis, and this scenario does not provide data to support the need for intubation.
DIF: Cognitive Level: Analysis REF: p. 450
OBJ: Describe the medical management of the patient with acute kidney injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The removal of plasma water and some lowmolecular weight particles by using a pressure or osmotic
gradient is known as:
a.
dialysis.
b.
diffusion.
c.
clearance.
d.
ultrafiltration.
ANS: D
Ultrafiltration is the removal of plasma water and some lowmolecular weight particles by using a pressure
or
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273
osmotic gradient. Ultrafiltration is primarily aimed at controlling fluid volume, whereas dialysis is aimed at
decreasing waste products and treating fluid and electrolyte imbalances. Diffusion (or clearance) is the
movement of solutes such as urea from the patients blood to the dialysate cleansing fluid, across a
semipermeable membrane (the hemofilter).
DIF: Cognitive Level: Knowledge REF: p. 452
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
28. The patient is in need of immediate hemodialysis, but has no vascular access. The nurse prepares the
patient for insertion of:
a.
a percutaneous catheter at the bedside.
b.
a percutaneous tunneled catheter at the bedside.
c.
an arteriovenous fistula.
d.
an arteriovenous graft.
ANS: A
Temporary percutaneous catheters are commonly used in patients with acute kidney injury because they can be
used immediately. Occasionally a percutaneous tunneled catheter is placed if the patient needs ongoing
hemodialysis; however, these catheters are usually inserted in the operating room. An arteriovenous fistula is
an internal, surgically created communication between an artery and a vein. This method produces a vessel that
is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use. Arteriovenous grafts are
created by using different types of prosthetic material, most commonly polytetrafluoroethylene and Teflon.
Grafts are placed under the skin and are surgically anastomosed between an artery and a vein. The graft site
usually heals within 2 to 4 weeks.
DIF: Cognitive Level: Application REF: p. 452
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
29. The patient has a temporary percutaneous catheter in place for treatment of acute kidney injury. The
catheter has been in place for 5 days. The nurse should:
a.
prepare to assist with a routine dialysis catheter change to replace the existing catheter.
b.
evaluate the patient for signs and symptoms of infection.
c.
teach the patient that the catheter is designed for long-term use.
d.
use one of the three lumens for fluid administration.
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ANS: B
Routine replacement of hemodialysis catheters to prevent infection is not recommended. The decision to
remove or replace the catheter is based on clinical need and/or signs and symptoms of infection. The typical
catheter has a single or double lumen and is designed only for short-term renal replacement therapy during
acute situations. The catheter is not used for fluid and medication administration.
DIF: Cognitive Level: Application REF: p. 452
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
30. The patient has just returned from having an arteriovenous fistula placed. The patient asks, When will they
be able to use this and take this other catheter out? The nurse should reply,
a.
It can be used immediately so the catheter can come out anytime.
b.
It will take 2 to 4 weeks to heal before it can be used.
c.
The fistula will be usable in about 4 to 6 weeks.
d.
The fistula was made using graft material so it depends on the manufacturer.
ANS: C
An arteriovenous fistula is an internal, surgically created communication between an artery and a vein. This
method produces a vessel that is easy to cannulate but requires 4 to 6 weeks before it is mature enough to use.
DIF: Cognitive Level: Comprehension REF: pp. 452-453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
31. The patient is in progressive care unit following arteriovenous fistula implantation in his left upper arm,
and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the
patient, the nurse should:
a.
draw blood from the left arm.
b.
take blood pressures from the left arm.
c.
start a new intravenous line in the left lower arm.
d.
auscultate the left arm for a bruit and palpate for a thrill.
ANS: D
An arteriovenous fistula should be auscultated for a bruit and palpated for the presence of a thrill or buzz
every
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8 hours. The extremity that has a fistula or graft must never be used for drawing blood specimens, obtaining
blood pressure measurements, administering intravenous therapy, or giving intramuscular injections. Such
activities produce pressure changes within the altered vessels that could result in clotting or rupture.
DIF: Cognitive Level: Application REF: p. 453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
32. The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill.
Pulses distal to the fistula are not palpable. The nurse should:
a.
reassess the patient in an hour.
b.
raise the arm above the level of the patients heart.
c.
notify the provider immediately.
d.
apply warm packs to the fistula site and reassess.
ANS: C
Inadequate collateral circulation past the fistula or graft may result in loss of this pulse. The physician is
notified immediately if no bruit is auscultated, no thrill is palpated, or the distal pulse is absent. Loss of bruit
and thrill indicate a loss of blood flow most likely due to clotting. The patient will need to return to surgery as
soon as possible for declotting. Raising the arm above the level of the heart will not help. Warm packs may or
may not help.
DIF: Cognitive Level: Application REF: p. 453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
33. The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for
this patient, the nurse should:
a.
apply a sterile gauze dressing to maintain sterility.
b.
replace the transparent dressing every 10 days to prevent manipulation.
c.
assess the catheter site for redness and/or swelling.
d.
use the catheter for drawing blood samples to reduce patient discomfort.
ANS: C
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Tenderness at the insertion site, swelling, erythema or drainage should be reported to the physician.
Transparent, semipermeable polyurethane dressings are recommended as they allow continuous visualization
for assessment of signs of infection. Replace transparent dressings on temporary percutaneous catheters at least
every 7 days and no more than once a week for tunneled percutaneous catheters unless the dressing is soiled or
loose. The catheter is not used for the administration of fluids or medications or for the sampling of blood
unless a specific order is obtained to do so.
DIF: Cognitive Level: Application REF: p. 453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
34. The patient is getting hemodialysis for the second time when he complains of a headache and nausea and, a
little later, of becoming confused. The nurse realizes these are symptoms of:
a.
dialyzer membrane incompatibility.
b.
a shift in potassium levels.
c.
dialysis disequilibrium syndrome.
d.
hypothermia.
ANS: C
Dialysis disequilibrium syndrome often occurs after the first or second dialysis treatment or in patients who
have had sudden, large decreases in BUN and creatinine levels as a result of the hemodialysis. Because of the
blood-brain barrier, dialysis does not deplete the concentrations of BUN, creatinine, and other uremic toxins in
the brain as rapidly as it does those substances in the extracellular fluid. An osmotic concentration gradient
established in the brain allows fluid to enter until the concentration levels equal those of the extracellular fluid.
The extra fluid in the brain tissue creates a state of cerebral edema for the patient, which results in severe
headaches, nausea and vomiting, twitching, mental confusion, and occasionally seizures. Dialyzer membrane
incompatibility may cause hypotension. Hyperthermia, not hypothermia, may result if the temperature control
devices on the dialysis machine malfunction. Potassium shifts may occur but would be manifested in cardiac
dysrhythmias.
DIF: Cognitive Level: Analysis REF: p. 453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
35. Continuous renal replacement therapy (CRRT) differs from conventional intermittent hemodialysis in that:
a.
a hemofilter is used to facilitate ultrafiltration.
b.
it provides faster removal of solute and water.
c.
it does not allow diffusion to occur.
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d.
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the process removes solutes and water slowly.
ANS: D
CRRT is a continuous extracorporeal blood purification system managed by the bedside critical care nurse. It is
similar to conventional intermittent hemodialysis in that a hemofilter is used to facilitate the processes of
ultrafiltration and diffusion. It differs in that CRRT provides a slow removal of solutes and water as compared
to the rapid removal of water and solutes that occurs with intermittent hemodialysis.
DIF: Cognitive Level: Comprehension REF: p. 454
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
36. Slow continuous ultrafiltration is also known as isolated ultrafiltration and is used to:
a.
remove plasma water in cases of volume overload.
b.
remove fluids and solutes through the process of convection.
c.
remove plasma water and solutes by adding dialysate.
d.
combine ultrafiltration, convection and dialysis.
ANS: A
Slow continuous ultrafiltration (SCUF) is also known as isolated ultrafiltration and is used to remove plasma
water in cases of volume overload. Continuous venovenous hemofiltration (CVVH) is used to remove fluids
and solutes through the process of convection. Continuous venovenous hemodialysis (CVVHD) is similar to
CVVH in that ultrafiltration removes plasma water. It differs in that dialysate solution is added around the
hemofilter membranes to facilitate solute removal by the process of diffusion. Continuous venovenous
hemodiafiltration (CVVHDF) combines ultrafiltration, convection, and dialysis to maximize fluid and solute
removal.
DIF: Cognitive Level: Comprehension REF: p. 454
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
37. Continuous venovenous hemofiltration is used to:
a.
remove fluids and solutes through the process of convection.
b.
remove plasma water in cases of volume overload.
c.
remove plasma water and solutes by adding dialysate.
d.
combine ultrafiltration, convection and dialysis.
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ANS: A
Continuous venovenous hemofiltration (CVVH) is used to remove fluids and solutes through the process of
convection. Slow continuous ultrafiltration (SCUF) is used to remove plasma water in cases of volume
overload. Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes
plasma water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute
removal by the process of diffusion. Continuous venovenous hemodiafiltration (CVVHDF) combines
ultrafiltration, convection, and dialysis to maximize fluid and solute removal.
DIF: Cognitive Level: Comprehension REF: p. 454
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
38. Continuous venovenous hemodialysis is used to:
a.
remove fluids and solutes through the process of convection.
b.
remove plasma water in cases of volume overload.
c.
remove plasma water and solutes by adding dialysate.
d.
combine ultrafiltration, convection and dialysis
ANS: C
Continuous venovenous hemodialysis (CVVHD) is similar to CVVH in that ultrafiltration removes plasma
water. It differs in that dialysate solution is added around the hemofilter membranes to facilitate solute removal
by the process of diffusion. Continuous venovenous hemofiltration (CVVH) is used to remove fluids and
solutes through the process of convection. Slow continuous ultrafiltration (SCUF) is also known as isolated
ultrafiltration and is used to remove plasma water in cases of volume overload. Continuous venovenous
hemodiafiltration (CVVHDF) combines ultrafiltration, convection and dialysis to maximize fluid and solute
removal.
DIF: Cognitive Level: Comprehension REF: pp. 454-455
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
39. The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement
therapy (CRRT). In doing so, the nurse should:
a.
assess that the blood tubing is warm to the touch.
b.
assess the hemofilter every 6 hours for clotting.
c.
cover the dialysis lines to protect them from light.
d.
use clean technique during vascular access dressing changes.
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ANS: A
The critical care nurse is responsible for monitoring the patient receiving CRRT. The hemofilter is assessed
every 2 to 4 hours for clotting (as evidenced by dark fibers or a rapid decrease in the amount of ultrafiltration
without a change in the patients hemodynamic status). The CRRT system is frequently assessed to ensure filter
and lines are visible at all times, kinks are avoided, and the blood tubing is warm to the touch. The ultrafiltrate
is assessed for blood (pink-tinged to frank blood), which is indicative of membrane rupture. Sterile technique is
performed during vascular access dressing changes.
DIF: Cognitive Level: Application REF: pp. 456-457
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
40. Peritoneal dialysis is different from hemodialysis in that peritoneal dialysis:
a.
is more frequently used for acute kidney injury.
b.
uses the patients own semipermeable membrane (peritoneal membrane).
c.
is not useful in cases of drug overdose or electrolyte imbalance.
d.
is not indicated in cases of water intoxication.
ANS: B
Peritoneal dialysis is the removal of solutes and fluid by diffusion through a patients own semipermeable
membrane (the peritoneal membrane) with a dialysate solution that has been instilled into the peritoneal cavity.
This renal replacement therapy is not commonly used for the treatment of acute kidney injury because of its
comparatively slow ability to alter biochemical imbalances. Clinical indications for peritoneal dialysis include
acute and chronic kidney injury, severe water intoxication, electrolyte disorders, and drug overdose.
DIF: Cognitive Level: Comprehension REF: pp. 456-457
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity
41. An advantage of peritoneal dialysis is that:
a.
peritoneal dialysis is time intensive.
b.
a decreased risk of peritonitis exists.
c.
biochemical disturbances are corrected rapidly.
d.
the danger of hemorrhage is minimal.
ANS: D
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Advantages of peritoneal dialysis include that the equipment is assembled easily and rapidly, the cost is
relatively inexpensive, the danger of acute electrolyte imbalances or hemorrhage is minimal, and dialysate
solutions can be individualized. In addition, automated peritoneal dialysis systems are available.
Disadvantages of peritoneal dialysis include that it is time intensive, requiring at least 36 hours for a
therapeutic effect to be achieved; biochemical disturbances are corrected slowly; access to the peritoneal cavity
is sometimes difficult; and the risk of peritonitis is high.
DIF: Cognitive Level: Comprehension REF: p. 457
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Analysis MSC: NCLEX: Physiological Integrity
42. The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal
pain and chills. The patients temperature is elevated. The nurse should:
a.
assess peritoneal dialysate return.
b.
check the patients blood sugar.
c.
evaluate the patients neurological status.
d.
inform the provider of probable visceral perforation.
ANS: A
Peritonitis is the most common complication of peritoneal dialysis therapy and is usually caused by
contamination in the system. Peritonitis is manifested by abdominal pain, cloudy peritoneal fluid, fever and
chills, nausea and vomiting, and difficulty in draining fluid from the peritoneal cavity.
DIF: Cognitive Level: Analysis REF: p. 457
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
43. The patient is on intake and output (I&O) as well as daily weights. The nurse notes that output is
considerably less than intake over the last shift, and daily weight is 1 kg more than yesterday. The nurse
should:
a.
draw a trough level after the next dose of antibiotic.
b.
obtain an order to place the patient on fluid restriction.
c.
assess the patients lungs.
d.
insert an indwelling catheter.
ANS: C
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The scenario indicates retention of fluid; therefore, the nurse must assess for symptoms of fluid overload, for
example, by auscultating the lung fields. Adequate hydration is essential and fluid restriction would be
determined by the physician upon physical examination and analysis of laboratory results. An indwelling
urinary catheter should not routinely be inserted because it increases the risk of infection. A trough level is
drawn just before the next dose of a drug is given and is an indicator of how the body has cleared the drug; it
would not be done secondary to imbalanced intake and output.
DIF: Cognitive Level: Application REF: p. 446
OBJ: Describe the medical management of the patient with acute kidney injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
44. The patient has been admitted to the hospital with nausea and vomiting that started 5 days earlier. His
blood pressure is 80/44 mm Hg and heart rate is 122 beats/min; he has not voided in 8 hours and his bladder is
not distended. The nurse anticipates an order for stat administration of:
a.
a blood transfusion.
b.
fluid replacement with 0.45% saline.
c.
infusion of an inotropic agent.
d.
an antiemetic.
ANS: B
This scenario indicates hypovolemia from the nausea and vomiting, requiring volume replacement.
Hypovolemia resulting from large urine or gastrointestinal losses often requires the administration of a
hypotonic solution, such as 0.45% saline. Blood products would be indicated only in the presence of bleeding
following assessment of hemoglobin and hematocrit levels. The inotrope is contraindicated in the presence of
volume depletion. An antiemetic may be needed; however, the priority to prevent shock and acute kidney
injury is fluid administration.
DIF: Cognitive Level: Analysis REF: p. 440
OBJ: Describe the medical management of the patient with acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Identify which substances would indicate a problem with renal function. (Select all that apply).
a.
protein.
b.
sodium.
c.
creatinine.
d.
red blood cells.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
e.
282
uric acid.
ANS: A, D, E
The glomerular capillary membrane is approximately 100 times more permeable than other capillaries. It acts
as a high-efficiency sieve and normally allows only substances with a certain molecular weight to cross.
Normal glomerular filtrate is basically protein free and contains electrolytes, including sodium, chloride, and
phosphate, and nitrogenous waste products, such as creatinine, urea, and uric acid, in amounts similar to those
in plasma.Red blood cells, albumin, and globulin are too large to pass through the healthy glomerular
membrane.
DIF: Cognitive Level: Knowledge REF: p. 433
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The patient is admitted with acute kidney injury from a postrenal cause. Acceptable treatments for that
diagnosis include: (Select all that apply.)
a.
bladder catheterization.
b.
increasing fluid volume intake.
c.
ureteral stenting.
d.
placement of nephrostomy tubes.
e.
increasing cardiac output.
ANS: A, C, D
The location of the obstruction in the urinary tract determines the method by which the obstruction is treated
and may include bladder catheterization, ureteral stenting, or the placement of nephrostomy tubes. Fluid
volume intake may be recommended to treat prerenal causes of AKI. Increasing cardiac output would be
indicated in certain prerenal causes of AKI.
DIF: Cognitive Level: Knowledge REF: pp. 436-437
OBJ: Review the anatomy and physiology of the renal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. Noninvasive diagnostic procedures used to determine kidney function include which of the following?
(Select all that apply.)
a.
Kidney, ureter, bladder (KUB) x-ray
b.
Renal ultrasound
c.
Magnetic resonance imaging (MRI)
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
Intravenous pyelography (IVP)
e.
Renal angiography
283
ANS: A, B, C
Noninvasive diagnostic procedures are usually performed before any invasive diagnostic procedures are
conducted. Noninvasive diagnostic procedures that assess the renal system are radiography of the kidneys,
ureters, and bladder (KUB); renal ultrasonography; and magnetic resonance imaging. Invasive diagnostic
procedures for assessing the renal system include intravenous pyelography, computed tomography, renal
angiography, renal scanning, and renal biopsy.
DIF: Cognitive Level: Knowledge REF: p. 444
OBJ: Describe the methods for assessing the renal system, including physical assessment, and interpretation of
laboratory values and radiological diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The most common reasons for initiating dialysis in acute kidney injury include which of the following?
(Select all that apply.)
a.
Acidosis
b.
Hypokalemia
c.
Volume overload
d.
Hyperkalemia
e.
Uremia
ANS: A, C, D, E
The most common reasons for initiating dialysis in acute kidney injury include acidosis, hyperkalemia, volume
overload, and uremia. Dialysis is usually started early in the course of the renal dysfunction before uremic
complications occur. In addition, dialysis may be started for fluid management when total parenteral nutrition
is administered.
DIF: Cognitive Level: Knowledge REF: p. 452
OBJ: Describe the medical management of the patient with acute kidney injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. Complications common to patients receiving hemodialysis for acute kidney injury include which of the
following? (Select all that apply.)
a.
Hypotension
b.
Dysrhythmias
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Muscle cramps
d.
Hemolysis
e.
Air embolism
284
ANS: A, B
Hypotension is common and is usually the result of preexisting hypovolemia, excessive amounts of fluid
removal, or excessively rapid removal of fluid. Dysrhythmias may occur during dialysis. Causes of
dysrhythmias include a rapid shift in the serum potassium level, clearance of antidysrhythmic medications,
preexisting coronary artery disease, hypoxemia, or hypercalcemia from rapid influx of calcium from the
dialysate solution. Muscle cramps occur more commonly in chronic renal failure. Hemolysis, air embolism,
and hyperthermia are rare complications of hemodialysis.
DIF: Cognitive Level: Knowledge REF: p. 453
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The patient is in the critical care unit and will receive dialysis this morning. The nurse will: (Select all that
apply.)
a.
evaluate morning laboratory results and report abnormal results.
b.
administer the patients antihypertensive medications.
c.
assess the dialysis access site and report abnormalities.
d.
weigh the patient to monitor fluid status.
e.
give all medications except for antihypertensive medications.
ANS: A, C, D
The patient receiving hemodialysis requires specialized monitoring and interventions by the critical care nurse.
Laboratory values are monitored and abnormal results reported to the nephrologist and dialysis staff. The
patient is weighed daily to monitor fluid status. On the day of dialysis, dialyzable (water-soluble medications
are not given until after treatment. The dialysis nurse or pharmacist can be consulted to determine which
medications to withhold or administer. Supplemental doses are administered as ordered after dialysis.
Administration of antihypertensive agents is avoided for 4 to 6 hours before treatment, if possible. Doses of
other medications that lower blood pressure (narcotics, sedatives are reduced, if possible. The percutaneous
catheter, fistula, or graft is assessed frequently; unusual findings such as loss of bruit, redness, or drainage at
the site must be reported. After dialysis, the patient is assessed for signs of bleeding, hypovolemia, and dialysis
disequilibrium syndrome.
DIF: Cognitive Level: Knowledge REF: p. 454
OBJ: Discuss the nursing care of the patient receiving renal replacement therapy.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
285
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286
Chapter 17: Gastrointestinal Alterations
MULTIPLE CHOICE
1. The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to:
a.
give medications that will suppress the autonomic nervous system.
b.
provide therapies that will innervate the autonomic nervous system.
c.
teach the patient that the submucosa is the innermost part of the gut wall.
d.
give medications intravenously since the submucosa has no blood vessels.
ANS: B
The second layer of the gut wall, the submucosa, is composed of connective tissue, blood vessels, and nerve
fibers. Beneath the mucosa, submucosa, and muscular layer are various nerve plexuses that are innervated by
the autonomic nervous system. Disturbances in these neurons in a given segment of the GI tract cause a lack of
motility. Therapies innervating the autonomic nervous system are thus appropriate. The muscular layer is the
major layer of the wall. The serosa is the outermost layer.
DIF: Cognitive Level: Application REF: p. 503
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse is assessing the patient and notices that his oral cavity is only slightly moist and contains a scant
amount of thick saliva even though the patients fluid intake has been sufficient. The nurses realizes that the
condition of the patients mouth is probably caused by:
a.
thoughts of food.
b.
sympathetic nerve stimulation.
c.
overstimulation of the sublingual glands.
d.
parasympathetic nerve stimulation.
ANS: B
Saliva is the major secretion of the oropharynx and is produced by three pairs of salivary glands: submaxillary,
sublingual, and parotid. Stimuli such as sight, smell, thoughts, and taste of food stimulate salivary gland
secretion. Parasympathetic stimulation promotes a copious secretion of watery saliva. Conversely, sympathetic
stimulation produces a scant output of thick saliva. The normal daily secretion of saliva is 1200 mL.
DIF: Cognitive Level: Comprehension REF: p. 503
OBJ: Review the anatomy and physiology of the gastrointestinal system.
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TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from
forming, the nurse should be prepared to administer:
a.
H2-histamine receptor blockers.
b.
gastrin.
c.
vagal stimulation.
d.
vitamin B12.
ANS: A
Stimulants of hydrochloric acid secretion include vagal stimulation, gastrin, and the chemical properties of
chyme. Histamine, which stimulates the release of gastrin, also stimulates the secretion of hydrochloric acid.
Current drug therapies for ulcer disease use H2-histamine receptor blockers that block the effects of histamine
and therefore hydrochloric acid stimulation. Vitamin B12 is critical for the formation of red blood cells
(RBCs), and a deficiency in this vitamin causes anemia but has no effect on ulcer formation. Gastrin is a
hormone that stimulates acid. The vagus nerve helps digestion; however, vagal stimulation is not a treatment
for peptic ulcer disease.
DIF: Cognitive Level: Application REF: p. 504, 518 | Table 17-7
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the
sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following?
a.
Assess for signs of peptic ulcer.
b.
Be watchful for increased saliva production.
c.
Evaluate for a decrease in potassium level.
d.
Give the patient medications to prevent anemia.
ANS: A
Secretion of mucus by Brunners glands is inhibited by sympathetic stimulation, which leaves the duodenum
unprotected from gastric juice. This inhibition is thought to be one of the reasons why this area of the GI tract
is the site for more than 50% of peptic ulcers. Sympathetic stimulation produces a scant output of thick saliva.
Vitamin B12 is critical for the formation of red blood cells (RBCs, and a deficiency in this vitamin causes
anemia. However, the patient is receiving vitamin B12. The stomach also secretes fluid that is rich in sodium,
potassium, and other electrolytes. Loss of these fluids via vomiting or gastric suction places the patient at risk
for fluid and electrolyte imbalances and acid-base disturbances. However, nothing indicates that the patient is
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288
vomiting or has GI suction.
DIF: Cognitive Level: Application REF: p. 504, 506 | Box 17-2
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. After gastric bypass surgery, the patient is getting vitamin B12 via injection. The patient asks why he cant
get the vitamin by mouth. The nurse explains that:
a.
the patient may not have enough intrinsic factor for normal absorption.
b.
the patient would have to drink water, and the small intestine cant handle water.
c.
the vitamin is absorbed in the upper part of the small bowel and would travel too fast.
d.
all vitamins are absorbed in the terminal ileum and it would take too long for B12.
ANS: A
Vitamin B12 is absorbed in the terminal ileum in the presence of intrinsic factor produced in the stomach.
Gastric bypass may lead to reduced levels of intrinsic factor. The small intestine also handles water,
electrolyte, and vitamin absorption. Vitamins, with the exception of B12, and iron are absorbed in the upper
part of the small bowel.
DIF: Cognitive Level: Comprehension REF: p. 505
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse is assessing the patient admitted with pancreatitis. In doing so, the nurse:
a.
palpates the pancreas for size and shape.
b.
emphasizes to the patient that pancreatic inflammation does not spread.
c.
assesses symptoms that could indicate involvement of the stomach.
d.
explains to the patient that back pain is not a sign of pancreatitis.
ANS: C
Because the pancreas lies retroperitoneally, it cannot be palpated; this characteristic explains why diseases of
the pancreas can cause pain that radiates to the back. In addition, a well-developed pancreatic capsule does not
exist, and this may explain why inflammatory processes of the pancreas can spread freely and affect the
surrounding organs (stomach and duodenum.
DIF: Cognitive Level: Application REF: p. 505
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289
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a patient with liver disease. When assessing the patients laboratory values, the nurse
should:
a.
disregard the level of conjugated bilirubin.
b.
assess the indirect serum bilirubin.
c.
call the provider immediately if the direct bilirubin is elevated.
d.
be aware that unconjugated bilirubin is harmless.
ANS: B
Bilirubin enters the circulation bound to albumin and is unconjugated. This portion of the bilirubin is reflected
in the indirect serum bilirubin level. Accumulation of unconjugated bilirubin is toxic to cells. In the liver,
bilirubin is conjugated with glucuronic acid. Conjugated bilirubin is soluble and excreted in bile. Some
conjugated bilirubin returns to the blood and is reflected in the direct serum bilirubin level.
DIF: Cognitive Level: Comprehension REF: p. 507
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
8. The liver plays a major role in homeostasis by:
a.
synthesizing factor I but not factor II.
b.
synthesizing clotting factors without the need for vitamin K.
c.
removing active clotting factors from the circulation.
d.
synthesizing factor II but not factor I.
ANS: C
The liver synthesizes fibrinogen (factor I); prothrombin (factor II); and factors VII, IX, and X. Vitamin K is
essential for the synthesis of other clotting factors. The liver also removes active clotting factors from the
circulation and therefore prevents clotting in the macrovasculature and microvasculature.
DIF: Cognitive Level: Comprehension REF: pp. 507-508
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
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9. The liver detoxifies the blood by:
a.
converting fat-soluble compounds to water-soluble compounds.
b.
converting water-soluble compounds to fat-soluble compounds.
c.
excreting fat-soluble compounds in feces.
d.
metabolizing inactive toxic substances to active forms.
ANS: A
Drugs, hormones, and other toxic substances are metabolized by the liver into inactive forms for excretion.
This process is usually accomplished by conversion of the fat-soluble compounds to water-soluble compounds.
They can then be excreted via the bile or the urine.
DIF: Cognitive Level: Comprehension REF: p. 507
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. The patient is being admitted to the hospital. At home, the patient take an over-the-counter supplement of
Vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The
nurse explains that
a.
the body does not store vitamins so the doctor will have to be called.
b.
the kidneys will produce enough vitamin D and that supplements are not needed.
c.
over-the-counter supplements are never given in the hospital.
d.
vitamins D is stored in the liver with a 10-month supply to prevent deficiency.
ANS: D
The liver plays a central role in the storage, synthesis, and transport of various vitamins and minerals. It
functions as a storage depot principally for vitamins A, D, and B12, where up to 3-, 10-, and 12-month
supplies, respectively, of these nutrients are stored to prevent deficiency states. The kidneys do not produce
vitamin D. Over-the-counter supplements are ordered depending on the patients status.
DIF: Cognitive Level: Comprehension REF: p. 507
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
11. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic
medications to slow down the heart rate. With this type of medication, the nurse should
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
evaluate the patient for symptoms of constipation.
b.
observe for diarrhea.
c.
assess mucus membranes for signs of dryness.
d.
expect decreased bowel sounds.
291
ANS: B
Functions of the GI system are influenced by neural and hormonal factors. Parasympathetic cholinergic fibers,
or drugs that mimic parasympathetic effects, stimulate GI secretion and motility.
DIF: Cognitive Level: Application REF: p. 507
OBJ: Review the anatomy and physiology of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
12. In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that:
a.
pain receptors in the abdomen are more likely to be localized.
b.
pain of a peptic ulcer is easily distinguished from that of heart attack.
c.
visceral pain often leads to tachycardia and hypertension.
d.
increasing intensity of pain is always significant.
ANS: D
Pain assessment is challenging. Pain receptors in the abdomen are less likely to be localized and are mediated
by common sensory structures projected to the skin. Therefore, distinguishing the pain of a peptic ulcer or
cholecystitis from that of a myocardial infarction is often difficult. Abdominal pain often is caused by
engorged mucosa, pressure in the mucosa, distention, or spasm. Visceral pain is likely to cause pallor,
perspiration, bradycardia, nausea and vomiting, weakness, and hypotension. Increasing intensity of pain,
especially after surgery or other intervention, is always significant and usually signifies complicating factors,
such as inflammation, gastric distention, hemorrhage into tissue or the peritoneal space, or peritonitis.
DIF: Cognitive Level: Application REF: p. 510
OBJ: Describe general assessment of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the
nurse:
a.
observes for skin pigmentation and discolorations.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
looks for pulsations originating from the vena cava.
c.
has the patient take a deep breath.
d.
watches for signs of pain and distention.
292
ANS: C
The nurse looks for any obvious abdominal masses, which are best seen on deep inspiration. Pulsations, if they
are seen, usually originate from the aorta. The nurse observes for pigmentation of skin (jaundice), lesions,
discolorations, old or new scars, and vascular and hair patterns that may indicate general nutrition and
hydration status, not masses. Abdominal distention, particularly in the presence of pain, should always be
investigated because it usually indicates trapped air or fluid within the abdominal cavity.
DIF: Cognitive Level: Application REF: p. 511
OBJ: Describe general assessment of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. When assessing the patients bowel sounds, the nurse:
a.
listens to the abdomen after palpation is done.
b.
places the patient in a relaxed prone position.
c.
listens to bowel sounds before palpation.
d.
places a pillow over the patients knees.
ANS: C
Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract.
Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel
sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is
performed before auscultation is begun. A supine position with the patients arms at the sides or folded at the
chest is usually recommended. Placing a pillow under the patients knees also helps to relax the abdominal wall.
DIF: Cognitive Level: Application REF: p. 511
OBJ: Describe general assessment of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. When assessing bowel sounds, the nurse:
a.
uses the bell part of the stethoscope.
b.
listens at least 15 minutes.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
expects bowel sounds to be regular in rhythm.
d.
listens for 5 minutes before noting absent bowel sounds.
293
ANS: D
Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four
quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel
sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for
bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel
sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.
DIF: Cognitive Level: Application REF: p. 511
OBJ: Describe general assessment of the gastrointestinal system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. Infection by Helicobacter pylori bacteria is a major cause of:
a.
duodenal ulcers.
b.
Cushings ulcers.
c.
Curlings ulcers.
d.
stress ulcers.
ANS: A
Infection with Helicobacter pylori bacteria is a major cause of duodenal ulcers. A stress ulcer is an acute form
of peptic ulcer that often accompanies severe illness, systemic trauma, or neurological injury. Stress ulcers that
develop as a result of burn injury are often called Curlings ulcers. Stress ulcers associated with severe head
trauma or brain surgery are called Cushings ulcers.
DIF: Cognitive Level: Knowledge REF: p. 512
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical
care unit, and is receiving a proton pump inhibitors (PPI) to reduce the risk for a stress ulcer. In this scenario, a
stress ulcer is likely secondary to:
a.
infection with Helicobacter pylori bacteria.
b.
decreased acetylcholine production.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
a decreased number of parietal cells.
d.
ischemia associated with sepsis.
294
ANS: D
A stress ulcer is an acute form of peptic ulcer that often accompanies severe illness, systemic trauma, or
neurological injury. Ischemia is the prior etiology associated with stress ulcer formation. Ischemic ulcers
develop within hours of an event such as hemorrhage, multisystem trauma, severe burns, heart failure, or
sepsis. The shock, anoxia, and sympathetic responses decrease mucosal blood flow leading to ischemia. The
secretion of acid is important in the pathogenesis of ulcer disease. Acetylcholine (a neurotransmitter), gastrin (a
hormone), and secretin (a hormone) stimulate the chief cells, which stimulate acid secretion. Parietal cell mass
in people with peptic ulcer disease is 1.5 to 2 times greater than in persons without disease. Infection with
Helicobacter pylori bacteria is a major cause of duodenal ulcers.
DIF: Cognitive Level: Comprehension REF: p. 512
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. The patient is admitted with upper GI bleeding following an episode of forceful retching following
excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that:
a.
a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa.
b.
this type of bleeding is treated by giving chewable aspirin.
c.
the bleeding, although impressive, is self-limiting with little actual blood loss.
d.
is not usually associated with alcohol intake or retching.
ANS: A
A Mallory-Weiss tear is an arterial hemorrhage from an acute longitudinal tear in the gastroesophageal mucosa
and accounts for 10% to 15% of upper GI bleeding episodes. It is associated with long-term nonsteroidal
antiinflammatory drug or aspirin ingestion and with excessive alcohol intake. The upper GI bleeding usually
occurs after episodes of forceful retching. Bleeding usually resolves spontaneously; however, lacerations of the
esophagogastric junction may cause massive GI bleeding, requiring surgical repair.
DIF: Cognitive Level: Comprehension REF: p. 512
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert
a nasogastric tube to:
a.
rule out massive upper GI bleeding.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
detect the presence of melena in the stomach.
c.
visually determine the presence of occult bleeding.
d.
obtain samples for guaiac to confirm current bleeding.
295
ANS: A
Bright red or maroon blood (hematochezia) is usually a sign of a lower GI source of bleeding but can be seen
when upper GI bleeding is massive (more than 1000 mL). Melena is shiny, black, foul-smelling stool; it is not
present in the stomach. Occult bleeding means that blood is not visible and is detected only by testing the stool
with a chemical reagent (guaiac).
DIF: Cognitive Level: Application REF: p. 514
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. The patient is admitted with generalized fatigue and a low hemoglobin and hematocrit (anemia). The
patient denies vomiting and states that his last bowel movement earlier that day was normal in color and
consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to:
a.
obtain a stool sample for guaiac testing.
b.
chart that the patient reports the presence of melena in his stool.
c.
inspect the patients next stool for the presence of coffee-ground contents.
d.
obtain guaiac positive stools only if bleeding is current.
ANS: A
GI blood loss is often occult or detected only by testing the stool with a chemical reagent (guaiac. Stool and
nasogastric drainage can test guaiac positive for up to 10 days after a bleeding episode. Melena is shiny, black,
foul-smelling stool and results from the degradation of blood by stomach acids or intestinal bacteria. Vomiting
or drainage from a nasogastric tube that yields blood or coffee-groundlike material is associated with upper GI
bleeding. However, blood or coffee-groundlike contents may not be present if bleeding has ceased or if it
arises beyond a closed pylorus.
DIF: Cognitive Level: Application REF: p. 514
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
21. The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the
following assessments would the nurse expect to find with this amount of blood loss?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
all vital signs would expect to be normal with this amount of blood loss.
b.
oral temperature of 103.
c.
heart rate 125 beats per minute.
d.
systolic blood pressure of 120 mm Hg.
296
ANS: C
As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the skin,
lungs, liver, and kidneys.
Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural
decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a
blood loss of at least 1000 mL25% of the total blood volume.
DIF: Cognitive Level: Application REF: p. 514
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
22. The patient is admitted with the diagnosis of GI bleeding. The patients heart rate is 140 beats per minute,
and his blood pressure is 84/44 mm Hg. These values may indicate:
a.
a need for hourly vital signs.
b.
approximately 25% loss of total blood volume.
c.
resolution of hypovolemic shock.
d.
increased blood flow to the skin, lungs, and liver.
ANS: B
Hypotension is an advanced sign of shock. As a rule, a systolic pressure of less than 100 mm Hg, a postural
decrease in blood pressure of greater than 10 mm Hg, or a heart rate of greater than 120 beats/min reflects a
blood loss of at least 1000 mL25% of the total blood volume. Vital signs should be monitored at least every 15
minutes. As blood loss exceeds 1000 mL, the shock syndrome progresses, causing decreased blood flow to the
skin, lungs, liver, and kidneys.
DIF: Cognitive Level: Analysis REF: p. 514, 515
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
23. The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
297
levels. The nurse understands that:
a.
the hematocrit is a direct reflection of quick blood loss.
b.
as extravascular fluid enters the vascular space the hematocrit increases.
c.
the hematocrit value does not change substantially during the first few hours.
d.
the administration of intravenous fluids has no effect on hematocrit levels.
ANS: C
The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding
episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular
fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated
by fluids and blood products that are administered during the resuscitation period.
DIF: Cognitive Level: Comprehension REF: p. 515
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
24. The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed
red blood cells to the patient and repeats the labwork a few hours later. The new hemoglobin and hematocrit
would be expected to be:
a.
hemoglobin 7.5 g/dL and hematocrit 25%.
b.
hemoglobin 9.5 g/dL and hematocrit 29%.
c.
hemoglobin 10.5 g/dL and hematocrit 32%.
d.
hemoglobin 12.5 g/dL and hematocrit 36%.
ANS: C
One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%,
but this effect is influenced by the patients intravascular volume status and whether the patient is actively
bleeding.
DIF: Cognitive Level: Analysis REF: p. 518
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
25. The patient is ordered to have large volume gastric lavage. The nurse will most likely need to:
a.
insert a small-bore nasogastric tube.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
use 2 to 4 liters of room temperature normal saline.
c.
remove the nasogastric tube before lavage is started.
d.
insert a large-bore nasogastric tube.
298
ANS: D
Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides
better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction.
If lavage is ordered, 1 to 2 liters of room temperature normal saline is instilled via nasogastric tube and is then
gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric
tube may be left in or removed.
DIF: Cognitive Level: Application REF: p. 518
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
26. The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and
tetracycline but is not responding. The nurse expects that:
a.
bismuth will be added to the current triple therapy.
b.
a 6-day course of levofloxacin may be used.
c.
a second-line therapy is not usually effective.
d.
the proton pump inhibitor will be changed to a higher dose.
ANS: A
Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended
treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has
been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth,
metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line
therapy for H. pylori infections.
DIF: Cognitive Level: Comprehension REF: p. 518
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The nurse is to assist the provider in performing bedside endoscopy on a patient. The prevent respiratory
complications, the nurse places the patient:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
supine in Trendelenburg position.
b.
in a left lateral reverse Trendelenburg position.
c.
flat with the feet elevated.
d.
in a semi-fowlers position.
299
ANS: B
Because endoscopy is performed at the patients bedside, the nurse assists with procedures and monitors for
untoward effects. Maintenance of airway and breathing during endoscopic procedures is of major concern.
Placement of the patient in a left lateral reverse Trendelenburg position helps to prevent respiratory
complications.
DIF: Cognitive Level: Application REF: p. 518
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
28. The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells
that her abdomen is killing her. The nurse notes that the patients abdomen is rigid. The nurse should:
a.
call the provider immediately.
b.
give the patient pain medication.
c.
remove the NG tube.
d.
give the patient an antacid.
ANS: A
Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs
of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent
surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These
patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine
blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for
patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the
time of surgery; therefore, it is essential that the provider be called immediately.
DIF: Cognitive Level: Analysis REF: p. 520
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
29. The patient is admitted for GI bleeding, but the source is not known. Before ordering endoscopy, the
provider orders Sandostatin (octreotide) to be given intravenously. The purpose of this medication is to:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
increase portal pressure and improve liver function.
b.
decrease splanchnic blood flow and portal pressure.
c.
vasodilate the splanchnic arteriolar bed.
d.
increase blood flow in the livers collateral circulation.
300
ANS: B
Somatostatin or octreotide is commonly ordered to slow or stop bleeding. Early administration provides for
stabilization before endoscopy. These drugs decrease splanchnic blood flow and reduce portal pressure, and
have minimal adverse effects. Vasopressin is used to lower (not increase) portal pressure by vasoconstriction
of the splanchnic arteriolar bed. Ultimately, it decreases pressure and flow in liver collateral circulation
channels to decrease bleeding. However, vasopressin is not a first-line therapy because of its adverse effects.
DIF: Cognitive Level: Comprehension REF: p. 520
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
30. The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient,
the nurse must:
a.
maintain as little traction as possible.
b.
apply external traction using side rail of the bed.
c.
deflate the gastric balloon before the esophageal balloon.
d.
deflate the esophageal balloon before the gastric balloon.
ANS: D
It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube
will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an
external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached
to a helmet or to the foot of the bed (not the side rail. Proper amounts of traction are essential because too
little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on
the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.
DIF: Cognitive Level: Application REF: pp. 521-522
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
31. The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of
severe pain and respiratory distress. The nurse should:
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
cut the gastric balloon lumen and watch for improved symptoms.
b.
cut the esophageal lumen and watch for improvement.
c.
cut all three lumina and remove the tube.
d.
call the provider with an update of the patients condition.
301
ANS: C
Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other
possible complications that need to be assessed. Esophageal rupture may occur and is characterized by the
abrupt onset of severe pain. In the event of either of these two life-threatening emergencies, all three lumina
are cut and the entire tube is removed. For this reason, scissors are kept at the patients bedside at all times.
Endotracheal intubation is strongly recommended to protect the airway.
DIF: Cognitive Level: Application REF: p. 522
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
32. The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that
this procedure:
a.
improves survival in patients with varices.
b.
decreases the risk of encephalopathy.
c.
decreases the incidence of ascites.
d.
decreases rebleeding.
ANS: D
Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk
of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites
occurs after all these procedures, and careful assessments and interventions are required in the care of this
patient population.
DIF: Cognitive Level: Comprehension REF: p. 523
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
33. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, What
causes this? Why does it hurt so much? The nurse should answer:
a.
Pancreatitis is extremely rare and no one knows why it causes pain.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Pancreatitis is caused by diabetes; you should be checked.
c.
Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain.
d.
The pain is localized to the pancreas. Fortunately, it will not affect anything else.
302
ANS: C
The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic
acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin,
chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is
one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down
tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now
toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and
organ systems, such as the hepatic and renal systems.
DIF: Cognitive Level: Comprehension REF: p. 523
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
34. The patient is admitted with acute pancreatitis. The nurse should:
a.
assess pain level because pancreatic pain is unique in character.
b.
examine laboratory values for low amylase levels.
c.
expect lipase levels to decrease within 24 hours.
d.
evaluate C-reactive protein as a gauge of severity.
ANS: D
The diagnosis of acute pancreatitis is based on clinical findings, the presence of associated disorders, and
laboratory testing. Pain associated with acute pancreatitis is similar to that associated with peptic ulcer disease,
gallbladder disease, intestinal obstruction, and acute myocardial infarction. This similarity exists because pain
receptors in the abdomen are poorly differentiated as they exit the skin surface. Serum lipase and amylase tests
are the most specific indicators of acute pancreatitis because as the pancreatic cells and ducts are destroyed,
these enzymes are released. An elevated serum amylase level is a characteristic diagnostic feature. Amylase
levels usually rise within 12 hours after the onset of symptoms and return to normal within 3 to 5 days. Serum
lipase levels increase within 4 to 8 hours of clinical symptom onset and then decrease within 8 to 14 days. Creactive protein increases within 48 hours and is a marker of severity.
DIF: Cognitive Level: Application REF: p. 525
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
303
35. The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and
ascites. Using the Ranson classification criteria, the nurse determines that this patient:
a.
has a 99% chance of survival.
b.
has a 15% chance of dying.
c.
has a 40% chance of dying.
d.
has no chance of survival.
ANS: B
Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has
addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification
criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of
admission directly relates to the patients chance of significant morbidity and mortality. In Ransons research,
patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality
rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100%
mortality rate.
DIF: Cognitive Level: Analysis REF: p. 525 | Box 17-12
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
36. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should:
a.
monitor the patients blood pressure and evaluate for signs of dehydration.
b.
restrict intravenous and oral fluid intake because of fluid shifts.
c.
avoid the use of colloid IV solutions in managing the patients fluid status.
d.
only use crystalloid fluids to prevent IV lines from clotting.
ANS: A
In patients with severe acute pancreatitis, some fluid collects in the retroperitoneal space and peritoneal cavity.
Patients sequester up to one third of their plasma volume. Initially, most patients develop some degree of
dehydration and, in severe cases, hypovolemic shock. Fluid replacement is a high priority in the treatment of
acute pancreatitis. The IV solutions ordered for fluid resuscitation are usually colloids or lactated Ringers
solution; however, fresh frozen plasma and albumin may also be used. IV fluid administration with crystalloids
at 500 mL/hr is at times required to maintain hemodynamic status. Often, vigorous IV fluid replacement at 250
to 300mL/hr continues for the first 48 hours or a volume adequate to maintain a urine output of greater than or
equal to 0.5 mL/kg body weight per hour. Fluid replacement helps to maintain perfusion to the pancreas and
kidneys, reducing the potential for complications.
DIF: Cognitive Level: Application REF: p. 528
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
304
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
37. The nurse is caring for a patient with severe pancreatitis and who is orally intubated and on mechanical
ventilation. The patients calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and:
a.
places the patient on seizure precautions.
b.
expects that the provider will come and remove the endotracheal tube.
c.
withhold any further calcium treatments.
d.
place an oral airway at the bedside.
ANS: A
Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure
precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this
case, the patient is already intubated so an oral airway is not needed. This value is critically low and
replacement of calcium is expected.
DIF: Cognitive Level: Application REF: p. 528
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
38. Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse
understands that:
a.
patients with pancreatitis must eat nothing in order to prevent release of secretin.
b.
nasogastric suction is essential in treating patients with pancreatitis.
c.
a nasogastric tube is no longer required to treat patients with ileus.
d.
immediate oral feeding in patients with mild pancreatitis may help recovery.
ANS: D
Nasogastric suction and nothing by mouth status were classic treatments for patients with acute pancreatitis to
suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally,
secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum;
therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be
decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric
distention, and a decreased level of consciousness to prevent complications resulting from pulmonary
aspiration. Trends in nutritional management are changing. Early nutritional support may be ordered to prevent
atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal
permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
305
recovery. Early enteral nutrition appears effective and safe.
DIF: Cognitive Level: Comprehension REF: pp. 528-529
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
39. Pain control is a nursing priority in patients with acute pancreatitis because pain:
a.
increases pancreatic secretions.
b.
is caused by decreased distention of the pancreatic capsule.
c.
decreases the patients metabolism.
d.
is caused by dilation of the biliary system.
ANS: A
Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces
extreme patient discomfort but also because pain increases the patients metabolism and thus increases
pancreatic secretions. The pain of pancreatitis is caused by edema and distention of the pancreatic capsule,
obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe
and unrelenting and is related to the degree of pancreatic inflammation.
DIF: Cognitive Level: Comprehension REF: p. 529
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
40. The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse:
a.
should suggest that the patient receive epidural analgesia.
b.
provides oral pain medication on an as needed (PRN) basis.
c.
removes any nasogastric tubes.
d.
administers pain medication on a routine schedule.
ANS: D
Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the
form of a patient-controlled analgesia (PCA pump. In the case in which a PCA pump is not ordered, pain
medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal
pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.
DIF: Cognitive Level: Application REF: p. 529
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OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
41. The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse
realizes that:
a.
surgery for pseudocysts must be done immediately.
b.
a cholecystectomy is usually done when pseudocysts are found.
c.
pseudocysts may resolve spontaneously, so surgery may be delayed.
d.
pseudocysts require pancreatic resection, removing the entire pancreas.
ANS: C
Surgery may also be indicated for pseudocysts; however, surgery is usually delayed because some pseudocysts
resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute
pancreatitis. A cholecystectomy is usually performed.
Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of
the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of
the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the
use of conventional treatments, or the presence of peritonitis.
DIF: Cognitive Level: Comprehension REF: p. 530
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
42. The patient is diagnosed with hepatitis. In caring for this patient, the nurse should:
a.
administer antiinflammatory medications.
b.
provide rest, nutrition, and antiemetics if needed.
c.
provide antianxiety medications freely to decrease agitation.
d.
instruct the patient to take over-the-counter antiinflammatory medications at home.
ANS: B
No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include
providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to
decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which
is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful.
Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any
over-the-counter drugs that can cause liver damage. Alcohol should be avoided.
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DIF: Cognitive Level: Application REF: p. 531
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
43. The nurse is caring for a critically ill patient with end stage liver disease. The nurse knows that the patient
is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a
hyperdynamic status?
a.
cardiac output of 8 L/min.
b.
normal sinus rhythm on the cardiac monitor.
c.
blood pressure of 180/90 mm Hg.
d.
Stools that are guaiac positive.
ANS: A
Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and
development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased
cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion
to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output
failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular
vein distention, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases and
dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.
DIF: Cognitive Level: Analysis REF: p. 534
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
44. The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine
in bed and complaining of difficulty breathing. The nurses first action should be to:
a.
measure abdominal girth to determine the amount of fluid accumulation.
b.
position the patient in a semi-Fowlers position.
c.
prepare the patient for emergent paracentesis.
d.
administer diuretics.
ANS: B
Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing
breathing. Positioning the patient in a semi-Fowlers position allows for free diaphragm movement. Frequent
monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest
action
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would be to place the patient in semi-Fowlers position. Paracentesis is sometimes done to relieve symptoms,
but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular
volume is depleted too quickly, acute renal failure may be induced.
DIF: Cognitive Level: Application REF: pp. 536-537
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
45. Lactulose is considered the first-line treatment for hepatic encephalopathy and works by:
a.
causing ammonia to enter the bloodstream via the colon.
b.
trapping ammonia in the bowel for excretion.
c.
causing constipation and inhibiting the excretion of ammonia.
d.
creating an alkaline environment in the bowel.
ANS: B
Lactulose is considered the first-line treatment for hepatic encephalopathy. Lactulose creates an acidic
environment in the bowel that causes the ammonia to leave the bloodstream and enter the colon. Ammonia is
trapped in the bowel. Lactulose also has a laxative effect that allows for elimination of the ammonia. Lactulose
is given orally or via a rectal enema.
DIF: Cognitive Level: Comprehension REF: p. 539
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
46. The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this
medication, it is especially important that the nurse:
a.
evaluate renal function studies daily.
b.
give the medication every 12 hours.
c.
evaluate liver studies for signs of neomycin-induced damage.
d.
obtain stool guaiac tests to ensure that pathogens are being destroyed.
ANS: A
Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing
protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to
the kidneys (not liver and therefore cannot be given to patients with renal failure. Daily renal function studies
are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.
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DIF: Cognitive Level: Application REF: p. 539
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
47. Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the
nurse:
a.
watches the patient for diarrhea.
b.
evaluates renal function daily.
c.
assesses the patient for epigastric discomfort.
d.
instructs the patient that this medication must be taken for 2 weeks.
ANS: C
Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole
is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic.
Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term
treatment.
DIF: Cognitive Level: Application REF: p. 539
OBJ: Formulate a plan of care for the patient with acute upper gastrointestinal bleeding, acute pancreatitis, or
hepatic failure. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the
following? (Select all that apply.)
a.
Obstructed portal circulation
b.
Dilated vessels
c.
Tortuous vessels
d.
Constricted vessels
e.
Presence of an abscess
ANS: B, C, D
Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous
hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with
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cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate
infection, abscess, or tumor.
DIF: Cognitive Level: Comprehension REF: p. 511
OBJ: Describe general assessment of the gastrointestinal system.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical
ventilation. As part of the patients care to prevent stress ulcers, the nurse would provide: (Select all that apply.)
a.
vagal stimulation.
b.
proton pump inhibitors.
c.
anticholinergic drugs
d.
antacids.
e.
cholinergic drugs.
ANS: B, C, D
Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with
anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.
DIF: Cognitive Level: Application REF: p. 512
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select
all that apply.)
a.
Severity of blood loss
b.
Hemodynamic stability
c.
Vital signs every 30 minutes
d.
Signs of hypervolemic shock
e.
Necessity for fluid resuscitation
ANS: A, B, E
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Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood
loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and
assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15
minutes.
DIF: Cognitive Level: Analysis REF: p. 514
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. Nursing priorities for the management of acute pancreatitis include: (Select all that apply.)
a.
managing respiratory dysfunction.
b.
assessing and maintaining electrolyte balance.
c.
withholding analgesics that could mask abdominal discomfort.
d.
stimulating gastric content motility into the duodenum.
e.
utilizing supportive therapies aimed at decreasing gastrin release.
ANS: A, B, E
Nursing and medical priorities for the management of acute pancreatitis include several interventions.
Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or
replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive
therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from
entering the duodenum.
DIF: Cognitive Level: Analysis REF: p. 528
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the
following? (Select all that apply.)
a.
Hypoglycemia
b.
Malnutrition
c.
Ascites
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
Hypercoagulation
e.
Disseminated intravascular coagulation
312
ANS: B, C, E
Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is
usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate
metabolism may also result in malnutrition and a decreased stress response.
Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also
thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an
essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased
synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms
range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular
coagulation may also develop.
DIF: Cognitive Level: Analysis REF: p. 534
OBJ: Compare the pathophysiology, assessment, nursing diagnoses, outcomes, and interventions for acute
upper gastrointestinal bleeding, acute pancreatitis, and hepatic failure.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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Chapter 17: Hematological and Immune Disorders
MULTIPLE CHOICE
1. Of the four major blood components, plasma:
a.
is made up of circulating ions.
b.
comprises about 55% of blood volume.
c.
is transported to the cells by serum proteins.
d.
comprises about 45% of blood volume.
ANS: B
Blood has four major components: (1) a fluid component called plasma, (2) circulating solutes such as ions, (3)
serum proteins, and (4) cells. Plasma comprises about 55% of blood volume and is the transportation medium
for important serum proteins such as albumin, globulin, fibrinogen, prothrombin, and plasminogen. The
hematopoietic cells comprise the remaining 45% of blood volume.
DIF: Cognitive Level: Comprehension REF: p. 460
OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. Erythrocytes (RBCs) are flexible biconcave disks without nuclei whose primary component is an oxygencarrying molecule called:
a.
erythropoietin.
b.
a reticulocyte.
c.
hemoglobin.
d.
2,3-DPG
ANS: C
Erythrocytes (RBCs are flexible biconcave disks without nuclei whose primary component is an oxygencarrying molecule called hemoglobin. RBCs are generated from precursor stem cells under the influence of a
growth factor called erythropoietin. Erythropoietin is secreted by the kidney in response to a perceived
decrease in perfusion or tissue hypoxia. Reticulocytes are immature RBCs that may be released when there is a
demand for RBCs that exceeds the number of available mature cells. The oxygen affinity for hemoglobin is
modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG and depends on the blood pH
and body temperature.
DIF: Cognitive Level: Knowledge REF: p. 464
OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.
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TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. Erythrocytes (RBCs) are generated from precursor stem cells under the influence of a growth factor called:
a.
reticulocytes.
b.
hemoglobin.
c.
2,3-DPG.
d.
erythropoietin.
ANS: D
RBCs are generated from precursor stem cells under the influence of a growth factor called erythropoietin.
Erythropoietin is secreted by the kidney in response to a perceived decrease in perfusion or tissue hypoxia.
Reticulocytes are immature RBCs that may be released when there is a demand for RBCs that exceeds the
number of available mature cells. The RBC transports hemoglobin, whose function is the transport of oxygen
and carbon dioxide. Hemoglobin binds with oxygen in the lungs and transports it to the tissues. The oxygen
affinity for hemoglobin is modulated primarily by the concentration of 2,3-diphosphoglycerate (2,3-DPG) and
depends on the blood pH and body temperature.
DIF: Cognitive Level: Knowledge REF: p. 464
OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a patient who has undergone a splenectomy, and notices that the patients platelet
count has increased. The nurse realizes that the increase is due to:
a.
platelet response to infection.
b.
stimulation secondary to erythropoietin.
c.
the patients inability to store platelets.
d.
the platelets 120-day life cycle.
ANS: C
Two thirds of the platelets circulate in the blood. The spleen stores the remaining third and may become
enlarged if excess or rapid platelet removal occurs. In patients who have had a splenectomy, 100% of the
platelets remain in circulation. Platelets are the first responders in the clotting response (not infection, and
they form a platelet plug that temporarily repairs an injured vessel. RBCs (not platelets are generated from
precursor stem cells under the influence of a growth factor called erythropoietin. Platelets have a life span of 8
to 12 days, but they may be used more rapidly if there are many vascular injuries or clotting stimuli.
Maturation of RBCs takes 4 to 5 days, and their life span is about 120 days.
DIF: Cognitive Level: Comprehension REF: p. 465
OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.
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TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. The nurse examines the patients complete blood count with differential analysis and notices that the patients
neutrophils are elevated, but the lymphocytes are lower than normal. The drop in lymphocyte count in the
differential is most likely due to:
a.
the increase in neutrophil count.
b.
a new viral infection.
c.
a decreased number of bands.
d.
the lack of immature neutrophils.
ANS: A
The differential count measures the percentage of each type of white blood cell (WBC) present in the venous
blood sample, the total adding up to 100%. If the percentage of one type of WBC goes up (neutrophil count),
the percentage of the remaining WBCs must go down as a result of the mathematical function of the
differential. An elevation in the neutrophil count usually indicates a bacterial infection. Bands are immature
neutrophils. The phrase a shift to the left refers to an increased number of bands, or band neutrophils,
compared with mature neutrophils on a complete blood count (CBC) report. This finding generally indicates an
acute bacterial infectious process (not viral) that draws on the WBC reserves in the bone marrow and causes
less mature forms to be released.
DIF: Cognitive Level: Comprehension REF: p. 466
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. The nurse is caring for a patient receiving chemotherapeutic agents, and notices that the patients neutrophils
count is low. The nurse realizes that:
a.
the patient has a bacterial infection.
b.
a shift to the left is occurring.
c.
chemotherapeutic agents alter the ability to fight infection.
d.
neutrophils have a long life span and multiply slowly.
ANS: C
The survival time of neutrophils is short. When serious infection is present, neutrophils may live only hours as
the neutrophils phagocytize infectious organisms. Because of this short life span, drugs that affect rapidly
multiplying cells (e.g., chemotherapeutic agents quickly decrease the neutrophil count and alter the patients
ability to fight infection. An elevation in the neutrophil count usually indicates a bacterial infection. Bands are
immature neutrophils. The phrase a shift to the left refers to an increased number of bands, or band neutrophils,
compared with mature neutrophils on a complete blood count (CBC) report.
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DIF: Cognitive Level: Analysis REF: p. 466
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. When examining the patients laboratory values, the nurse notices an elevation in the eosinophil count. The
nurse realizes that eosinophils become elevated:
a.
with acute bacterial infections.
b.
in response to allergens and parasites.
c.
when the spleen is removed.
d.
in situations that do not require phagocytosis.
ANS: B
An elevation in the neutrophil count (not eosinophil count) usually indicates a bacterial infection. Eosinophils
are important in the defense against allergens and parasites and are thought to be involved in the detoxification
of foreign proteins. Eosinophils are found largely in the tissues of the skin, lung, and gastrointestinal tract (not
the spleen). Eosinophils respond to chemotactic mechanisms triggering them to participate in phagocytosis.
DIF: Cognitive Level: Comprehension REF: p. 466
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. Although monocytes may circulate for only 36 hours, they can survive for months or even years as tissue
macrophages. Monocytes found in the liver are called:
a.
alveolar macrophages.
b.
Kupffers cells.
c.
histiocytes.
d.
monokines.
ANS: B
Monocytes are the largest of the leukocytes and constitute only 3% to 7% of the WBC differential. Once they
migrate from the bloodstream into the tissues, monocytes mature into tissue macrophages, which are powerful
phagocytes. In the lung, these tissue macrophages are known as alveolar macrophages; in the liver, they are
Kupffers cells; in connective tissue, they are histiocytes. When activated by antigens, macrophages secrete
substances called monokines that act as chemical communicators between the cells involved in the immune
response.
DIF: Cognitive Level: Knowledge REF: p. 466
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
317
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. Lymphocytes are made up of B cells and T cells. B cells:
a.
mature in lymphoid tissue.
b.
mediate humoral immunity.
c.
migrate to the thymus gland.
d.
destroy virus-infected cells.
ANS: B
Lymphocytes are responsible for specific immune responses and participate in two types of immunity: humoral
immunity, which is mediated by B lymphocytes; and cellular immunity, which is mediated by T lymphocytes.
B lymphocytes, or B cells, originate in the bone marrow and are also thought to mature there. B cells perform
in antibody production. T cells are produced in the bone marrow, but they migrate to the thymus for
maturation; then, most of them travel and reside in lymphoid tissues throughout the body. They live longer
than B cells and participate in long-term immunity. The natural killer cell is a third type of lymphocyte,
thought to be a differentiated form of the T lymphocyte. It is responsible for surveillance and destruction of
virus-infected and malignant cells.
DIF: Cognitive Level: Comprehension REF: p. 467
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
10. The process by which the body actively produces cells and mediators that result in the destruction of the
antigen is called:
a.
passive immunity.
b.
active immunity.
c.
autoimmunity.
d.
recognition of self as nonself.
ANS: B
Active immunity is a term used when the body actively produces cells and mediators that result in the
destruction of the antigen. Passive immunity is that which is transferred from another person (e.g., maternal
antibodies transferred to the newborn through the placenta. In autoimmunity, the body abnormally sees self as
nonself and an immune response is activated against those tissues.
DIF: Cognitive Level: Comprehension REF: p. 467
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318
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
11. The process in which antibody and complement proteins attach to the target cell and enhance the
phagocytes ability to engulf the target cell is known as:
a.
opsonization.
b.
phagocytosis.
c.
the lymphoreticular system.
d.
the portal circulation.
ANS: A
Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and
kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release
of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the
target cell and enhance the phagocytes ability to engulf the target cell. When infectious organisms escape the
local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages
within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood,
where infectious organisms can be removed before infecting the tissues.
DIF: Cognitive Level: Comprehension REF: p. 468
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
12. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. These
responses:
a.
are mutually exclusive.
b.
are non-specific immune responses.
c.
are producers of antigens.
d.
work together to provide immunity.
ANS: D
Specificity refers to the finding that an immune response stimulates cells to develop immunity for a specific
antigen. Two types of specific immune responses exist: humoral immunity and cell-mediated immunity. They
are not mutually exclusive but act together to provide immunity. They do not produce antigens; they produce
antibodies.
DIF: Cognitive Level: Comprehension REF: p. 468
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319
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
13. Cellular immunity is mediated by:
a.
B lymphocytes.
b.
T lymphocytes.
c.
immunoglobulins.
d.
suppressor B cells.
ANS: B
Cellular immunity is mediated by the T lymphocyte. Humoral immunity is mediated by B lymphocytes and
involves the formation of antibodies (immunoglobulins) in response to specific antigens that bind to their
receptor sites. Suppressor T cells (not B cells) downgrade and suppress the humoral and cell-mediated
responses.
DIF: Cognitive Level: Knowledge REF: p. 468
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
14. The ratio of helper T4 cell to suppressor T cells is normally 2:1. A lower than normal ratio may indicate
acquired immunodeficiency syndrome (AIDS). This is because T4 cells:
a.
enhance humoral immune response.
b.
suppress the humoral response.
c.
suppress the cell-mediated response.
d.
are a feature of an autoimmune disease.
ANS: A
Once contact is made with a specific antigen, the T lymphocyte differentiates into helper/inducer T cells,
suppressor T cells, and cytotoxic killer cells. Although these T cells are microscopically identical, they can be
distinguished by proteins present on the cell surface called cluster of differentiation (CD. Helper T cells (also
known as T4 cells because they carry a CD4 marker enhance the humoral immune response by stimulating B
cells to differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cellmediated responses. The ratio of helper to suppressor T cells is normally 2:1, and an alteration in this ratio may
cause disease. For example, a depressed ratio (a decrease of helper T cells in relation to suppressor T cells is
found in acquired immunodeficiency syndrome (AIDS, whereas a higher ratio (a decrease in suppressor T
cells in relation to helper T cells is a feature of an autoimmune disease.
DIF: Cognitive Level: Comprehension REF: p. 469
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
320
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
15. The mechanism responsible for the rejection of transplanted tissue and the destruction of single malignant
cells is known as immunosurveillance. The nurse understands that this is a function of:
a.
helper T lymphocytes.
b.
suppressor T lymphocytes.
c.
T4 lymphocytes.
d.
killer T lymphocytes.
ANS: D
Cytotoxic or killer T cells (CD8 marker) participate directly in the destruction of antigens by binding to and
altering the intracellular environment, which ultimately destroys the cell. Killer cells also release cytotoxic
substances into the antigen cell that cause cell lysis. Killer T cells additionally provide the body with
immunosurveillance capabilities that monitor for abnormal cells or tissue. This mechanism is responsible for
the rejection of transplanted tissue and the destruction of single malignant cells. Helper T cells (also known as
T4 cells because they carry a CD4 marker) enhance the humoral immune response by stimulating B cells to
differentiate and produce antibodies. Suppressor T cells downgrade and suppress the humoral and cellmediated responses.
DIF: Cognitive Level: Comprehension REF: p. 469
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
16. With minor vessel injury, primary hemostasis is achieved:
a.
after several minutes.
b.
with fibrin to solidify the platelet plug.
c.
usually within seconds.
d.
as a permanent solution.
ANS: C
With minor vessel injury, primary hemostasis is temporarily achieved with platelet plugs, usually within
seconds. During secondary hemostasis, the platelet plug is solidified with fibrin, an end product of the
coagulation pathway, and requires several minutes to reach completion.
DIF: Cognitive Level: Comprehension REF: p. 469
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
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321
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
17. In vivo, the primary activator of the coagulation cascade occurs via the:
a.
intrinsic pathway.
b.
extrinsic pathway.
c.
common pathway.
d.
either intrinsic or extrinsic pathway.
ANS: B
The classic theory of coagulation is viewed as occurring through two distinct pathways, intrinsic and extrinsic,
which share a common final pathway, formation of insoluble fibrin. It is now known that the classic cascade
theory of coagulation illustrates what occurs in vitro. In vivo, the primary activator of the coagulation cascade
occurs via the extrinsic pathway. The intrinsic pathway serves to amplify the coagulation cascade.
DIF: Cognitive Level: Knowledge REF: p. 470
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
18. Common to both the intrinsic and the extrinsic pathway is:
a.
factor XII
b.
factor VII.
c.
factor X.
d.
subendothelial collagen.
ANS: C
When blood is exposed to subendothelial collagen or is injured, factor XII is activated, which initiates
coagulation via the intrinsic pathway. In the extrinsic pathway, tissue injury precipitates release of a substance
known as tissue factor, which activates factor VII. Factor VII is key in initiating blood coagulation, and the two
pathways intersect at the activation of factor X. Both coagulation pathways illustrate a final common pathway
of clot formation, retraction, and fibrinolysis.
DIF: Cognitive Level: Knowledge REF: p. 470
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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19. The nurse is caring for a patient with cirrhosis of the liver. The nurse notes fresh blood starting to ooze
from the patients rectum and intravenous site. The nurse contacts the provider expecting an order for:
a.
an infusion of protein S factor.
b.
blood work to evaluate protein C level.
c.
a laboratory test to determine factor X level.
d.
vitamin K injections.
ANS: D
The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the
liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, and protein C and protein S
(anticoagulation factors). Thus, liver disease and vitamin K deficiency are commonly associated with impaired
hemostasis.
DIF: Cognitive Level: Analysis REF: p. 470
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
20. A patient with a history of pulmonary embolism is being worked up for a potential coagulopathy that
increases the risk for clotting. The nurse understands that the provider may order a test for
a.
factor VII deficiency.
b.
factor X deficiency.
c.
protein C deficiency.
d.
factor IX deficiency.
ANS: C
The coagulation factors are plasma proteins that circulate as inactive enzymes, and most are synthesized in the
liver. Vitamin K is necessary for synthesis of factors II, VII, IX, X, necessary for clotting to occur and for
anticoagulation factors protein C and protein S. A deficiency of anticoagulation factors could lead to increased
clot formation and problems such as stroke and pulmonary emboli.
DIF: Cognitive Level: Analysis REF: p. 470
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
21. 21. The nurse understands that when clots breakdown in a patient with a hematological disorder, that which
value will increase?
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
hemoglobin.
b.
white blood cell count.
c.
vitamin K.
d.
fibrin split products.
323
ANS: D
When plasmin digests fibrinogen, fragments known as fibrin split products, or fibrin degradation products, are
produced and function as potent anticoagulants. Fibrin split products are not normally present in the circulation
but are seen in some hematological disorders as well as with thrombolytic therapy. Vitamin K is necessary for
synthesis of factors II, VII, IX, X that are needed for clotting to occur. Hemoglobin may decrease if the patient
is bleeding, and WBCs are not relevant to this scenario.
DIF: Cognitive Level: Understanding REF: pp. 470-471
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
22. The patient is being seen for complaints of general malaise, fatigue, and shortness of breath. The patient
states that he has felt this way since he had a cold 6 weeks earlier. The nurse should expect the provider to
order:
a.
lymph node biopsy.
b.
differential blood count only.
c.
complete blood count (CBC) with differential.
d.
Bone marrow biopsy.
ANS: C
The first screening diagnostic tests performed to detect hematological or immunological dysfunction are a
Complete Blood Count (CBC with differential and a coagulation profile. The CBC evaluates the cellular
components of blood. The CBC reports the total RBC count and RBC indices, hematocrit, hemoglobin, WBC
count and differential, platelet count, and cell morphologies. The most invasive microscopic examinations of
the bone marrow or lymph nodes are reserved for circumstances when laboratory tests are inconclusive or
when an abnormality in cellular maturation is suspected (e.g., aplastic anemia, leukemia, or lymphoma. A
differential laboratory test is not done without the CBC first. A bone marrow biopsy is not warranted; it would
only be done if preliminary studies indicated a hematological problem.
DIF: Cognitive Level: Analysis REF: p. 471
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
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324
23. A reduction in the number of circulating RBCs or hemoglobin, which leads to inadequate oxygenation of
tissues, is known as:
a.
polycythemia.
b.
anemia.
c.
iron deficiency.
d.
an increase in hemoglobin.
ANS: B
The term anemia refers to a reduction in the number of circulating RBCs or hemoglobin, which leads to
inadequate oxygenation of tissues. Polycythemia, a disorder in which the number of circulating RBCs is
increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive pulmonary
disease). Iron deficiency anemia is the most common type of anemia.
DIF: Cognitive Level: Knowledge REF: p. 474 | Table 16-1
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
24. The patient is admitted with complaints of chronic fatigue and shortness of breath. The nurse notices that
the patient is tachycardic and has multiple bruises and petechiae on his body and arms. The patient also
complains of frequent nosebleeds. The nurse should evaluate the patients ____________
a.
complete blood count, including platelet count
b.
hemoglobin and hematocrit
c.
electrolyte values.
d.
blood culture results
ANS: A
In addition to the general symptoms of anemia, unique disorders have their own classic clinical features. The
patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight
infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the
bone marrow fails to produce blood cells. The CBC with differential, which includes a platelet count, would
allow for evaluation of all aspects of aplastic anemia. Hemoglobin and hematocrit help to assess for blood
loss, but assessment of cause (e.g., low platelets is more important. Electrolyte values and blood culture
results are not relevant to this scenario.
DIF: Cognitive Level: Analysis REF: p. 471, 474 | Table 16-6 | Table 16-7
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
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325
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
25. The nurse is assessing a patient being admitted with complaints of fatigue and shortness of breath as well
as abdominal tenderness. The nurse notes that the patient is jaundiced; the physical examination reports an
enlarged liver The nurse suspects that the patient has
a.
aplastic anemia.
b.
hemolytic anemia.
c.
sickle cell anemia.
d.
anemia due to acute blood loss.
ANS: B
Assessment of the patient with hemolytic anemia may reveal jaundice, abdominal pain, and enlargement of the
spleen or liver. These findings result from the increased destruction of RBCs, their sequestration (abnormal
distribution in the spleen and liver), and the accumulation of breakdown products. The patient with aplastic
anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight infections. These effects
result from thrombocytopenia and decreased WBC counts, which occur when the bone marrow fails to produce
blood cells. Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual
development. Decreased circulating volume is manifested by clinical findings reflective of low blood volume
(e.g., low right atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis).
DIF: Cognitive Level: Analysis REF: p. 480
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
26. The patient is complaining of severe joint pain as well as fatigue and shortness of breath. The nurse notices
that the patients joints are swollen and his legs are edematous. The nurse realizes that these are symptoms of:
a.
anemia reflective of low volume.
b.
aplastic anemia.
c.
hemolytic anemia.
d.
sickle cell anemia.
ANS: D
Patients with sickle cell anemia may have joint swelling or pain, and delayed physical and sexual development.
In crisis, the sickle cell patient often has decreased urine output, peripheral edema, and signs of uremia because
renal tissue perfusion is impaired as a result of sluggish blood flow.
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Decreased circulating volume is manifested by clinical findings reflective of low blood volume (e.g., low right
atrial pressure) and the effects of gravity on the lack of volume (e.g., orthostasis).
The patient with aplastic anemia may have bruising, nosebleeds, petechiae, and a decreased ability to fight
infections. These effects result from thrombocytopenia and decreased WBC counts, which occur when the
bone marrow fails to produce blood cells. Assessment of the patient with hemolytic anemia may reveal
jaundice, abdominal pain, and enlargement of the spleen or liver. These findings result from the increased
destruction of RBCs, their sequestration (abnormal distribution in the spleen and liver), and the accumulation
of breakdown products.
DIF: Cognitive Level: Analysis REF: p. 478 | Table 16-8
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
27. The patient has yellow skin and low hemoglobin and hematocrit levels. The nurse should look for:
a.
an elevated bilirubin level.
b.
a low reticulocyte count.
c.
sickled cells.
d.
low white blood cell and platelet counts.
ANS: A
Laboratory findings in anemia include a decreased RBC count and decreased hemoglobin and hematocrit
values. The reticulocyte count is usually increased, indicating a compensatory increased RBC production with
release of immature cells. This patients jaundice is indicative of hemolytic anemia. Patients with hemolytic
anemia also have an increased bilirubin level. In sickle cell disease, a stained blood smear reveals sickled cells.
In aplastic anemia, the reticulocyte, platelet, RBC, and WBC counts are decreased because the marrow fails to
produce any cells.
DIF: Cognitive Level: Analysis REF: p. 480
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
28. Critical to caring for the immunocompromised patient is the understanding that:
a.
the immunocompromised patient has normal white blood cell (WBC) physiology.
b.
the immunosuppression involves a single element or process.
c.
infection is the leading cause of death in these patients.
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d.
327
immune incompetence is symptomatic even without pathogen exposure.
ANS: C
Infection is the leading cause of death in the immunocompromised patient. The immunocompromised patient is
one with defined quantitative or qualitative defects in WBCs or immune physiology. The defect may be
congenital or acquired, and may involve a single element or multiple processes. Regardless of the cause, the
physiological outcome is immune incompetence, with lack of normal inflammatory, phagocytic, antibody, or
cytokine responses. Immune incompetence is often asymptomatic until pathogenic organisms invade the body
and create infection.
DIF: Cognitive Level: Comprehension REF: p. 481
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
29. The nurse is evaluating the patients laboratory values and notes an IgG level of 240 mg/dL. The nurse
realizes that this patient is a candidate for:
a.
no change in therapy because the level is normal.
b.
an immunoglobulin infusion.
c.
gene replacement therapy.
d.
increased doses of immunosuppressive medications.
ANS: B
Medical therapy is directed at reversing the cause of the immune dysfunction and preventing infectious
complications. In primary immunodeficiencies, B-cell and T-cell defects are treated with specific replacement
therapy or bone marrow transplantation. IgG blood levels of less than 300 mg/dL warrant immunoglobulin
infusion. Gene replacement therapy may soon be a realistic curative treatment option for some disorders. In
secondary immunodeficiencies, the underlying causative condition is treated. For example, malnutrition is
corrected, or doses of immunosuppressive medications are adjusted. For this patient, immunosuppressive
medications should be discontinued or doses lowered.
DIF: Cognitive Level: Analysis REF: p. 483
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
30. The patient is admitted for chemotherapy, but the nurse notices laboratory values indicating that the patient
is immunosuppressed. The nurse should:
a.
place the patient in a single room with a HEPA filtration system.
b.
tell staff that hand washing is not recommended when working with this patient.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
start as many intravenous lines as possible to provide potential antibiotics.
d.
avoid the use of antimicrobial soaps when bathing and providing perineal care.
328
ANS: A
Nursing interventions focus on protecting the patient from infection. Research studies support the use of highefficiency particulate air (HEPA) filtration and laminar airflow in single-patient rooms for prevention of
infection with airborne microorganisms. Nurses should diligently ensure adequate hygiene measures that
include general bathing with antimicrobial soaps, oral care, and perineal care. Hand washing is paramount for
staff, patients, and visitors. Nursing staff members play an important role in limiting breaks in skin integrity
and ensuring sterile technique when procedures are unavoidable.
DIF: Cognitive Level: Application REF: p. 483
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
31. The nurse notes that the patients neutrophil count is less than 500 cells/microliter. The nurse realizes that
this patient is:
a.
is at low risk for infection.
b.
is at mild risk for infection.
c.
is at moderated risk for infection.
d.
is at severe risk for infection.
ANS: D
Neutropenia is defined as an absolute neutrophil count of less than 1500 cells/microliter of blood. Neutropenia
may occur as a result of inadequate production or excess destruction of neutrophils. Patients with low
neutrophil counts are predisposed to infections because of the bodys reduced phagocytic ability. Neutropenia is
classified based on the patients predicted risk for infection: mild (1000 to 1500 cells/microliter, moderate (500
to 1000 cells/microliter, and severe (<500 cells/microliter.
DIF: Cognitive Level: Analysis REF: p. 482 | Table 16-9
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
32. The patient is admitted with neutropenia. The nurse should continually assess the patient for:
a.
signs of systemic infection.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
a drop in temperature from its normal set point.
c.
the absence of chills.
d.
bradycardia.
329
ANS: A
There are no specific signs or symptoms of a low neutrophil count. Every body system is examined for
physical findings of infection. Typical signs may not be evident. Pain such as sore throat or urethral discomfort
may be indicative of an infected site. Areas of heavy bacterial colonization (e.g., oral mucosa, perineal area,
and venipuncture and catheter sites) have the highest risk of infection; however, the most common clinical
infections are sepsis and pneumonia. Additional signs or symptoms of systemic infection include a rise in
temperature from its normal set point, chills, and accompanying tachycardia.
DIF: Cognitive Level: Application REF: p. 486
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
33. The patients white blood cell (WBC) level is 4000 cells/microliter. The differential shows a neutrophil
count of 65% and a band level of 5%. The absolute neutrophil count is
a.
4000 cells/microliter.
b.
3000 cells/microliter.
c.
2800 cells/microliter.
d.
2600 cells/microliter.
ANS: C
The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute
neutrophil count is calculated by multiplying the total WBC count (without a decimal point by the percentages
(with decimal points of polymorphonuclear leukocytes (polys; also called segs or neutrophils and bands
(immature neutrophils.
WBC (segs + bands
This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia.
DIF: Cognitive Level: Application REF: p. 486
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
330
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
34. The patient has a total white blood cell (WBC) count of 600 cells/microliter. The differential shows a
normal neutrophil level of 70% with 5% bands. This patient:
a.
is at low risk for infection.
b.
is at mild risk for infection.
c.
is at moderated risk for infection.
d.
is at severe risk for infection.
ANS: D
The differential demonstrates the percentage of each type of WBC circulating in the bloodstream. The absolute
neutrophil count is calculated by multiplying the total WBC count (without a decimal point) by the percentages
(with decimal points) of polymorphonuclear leukocytes (polys; also called segs or neutrophils) and bands
(immature neutrophils).
WBC (segs + bands)
600 (0.70 + 0.05)
600 0.75 = 450 cells/microliter
This gives an actual number that is translated into the categories of mild, moderate, or severe neutropenia.
Neutropenia is classified based on the patients predicted risk for infection: mild (1000 to 1500 cells/microliter),
moderate (500 to 1000 cells/microliter), and severe (<500 cells/microliter).
DIF: Cognitive Level: Analysis REF: p. 486
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
35. Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired
patient outcomes related to medical and nursing interventions include absence of infection, negative cultures,
and an absolute neutrophil count of :
a.
less than 500 cells/microliter.
b.
500 to 1000 cells/microliter.
c.
1000 to 1500 cells/microliter.
d.
1500 cells/microliter or higher.
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331
ANS: D
Nursing care of patients with neutropenia is the same as for all immunocompromised patients. Desired patient
outcomes related to medical and nursing interventions include absence of infection, negative cultures, and an
absolute neutrophil count of 1500 cells/microliter or higher.
DIF: Cognitive Level: Comprehension REF: p. 487
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
36. The patient is diagnosed with lymphoma, but has a normal white blood cell (WBC) count. The nurse
understands that this patient
a.
has normal WBC function since the WBC is normal.
b.
will have increased bruising and bleeding.
c.
is at risk for infection.
d.
is at risk for an allergic reaction.
ANS: C
Malignant diseases involving WBCs are termed leukemia, lymphoma, and plasma cell neoplasm (multiple
myeloma). Regardless of the specific neoplastic disorder, a deficiency of functional WBCs is a common
problem. Despite normal serum cell counts, WBC activity is always impaired, and infection is the most
common complication of all these disorders.
DIF: Cognitive Level: Analysis REF: p. 487
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
37. The patient is admitted with multiple myeloma. The nurse assesses the patient and is aware that the
symptom most unique to this disease is:
a.
fever.
b.
night sweats.
c.
bone pain.
d.
lymph node enlargement.
ANS: C
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332
Bone pain is common in multiple myeloma, whereas lymph node enlargement is more representative of
lymphoma. Fever is particularly difficult to interpret because it may be a manifestation of the disease process
or may accompany an infectious complication. General signs and symptoms such as fatigue, malaise, myalgias,
activity intolerance, and night sweats are nonspecific indicators of immune disease.
DIF: Cognitive Level: Comprehension REF: p. 487 | Table 16-10
OBJ: Discuss the risk factors, pathophysiological process, clinical findings, nursing care, and medical
management of anemia, neutropenia, malignant white blood cell disorders, human immunodeficiency virus,
thrombocytopenia, and disseminated intravascular coagulation.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
38. Cases of primary immunodeficiency are usually related to:
a.
aging.
b.
nutritional deficiencies.
c.
malignancies.
d.
a single gene defect.
ANS: D
Most primary immunodeficiencies are congenital disorders related to a single gene defect. Secondary or
acquired immunodeficiency is the result of factors outside the immune system, is not related to a genetic
defect, and involves the loss of a previously functional immune defense system. Aging, dietary insufficiencies,
malignancies, stressors (emotional, physical), immunosuppressive therapies, and certain diseases such as
diabetes or sickle cell disease are examples of conditions that may be associated with acquired
immunodeficiencies.
DIF: Cognitive Level: Comprehension REF: p. 490
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
39. The patient comes to the hospital complaining of headache, fever, and sore throat for the past 2 weeks and
is concerned that he might have acquired immune deficiency syndrome (AIDS). The patients blood work
shows the presence of HIV antibodies. The nurse should explain that:
a.
HIV symptoms will continue throughout the patients life.
b.
HIV is an acute disease with a short prognosis.
c.
AIDS is considered a chronic disease.
d.
very few people with HIV develop AIDS.
ANS: C
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333
Seroconversion is manifested by the presence of HIV antibodies and usually occurs 2 to 4 weeks after the
initial infection. Symptoms associated with seroconversion include flu-like symptoms such as fever, sore
throat, headache, malaise, nausea and usually last 1 to 2 weeks. The earlier stages of HIV infection may last as
long as 10 years and may produce few or no symptoms, although viral particles are actively replacing normal
cells. AIDS is the final stage of HIV infection. It is estimated that 99% of untreated HIV-infected individuals
will progress to AIDS. Treatment regimens with combined antiviral drug regimens are controlling the
progression to AID. AIDS is now considered, for many infected individuals, a chronic disease.
DIF: Cognitive Level: Comprehension REF: p. 490
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
40. When caring for a patient with HIV, the nurse should:
a.
not focus on the mouth, as infections of the mouth are rare.
b.
assure the patient that infections are not a major problem at this point.
c.
inform the patient that the disease does not affect the respiratory system.
d.
monitor the patients medication regimen.
ANS: D
Nursing assessment includes evaluation of the neurological status, mouth, respiratory status, abdominal
symptoms, and peripheral sensation. As with all immunosuppressed patients, those with HIV infection must be
protected from infection. These patients provide additional clinical challenges because of their multisystemic,
clinical complications. For unclear reasons, persons with HIV infection have a higher propensity for adverse
drug reactions than other patient groups and require careful monitoring of all medication regimens.
DIF: Cognitive Level: Application REF: p. 492
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
41. The nurse is assessing a patient being admitted for anemia. The nurse sees no overt signs of bleeding. The
nurse understands that:
a.
all patients with bleeding disorders demonstrate active bleeding.
b.
many patients have bleeding that is not obvious.
c.
mucous membranes have a high threshold for bleeding.
d.
capillaries in mucous membranes lie deep in the membrane.
ANS: B
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
334
Although many patients with bleeding disorders demonstrate active bleeding from body orifices, mucous
membranes, and open lesions or intravenous line sites, equal numbers of patients have less obvious bleeding.
The most susceptible sites for bleeding are existing openings in the epithelial surfaces. Mucous membranes
have a low threshold for bleeding because the capillaries lie close to the membrane surface, and minor injury
may damage and expose vessels. Substantial blood loss can occur in any coagulopathy, resulting in
hypovolemic shock.
DIF: Cognitive Level: Comprehension REF: p. 492
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
42. The nurse is caring for a patient diagnosed with anemia. This mornings hematocrit level is 24%. Platelet
level is 200,000/microliter. The nurse can expect to:
a.
continue monitoring the patient, as this hematocrit is normal.
b.
administer platelets to help control bleeding.
c.
give fresh frozen plasma to decrease prothrombin time.
d.
provide RBC transfusion because this level is below the normal threshold.
ANS: D
Transfusion thresholds are established based on laboratory values and patient-specific variables. In general, a
threshold for RBC transfusion is considered a hematocrit of 28% to 31%, based on the patients cardiovascular
tolerance. If angina or orthostasis is present, a higher threshold may be maintained. The threshold for
transfusing platelets is usually between 20,000 and 50,000/microliter. Cryoprecipitate is usually infused if the
fibrinogen level is less than 100 mg/dL. Fresh frozen plasma is used to correct a prolonged prothrombin time
and partial thromboplastin time or a specific factor deficiency.
DIF: Cognitive Level: Analysis REF: p. 492
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
43. The patient is admitted with anemia caused by blood loss and thrombocytopenia. His platelet count is
22,000/microliter. The patient is scheduled for a transfusion of RBCs and a transfusion of platelets. The nurse
should:
a.
give the RBCs before the platelets.
b.
give the platelets before the RBCs.
c.
use local therapies to stop the bleeding.
d.
give the platelets and RBCs at the same time.
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ANS: B
When the patients blood does not clot because of thrombocytopenia, administration of RBCs before platelets
will result in RBC loss from disrupted vascular structures. Platelets should be given first. Local therapies to
stop bleeding are used when systemic anticoagulation is necessary for treatment of another health condition
(e.g., myocardial infarction, ischemic stroke, or pulmonary embolism). Local procoagulants act by direct tissue
contact and initiation of a surface clot.
DIF: Cognitive Level: Application REF: p. 496
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
44. The patient has a platelet count of 9,000/microliter. The nurse realizes that:
a.
this is a normal platelet level.
b.
spontaneous bleeding may occur.
c.
the patient is at great risk for fatal hemorrhage.
d.
this level is considered slightly low.
ANS: C
A quantitative deficiency of platelets is termed thrombocytopenia. By definition, this is a platelet count of less
than 150,000/microliter. A value of 30,000/microliter is considered critically low, and spontaneous bleeding
may occur. Fatal hemorrhage is a great risk when the count is less than 10,000/microliter.
DIF: Cognitive Level: Comprehension REF: p. 496
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
45. The patients platelet count is 35,000/microliter. The provider orders the administration of 10 units of
single-donor platelets. After transfusion, the nurse can expect the patients platelet count to be:
a.
between 85,000/microliter and 135,000/microliter.
b.
Between 50,000/microliter and 75,000/microliter.
c.
greater than 150,000/microliter.
d.
between 150,000/microliter and 185,000/microliter.
ANS: A
Medical treatment of thrombocytopenia includes infusions of platelets. Patients who require multiple platelet
transfusions should be evaluated for single-donor platelet products, which permit administration of 6 to 10
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units of platelets with exposure to the antigens of only one person. For every unit of single-donor platelets, the
platelet count should increase by 5000 to 10,000/microliter.
DIF: Cognitive Level: Analysis REF: p. 497
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
46. The patient is admitted with anemia and active bleeding. The nurse suspects intravascular disseminated
coagulation (DIC). Definitive diagnosis of DIC is made by evidence of:
a.
a decrease in fibrin degradation products.
b.
an increased D-dimer level.
c.
thrombocytopenia.
d.
low fibrinogen levels.
ANS: B
Diagnosis of DIC is made based on recognition of pertinent risk factors, clinical symptoms, and the results of
laboratory studies. Evidence of factor depletion in the form of thrombocytopenia and low fibrinogen levels is
seen in the early phase; however, definitive diagnosis is made by evidence of excess fibrinolysis detectable by
elevated fibrin degradation products, an increased D-dimer level, or a decreased antithrombin III level.
DIF: Cognitive Level: Knowledge REF: p. 499
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Numbers of white blood cells (WBCs) are increased in circumstances of: (Select all that apply.)
a.
inflammation.
b.
allergy.
c.
invasion by pathogenic organisms.
d.
malnutrition.
e.
immune diseases.
ANS: A, B, C
WBCs play a key role in the defense against infectious organisms and foreign antigens. Numbers of WBCs
are
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increased in circumstances of inflammation, tissue injury, allergy, or invasion with pathogenic organisms.
Numbers of WBCs are diminished in conditions of malnutrition, advancing age, and immune diseases.
DIF: Cognitive Level: Comprehension REF: p. 472 | Box 16-5
OBJ: Explain the normal anatomy and physiology of the hematological and immune systems.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. Autoimmunity can result from: (Select all that apply.)
a.
recognition of tissue as self.
b.
injury to tissues.
c.
infection.
d.
malignancy.
e.
unknown causes.
ANS: B, C, D, E
In autoimmunity, the body abnormally sees self as nonself and an immune response is activated against those
tissues. Autoimmunity can result from injury to tissues, infection, or malignancy, although in many cases the
cause is not known.
DIF: Cognitive Level: Comprehension REF: p. 467
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
3. Inflammation is initiated by cellular injury and: (Select all that apply.)
a.
is necessary for tissue repair.
b.
inhibits the process called chemotaxis.
c.
is harmful when uncontrolled.
d.
is less efficient when complement proteins are present.
e.
occurs when mediators cause vasoconstriction.
ANS: A, C
Inflammation is initiated by cellular injury, is necessary for tissue repair, and is harmful when uncontrolled.
When cellular injury occurs, a process called chemotaxis generates both a mediator and a neutrophil response.
Mediator substances (histamine, serotonin, kinins, lysosomal enzymes, prostaglandin, platelet-activating
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factor, clotting factors, and complement proteins) are released at the site of injury. These mediators cause
vasodilation, increase blood flow, induce capillary permeability, and promote chemotaxis and phagocytosis by
neutrophils. Inflammatory symptoms such as redness, heat, pain, and swelling are sequelae of these responses.
Complement proteins enhance the antibody activity, phagocytosis, and inflammation.
DIF: Cognitive Level: Comprehension REF: p. 468
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. Exudate formation at the inflammatory site functions to: (Select all that apply.)
a.
opsonize bacteria.
b.
dilute toxins.
c.
deliver proteins.
d.
attach to the target cell.
e.
carry away toxins.
ANS: B, C, E
Exudate formation at the inflammatory site has three functions: dilute toxins produced, deliver proteins and
leukocytes to the site, and carry away toxins and debris. Once phagocytes have been attracted to an area by the
release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach
to the target cell and enhance the phagocytes ability to engulf the target cell.
DIF: Cognitive Level: Comprehension REF: p. 468
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
5. Causes of anemia include: (Select all that apply.)
a.
hypoxic states.
b.
blood loss.
c.
impaired production of red blood cells.
d.
increased destruction of red blood cells.
e.
chronic obstructive pulmonary disease.
ANS: B, C, D
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Causes of anemia include (1) blood loss (acute or chronic), (2) impaired production of RBCs, (3) increased
RBC destruction, or (4) a combination of these. Polycythemia, a disorder in which the number of circulating
RBCs is increased, is seen less often but can affect hypoxic patients (e.g., those with chronic obstructive
pulmonary disease).
DIF: Cognitive Level: Comprehension REF: pp. 474-475
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
6. When dealing with hematological malignancies, therapies that have significant management roles include:
(Select all that apply.)
a.
chemotherapy.
b.
biotherapy.
c.
bone marrow transplantation.
d.
surgery.
e.
radiation.
ANS: A, B, C, E
Therapy commonly includes chemotherapy and biotherapy. Bone marrow transplantation is used in selected
cases. Surgery may be performed to establish a pathological diagnosis by excisional or incisional biopsy but
has no other significant role in the management of hematological malignancies. Radiation may be used to treat
lymphoma when the disease is limited to single nodes or node groups.
DIF: Cognitive Level: Comprehension REF: p. 490
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
7. Secondary immunodeficiency involves the loss of a previously functional immune defense system that can
be caused by: (Select all that apply.)
a.
a single gene defect.
b.
AIDS.
c.
aging.
d.
nutritional deficiencies.
e.
immunosuppressive therapies
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340
ANS: B, C, D, E
In primary immunodeficiency, the dysfunction exists in the immune system. Most primary immunodeficiencies
are congenital disorders related to a single gene defect. Secondary or acquired immunodeficiency is the result
of factors outside the immune system, is not related to a genetic defect, and involves the loss of a previously
functional immune defense system. AIDS is the most notable secondary immunodeficiency disorder caused by
an infection. Aging, dietary insufficiencies, malignancies, stressors (emotional, physical), immunosuppressive
therapies, and certain diseases such as diabetes or sickle cell disease are additional examples of conditions that
may be associated with acquired immunodeficiencies.
DIF: Cognitive Level: Comprehension REF: p. 490
OBJ: Describe pathophysiological changes that affect hematological and immunological structure and
function.TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
8. The nurse is caring for an elderly patient who is being admitted for anemia of unknown cause. The patient
has been on multiple medications at home for various ailments. In assessing the patients medication list, the
nurse notes medications that may alter hemostasis, including: (Select all that apply.)
a.
aminoglycosides.
b.
antiplatelet agents.
c.
cephalosporins.
d.
vasoconstrictors.
e.
sulfonamides.
ANS: A, B, C, E
Medications that may alter hemostasis include aminoglycosides, anticoagulants, antiplatelet agents,
cephalosporins, histamine blockers, nitrates, sulfonamides, sympathomimetics, and vasodilators.
DIF: Cognitive Level: Analysis REF: p. 480
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. In caring for the patient who has a coagulopathy, the nurse should: (Select all that apply.)
a.
assess fluids for occult blood.
b.
observe for oozing and bleeding and remove clots that form.
c.
limit invasive procedures.
d.
take temperatures rectally to increase accuracy.
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e.
341
weigh dressings to assess blood loss.
ANS: A, C, E
Additional nursing interventions specific to the patient with a coagulopathy include the following: weigh
dressings to assess blood loss, assess fluids for occult blood, observe for oozing and bleeding from skin and
mucous membranes, and leave clots undisturbed. Precautions such as limiting invasive procedures, including
indwelling urinary catheters or rectal temperature measurement, are also important.
DIF: Cognitive Level: Application REF: p. 492
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. Accepted treatments for disseminated intravascular coagulation (DIC) may require: (Select all that apply.)
a.
platelet infusions.
b.
administration of fresh frozen plasma.
c.
cryoprecipitate.
d.
packed RBCs.
e.
heparin.
ANS: A, B, C, D
Administration of platelets is the highest priority for transfusion because they provide the clotting factors
needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for
fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often
inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of
cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparins
antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further
problems. Its use is controversial when it is administered to patients with DIC.
DIF: Cognitive Level: Comprehension REF: pp. 499-500
OBJevelop plans of care for the immunocompromised host and the patient who has a bleeding disorder.TOP:
Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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342
Chapter 19: Endocrine Alterations
MULTIPLE CHOICE
1. A patient with type 1 diabetes who is receiving a continuous subcutaneous insulin infusion via an insulin
pump contacts the clinic to report mechanical failure of the infusion pump. The nurse instructs the patient to
begin monitoring for signs of:
a.
adrenal insufficiency.
b.
diabetic ketoacidosis.
c.
hyperosmolar, hyperglycemic state.
d.
hypoglycemia.
ANS: B
If the insulin pump fails, the patient with type 1 diabetes will have a complete interruption of insulin delivery;
diabetic ketoacidosis will occur. Adrenal insufficiency would not result from insulin pump failure.
Hyperosmolar, hyperglycemic state is a hyperglycemic complication associated with type 2 diabetes; this
patient has type 1 diabetes. Interruption of insulin delivery in type 1 diabetes would result in hyperglycemia,
not hypoglycemia.
DIF: Cognitive Level: Analysis REF: p. 553 | Box 18-4
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
2. Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
a.
An 18-year-old college student with type 1 diabetes who exercises excessively
b.
A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
c.
A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on
insulin injections
d.
An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimers disease
who recently developed influenza
ANS: D
Hyperosmolar hyperglycemic syndrome is more common in type 2 diabetes; influenza is a stressor that would
result in further increases in blood sugar. Some individuals with advanced Alzheimers disease cannot
communicate thirst needs and may be incontinent, making hypertonic fluid loss more difficult to estimate.
Uncontrolled type 1 diabetes is associated with diabetic ketoacidosis. Interruption of insulin delivery related to
a missed insulin dose in type 1 diabetes creates a situation of absolute insulin deficiency in type 1 diabetes and
is associated with diabetic ketoacidosis. A patient with type 2 diabetes who is new to insulin is at risk for
hypoglycemia.
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DIF: Cognitive Level: Analysis REF: pp. 552-553
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. Which of the following laboratory values would be more common in patients with diabetic ketoacidosis?
a.
Blood glucose >1000 mg/dL
b.
Negative ketones in the urine
c.
Normal anion gap
d.
pH 7.24
ANS: D
A pH of 7.24 is indicative of an acidotic state that may accompany diabetic ketoacidosis.
Glucose values of more than 1000 mg/dL are more commonly associated with hyperosmolar hyperglycemic
syndrome. Diabetic ketoacidosis is associated with positive urine ketones and an increased anion gap.
DIF: Cognitive Level: Comprehension REF: Laboratory Alert: Pancreatic Endocrine Disorders
OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and
interpretation of laboratory and other diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. Which of the following is a high-priority nursing diagnosis for both diabetic ketoacidosis and hyperosmolar
hyperglycemic syndrome?
a.
Activity intolerance
b.
Fluid volume deficient
c.
Hyperthermia
d.
Impaired nutrition, more than body requirements
ANS: B
Both diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome result in dehydration and hypovolemia;
therefore, fluid volume deficit is a priority nursing diagnosis. Even though activity intolerance is a potential
nursing diagnosis related to the fatigue associated with metabolic changes in hyperglycemic conditions, it is
not a first priority. Hyperthermia is associated with thyroid crisis. Although overweight and obesity are risk
factors for type 2 diabetes, during metabolic crisis, the patient has inadequate energy available to tissues
because of limited availability and poor utilization of insulin.
DIF: Cognitive Level: Analysis REF: p. 557
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344
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Planning MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is assigned to care for a patient who presented to the emergency department with diabetic
ketoacidosis. A continuous insulin intravenous infusion is started, and hourly bedside glucose monitoring is
ordered. The targeted blood glucose value after the first hour of therapy is:
a.
70 to 120 mg/dL.
b.
a decrease of 25 to 50 mg/dL compared with admitting values.
c.
a decrease of 50 to 75 mg/dL compared with admitting values.
d.
less than 200 mg/dL.
ANS: C
Initial insulin infusions should be administered with a target blood glucose reduction of 50 to 75 mg/dL per
hour. Decreases of less than this rate may be associated with inadequate insulin replacement and allow for the
persistence of the ketotic state. Rapid reductions of blood glucose may precipitate life-threatening cerebral
edema; thus, controlled reduction of glucose is required.
DIF: Cognitive Level: Application REF: p. 558
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
6. A patient has been on daily, high-dose glucocorticoid therapy for the treatment of rheumatoid arthritis. His
prescription runs out before his next appointment with his physician. Because he is asymptomatic, he thinks it
is all right to withhold the medication for 3 days. What is likely to happen to this patient?
a.
He will go into adrenal crisis.
b.
He will go into thyroid storm.
c.
His autoimmune disease will go into remission.
d.
Nothing; it is appropriate to stop the medication for 3 days.
ANS: A
Patients on long-term corticosteroid therapy are at high risk for adrenal crisis, because therapy suppresses the
endogenous production of steroids. Adrenal crisis may be precipitated by sudden withdrawal of glucocorticoid
therapy. Thyroid storm may occur when antithyroid medications are suddenly withdrawn. Rheumatoid arthritis
is likely to exacerbate with the withdrawal of glucocorticoids. Adrenal crisis may occur shortly after
withdrawal of glucocorticoids.
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345
DIF: Cognitive Level: Analysis REF: p. 565
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
7. The nurse is caring for a 27-year-old patient with a diagnosis of head trauma. The nurse notes that the
patients urine output has increased tremendously over the past 18 hours. The nurse suspects that the patient
may be developing:
a.
diabetes insipidus.
b.
diabetic ketoacidosis.
c.
hyperosmolar hyperglycemic syndrome.
d.
syndrome of inappropriate secretion of antidiuretic hormone.
ANS: A
Diabetes insipidus results in large volumes of urine; dehydration and hypovolemia can result. Head trauma and
resulting increased intracranial pressure are potential causes of diabetes insipidus. High urine output following
head trauma is associated with diabetes insipidus. Even though hyperosmolar hyperglycemic syndrome results
in osmotic diuresis, the cause is a deficiency in insulin in type 2 diabetes, not head trauma. SIADH may occur
with head trauma but results in reduced urine output and, potentially, hypervolemia.
DIF: Cognitive Level: Analysis REF: pp. 581-582 | Box 18-23
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse is providing postoperative care to a patient who underwent a transsphenoidal hypophysectomy for
a benign pituitary tumor. The nurse administers replacement hydrocortisone, thyroid hormone, and
vasopressin. The nurse evaluates that the vasopressin replacement is effective when:
a.
the patients blood glucose is 110 mg/dL.
b.
the patient maintains a core body temperature of 98.2 F (36.8 C).
c.
the patients urine specific gravity decreases.
d.
2 liters of urine are produced in a 24-hour period.
ANS: D
Vasopressin is administered to replace antidiuretic hormone following a hypophysectomy. Other lifesustaining hormones such as cortisol and thyroid hormone that involve a feedback system between the pituitary
gland and the target gland also must be replaced. Vasopressin produces elevation of blood pressure, causes
retention of fluid, and reduces urine output. The result is a decrease in serum sodium and serum osmolality
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secondary to hemodilution and increase in urine specific gravity. Blood glucose control is not affected by
vasopressin; cortisol would directly affect blood glucose. Core body temperature would be most directly
affected by thyroid hormone. Urine specific gravity would increase, not decrease, following vasopressin
administration.
DIF: Cognitive Level: Analysis REF: p. 583
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
9. In the management of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, when is an
intravenous (IV) solution that contains dextrose started?
a.
Never; normal saline is the only appropriate solution in diabetes management
b.
When the blood sugar reaches 70 mg/dL
c.
When the blood sugar reaches 150 mg/dL
d.
When the blood glucose reaches 250 mg/dL
ANS: D
Normal saline is the best initial fluid choice for management of hyperglycemic states. However, when the
glucose reaches about 250 mg/dL, solutions containing dextrose are added to prevent hypoglycemia.
Hypotonic solutions are required to replace intracellular fluid deficits, and dextrose is required to prevent
hypoglycemia later when glucose levels reach initial targets. A glucose level of 70 mg/dL is suggestive of
hypoglycemia and would require oral glucose replacement, a 50% dextrose bolus, or glucagon administration.
DIF: Cognitive Level: Application REF: p. 558
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. A 32-year-old patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis.
Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins
to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring?
a.
Calcium
b.
Chloride
c.
Potassium
d.
Sodium.
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ANS: C
Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar
hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid
balance has been restored and glucose has returned to more normal levels. Insulin administration used in the
treatment of diabetic ketoacidosis further promotes lowering of potassium as the electrolyte is relocated to the
cellular bed. Calcium levels do not drastically change in hyperosmolar states and are not a primary concern
unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with
fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with
fluid replacement.
DIF: Cognitive Level: Application REF: p. 558
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
11. A patient is admitted to the oncology unit with a small cell lung carcinoma. During the admission, the
patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and
mental status changes. The nurse is aware that this clinical presentation is consistent with:
a.
adrenal crisis.
b.
diabetes insipidus.
c.
myxedema coma.
d.
syndrome of inappropriate secretion of antidiuretic hormone (SIADH).
ANS: D
SIADH may be induced by ectopic sources of antidiuretic hormone, including small cell lung carcinoma. The
clinical presentation of a dilutional hypervolemia is consistent with SIADH. Adrenal crisis is characterized by
fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss. Diabetes insipidus
is characterized by increased urine output and is not typically caused by lung tumors. Myxedema coma,
although characterized by facial and peripheral edema, does not result from small cell lung carcinoma.
DIF: Cognitive Level: Analysis REF: pp. 583-584
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic
ketoacidosis, with three major exceptions. What differences would you expect to see in patients with
hyperosmolar hyperglycemic syndrome?
a.
Lower serum glucose, lower osmolality, and greater ketosis
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Lower serum glucose, lower osmolality, and milder ketosis
c.
Higher serum glucose, higher osmolality, and greater ketosis
d.
Higher serum glucose, higher osmolality, and no ketosis
348
ANS: D
In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater,
resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than
those of diabetic ketoacidosis and are not typically accompanied by ketosis.
DIF: Cognitive Level: Analysis REF: p. 557
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. Which of the following statements is true about the medical management of diabetic ketoacidosis?
a.
Serum lactate levels are used to guide insulin administration.
b.
Sodium bicarbonate is a first-line medication for treatment.
c.
The degree of acidosis is assessed through continuous pulse oximetry.
d.
Volume replacement and insulin infusion often correct the acidosis.
ANS: D
Volume replacement promotes hemodilution in the face of a hyperosmolar state. Insulin administration
promotes entry of glucose into cells and relieves ketosis. As volume is replaced and glucose normalizes, the
acidosis often resolves. Insulin administration, not lactate levels, is guided by blood glucose values. Sodium
bicarbonate is only administered to correct severe acidosis (pH < 7.1). Degree of acidosis is assessed through
arterial blood gas readings and serum ketone levels.
DIF: Cognitive Level: Application REF: p. 558
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. An individual with type 2 diabetes who takes glipizide (Glucotrol) to control her blood glucose has begun a
formal exercise program at a local gym. While exercising on the treadmill, she becomes pale, diaphoretic, and
shaky. She has a headache and feels as though she is going to pass out. What is the individuals priority action?
a.
Drink additional water to prevent dehydration.
b.
Eat something with 15 g of simple carbohydrates.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Go to the first aid station to have glucose checked.
d.
Take another dose of the oral agent.
349
ANS: B
The patient is displaying classic symptoms of hypoglycemia. The patient is on sulfonylurea therapy, which
carries the risk of hypoglycemia. The walking may be more exercise than she is used to and may thereby cause
hypoglycemia. Fifteen grams of carbohydrate is appropriate for initial management of hypoglycemia.
Hypoglycemia does not place the patient at risk for dehydration. The patient requires immediate treatment and
could pass out while going to the first aid station. It cannot be assumed that the gym has access to diabetes
treatment supplies. Additional doses of oral diabetes medications should not be taken without consulting the
healthcare team. An additional dose of glipizide could promote further hypoglycemia.
DIF: Cognitive Level: Synthesis REF: p. 564
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. A 20-year-old female with a history of type 1diabetes and an eating disorder is found unconscious. In the
emergency department, the following lab values are obtained:
Glucose648 mg/dL
pH6.88
PaCO220 mm Hg
PaO295 mm Hg
HCO3 undetectable
Anion gap>31
Na+127 mEq/L
K+ 3.5 mEq/L
Creatinine1.8 mg/dL
After the patients airway and ventilation have been established, the next priority for this patient is:
a.
administration of a 1-L normal saline fluid bolus.
b.
administration of 0.1 unit of regular insulin IV push followed by an insulin infusion.
c.
administration of 20 mEq KCl in 100 mL.
d.
IV push administration of 1 amp of sodium bicarbonate.
ANS: A
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
350
After airway is established, the next priority in management of DKA is fluid resuscitation with 1 liter of
normal saline over 1 hour. The fluid resuscitation should begin prior to administration of insulin. Potassium
may be added to fluid replacement bags after the first liter of normal saline has infused, provided that the
serum potassium is greater than 3.3 mEq/L. Although bicarbonate replacement is indicated in this clinical
situation, the bicarbonate is administered by infusion, not by IV push, until the pH exceeds 7.0.
DIF: Cognitive Level: Analysis REF: p. 558
OBJ: Discuss the medical management of patients with hyperglycemic crisis,
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. Acute adrenal crisis is caused by:
a.
acute renal failure.
b.
deficiency of corticosteroids.
c.
high doses of corticosteroids.
d.
overdose of testosterone.
ANS: B
An adrenal crisis occurs because of a lack of corticosteroids. This may be due to lack of endogenous cortisol
production, lack of ACTH production, or inhibition of natural cortisol production by exogenous cortisol
administration. Acute renal failure would not be associated with adrenal crisis. High doses of corticosteroids
are associated with Cushings syndrome. Testosterone overdose would not be associated with adrenal crisis.
Steroid hormones may possess some corticoid properties.
DIF: Cognitive Level: Knowledge REF: p. 565 | Box 18-11
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
17. The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte balance is:
a.
fluid volume excess.
b.
hyperglycemia.
c.
hyperkalemia
d.
hypernatremia
ANS: C
Adrenal insufficiency may be characterized by inadequate amounts of cortisol and aldosterone. Aldosterone
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
351
acts to retain sodium, resulting is water retention and potassium loss. Inadequate levels of aldosterone therefore
result in hyponatremia, fluid loss, and hyperkalemia. Inadequate cortisol levels may cause weight loss,
weakness, and hypoglycemia. Fluid volume deficit may accompany adrenal crisis as a result of sodium loss
from decreases in cortisol and aldosterone. Hypoglycemia may accompany adrenal crisis as a consequence of
inadequate amounts of cortisol, which limits gluconeogenesis. Hyponatremia may accompany adrenal crisis
because of sodium losses secondary to aldosterone insufficiency that often accompanies the condition.
DIF: Cognitive Level: Analysis REF: p. 568
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
18. A patient presents to the emergency department with suspected thyroid storm. The nurse should be alert to
which of the following cardiac rhythms while providing care to this patient?
a.
Atrial fibrillation
b.
Idioventricular rhythm
c.
Junctional rhythm
d.
Sinus bradycardia
ANS: A
Increased heart rate and tachydysrhythmia, including atrial fibrillation, may accompany thyroid storm.
Bradycardiac rhythms may be suggestive of hypothyroidism.
DIF: Cognitive Level: Application REF: p. 573 | Box 18-19
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
19. An elderly female patient has presented to the emergency department with altered mental status,
hypothermia, and clinical signs of heart failure. Myxedema is suspected. Which of the following laboratory
findings support this diagnosis?
a.
Elevated adrenocorticotropic hormone
b.
Elevated cortisol levels
c.
Elevated T3 and T4
d.
Elevated thyroid-stimulating hormone
ANS: D
Thyroid hormones are low in myxedema. Thyroid-stimulating hormone is usually high in relation to the
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
352
feedback mechanisms for hormone regulation if myxedema is caused by primary hypothyroidism. Elevated
adrenocorticotropic hormone may be seen in pituitary conditions or adrenal insufficiency. Elevated cortisol
levels accompany Cushings syndrome. Elevated T3 and T4 levels are consistent with hyperthyroidism.
DIF: Cognitive Level: Application REF: p. 572
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
20. A patient presents to the emergency department (ED) with the following clinical signs:
Pulse: 132 beats/min
Blood pressure: 88/50 mm Hg
Respiratory rate: 32 breaths/min
Temperature: 104.8 F
Chest x-ray: Findings consistent with congestive heart failure
Cardiac rhythm: Atrial fibrillation with rapid ventricular response
These signs are consistent with which disorder?
a.
Adrenal crisis
b.
Myxedema coma
c.
Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
d.
Thyroid storm
ANS: D
Tachycardia, vascular collapse, rapid cardiac rhythms, congestive heart failure, and severe hyperthermia are
consistent with the clinical manifestations of the hypermetabolic state of thyroid storm. Adrenal insufficiency
presents with weakness, fatigue, weight loss, anorexia, abdominal pain, and hyperpigmentation. Myxedema
coma is an extreme form of hypothyroidism and is characterized by signs of hypometabolism, including
bradycardia, hypotension, hypothermia, cold intolerance, and neurological sluggishness. SIADH is
characterized by fluid retention, hyponatremia, and hemodilution. Heat intolerance and atrial fibrillation are
not typical characteristics of the condition.
DIF: Cognitive Level: Analysis REF: pp. 583-584
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
21. Which of the following would be seen in a patient with myxedema coma?
a.
Decreased reflexes
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Hyperthermia
c.
Hyperventilation
d.
Tachycardia
353
ANS: A
Myxedema coma is characterized by a hypometabolic state, and all body functions are slowed including
cardiovascular function, decreased gastrointestinal mobility, cold intolerance, and diminished reflexes.
Hyperthermia is characteristic of thyroid storm. Hyperventilation is characteristic of thyroid storm and diabetic
ketoacidosis. Tachycardia is characteristic of thyroid storm.
DIF: Cognitive Level: Comprehension REF: p. 572 | Box 18-18
OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and
interpretation of laboratory and other diagnostic tests.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
22. The nurse is caring for a patient who underwent pituitary surgery 12 hours ago. The nurse will give priority
to monitoring the patient carefully for which of the following?
a.
Congestive heart failure
b.
Hypovolemic shock
c.
Infection
d.
Volume overload
ANS: B
Pituitary surgery or manipulation of the pituitary stalk during surgery may precipitate diabetes insipidus.
Profound diuresis that accompanies diabetes insipidus may result in hypovolemic shock. Fluid volume deficit,
not overload, accompanies diabetes insipidus. Increased risk of infection may accompany hyperglycemia and
elevated cortisol levels. Fluid volume overload is more characteristic of SIADH.
DIF: Cognitive Level: Analysis REF: pp. 580-581
OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and
interpretation of laboratory and other diagnostic tests.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
23. The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit
following a motorcycle crash. What is an important assessment that will assist the nurse in early identification
of an endocrine disorder commonly associated with this condition?
a.
Daily weight
b.
Fingerstick glucose
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Lung sound auscultation
d.
Urine osmolality
354
ANS: D
Diabetes insipidus may result from traumatic brain injury. It results in passage of large volumes of dilute urine.
Urine osmolality is low in individuals with diabetes insipidus, and urine specific gravity assessments should be
incorporated into the care of at-risk patients. Even though daily weight monitoring is important in the
assessment of fluid balance disorders, it is not specific in determining cause. Urine specific gravity measuring
would be a more specific means of identifying diabetes insipidus. Blood glucose values would be abnormal in
diabetes mellitus but not diabetes insipidus. Changes in breath sounds accompany fluid overload states such as
SIADH. Diabetes insipidus is a hypovolemic condition.
DIF: Cognitive Level: Application REF: pp. 580-581
OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and
interpretation of laboratory and other diagnostic tests.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
24. Which of the following laboratory values would be found in a patient with syndrome of inappropriate
secretion of antidiuretic hormone?
a.
Fasting blood glucose 156 mg/dL
b.
Serum potassium 5.8 mEq/L
c.
Serum sodium 115 mEq/L
d.
Serum sodium 152 mEq/L
ANS: C
SIADH causes a dilutional hyponatremia, and central nervous system symptoms can occur. A low serum
sodium (below 135 mEq/L may accompany the syndrome. Glucose elevation is not a classic sign of SIADH.
Hyperkalemia does not accompany the dilutional hyponatremia of SIADH. Serum sodium levels are typically
lower in the dilutional hyponatremia that accompanies SIADH.
DIF: Cognitive Level: Analysis REF: p. 584
OBJ: Describe the methods for assessing the endocrine system, including physical assessment, and
interpretation of laboratory and other diagnostic tests.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
25. A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent
with syndrome of inappropriate secretion of antidiuretic hormone. The nurse anticipates that clinical
management of this condition will include:
a.
administration of 3% normal saline.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
administration of exogenous vasopressin.
c.
fluid restriction.
d.
low sodium diet.
355
ANS: C
The first treatment of this condition is volume restriction; other treatments may not be needed if restrictions
work. Extreme fluid restrictions (800 to 1000 mL/day) may be required in the treatment of SIADH. Hypertonic
saline administration may be used to treat severe hyponatremia (serum sodium < 110 mEq/L) but is not used in
most cases. The administration of hypertonic saline carries significant risk. Vasopressin replacement would
provide additional ADH and further complicate SIADH. Sodium replacement may be required to treat the
hemodilution associated with SIADH.
DIF: Cognitive Level: Application REF: p. 584
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH).
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
26. The nurse is providing insulin education for an elderly patient with longstanding diabetes. An order has
been written for the patient to take 20 units of insulin glargine (Lantus) at 10 PM nightly. The nurse should
instruct the patient that the peak of the insulin action for this agent is:
a.
0200.
b.
0400.
c.
0800.
d.
peakless.
ANS: D
Insulin glargine (Lantus is a long-acting insulin that has no specific peak in action.
The remaining times are associated with peaks of other short-acting and intermediate-acting insulin products.
DIF: Cognitive Level: Application REF: p. 547 | Figure 18-2
OBJ: Discuss the medical management of patients with hyperglycemic crisis, hypoglycemic crisis, adrenal
crisis, thyroid storm, myxedema coma, diabetes insipidus, and the syndrome of inappropriate secretion of
antidiuretic hormone (SIADH.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
27. The nurse is caring for a patient who suffered a head trauma following a fall. The patients heart rate is 112
beats/min and blood pressure is 88/50 mm Hg. The patient has poor skin turgor and dry mucous membranes.
The patient is confused and restless. The following laboratory values are reported: serum sodium is 115
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
356
mEq/L; blood urea nitrogen (BUN) 50 mg/dL; and creatinine 1.8 mg/dL. The findings are consistent with
which disorder?
a.
Cerebral salt wasting
b.
Diabetes insipidus
c.
Syndrome of inappropriate secretion of antidiuretic hormone
d.
Thyroid storm
ANS: A
Cerebral salt wasting may occur after head trauma and is characterized by low sodium in the face of classic
physical and laboratory signs of fluid volume deficit or dehydration, including tachycardia, hypotension, dry
mucous membranes, weight loss, and poor skin turgor. The patient also may experience the classic signs of
hyponatremia, including a serum sodium less than 135 mg/dL, confusion, lethargy, seizures, and coma.
Diabetes insipidus is characterized by clinical signs of dehydration with elevated serum sodium. SIADH is
characterized by hyponatremia and fluid volume overload. Thyroid storm would not directly affect sodium
levels.
DIF: Cognitive Level: Analysis REF: p. 585
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
28. A patient with newly diagnosed type 1 diabetes is being transitioned from an infusion of intravenous (IV)
regular insulin to an intensive insulin therapy regimen of insulin glargine (Lantus) and insulin aspart
(NovoLog). How should the nurse manage this transition in insulin delivery?
a.
Administer the insulin glargine and continue the IV insulin infusion for 24 hours.
b.
Administer the insulin glargine and discontinue the IV infusion in several hours.
c.
Discontinue the IV infusion and administer the insulin aspart with the next meal.
d.
Discontinue the IV infusion and administer the Lantus insulin at bedtime.
ANS: B
Subcutaneous insulin should be administered 1 to 4 hours before discontinuing the intravenous infusion to
allow the patient to reach adequate plasma insulin levels to prevent redevelopment of DKA. Continuation of
the insulin infusion in conjunction with the long-acting insulin glargine would result in hypoglycemia.
Discontinuation of intravenous insulin prior to administration of subcutaneous insulin would result in
reoccurrence of DKA in a patient with type 1 diabetes.
DIF: Cognitive Level: Analysis REF: p. 546
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
357
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all
that apply.)
a.
Administer levothyroxine (Synthroid) as ordered.
b.
Encourage the intake of foods high in sodium.
c.
Initiate passive rewarming interventions.
d.
Monitor airway and respiratory effort.
e.
Monitor urine osmolality.
ANS: A, C, D
Myxedema coma is a severe manifestation of hypothyroidism. Treatment entails replacement of thyroid
hormone, airway management related to respiratory depression and potential airway obstruction related to
tongue edema, thermoregulation, management of edema and congestive heart failure symptoms, and patient
education. Edema may accompany myxedema and necessitate use of sodium restriction. Urine osmolality is
monitored in conditions that affect antidiuretic hormone levels.
DIF: Cognitive Level: Analysis REF: p. 577 | Box 18-21
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Mechanisms for development of diabetes insipidus include which of the following? (Select all that apply.)
a.
ADH deficiency
b.
ADH excess
c.
ADH insensitivity
d.
ADH replacement therapy
e.
Water deprivation
ANS: A, C
Diabetes insipidus is caused by either a deficiency in ADH production (neurogenic or impaired renal response
to ADH (nephrogenic. ADH excess is characteristic of syndrome of inappropriate secretion of antidiuretic
hormone. ADH replacement therapy is a treatment for neurogenic diabetes insipidus. Water deprivation would
result in increased ADH secretion and further augment dehydration associated with diabetes insipidus.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
358
DIF: Cognitive Level: Application REF: p. 581
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. A college student was admitted to the emergency department after being found unconscious by a roommate.
The roommate informs emergency medical personnel that the student has diabetes and has been experiencing
flulike symptoms, including vomiting, since yesterday. The patient had been up all night studying for exams.
The patient used the last diabetes testing supplies 3 days ago and has not had time to go to the pharmacy to
refill prescription supplies. Based upon the history, which laboratory findings would be anticipated in this
client? (Select all that apply.)
a.
Blood glucose 43 mg/dL
b.
Blood glucose 524 mg/dL
c.
HCO3 10 mEq/L
d.
PaCO2 37 mm Hg
e.
pH 7.23
ANS: B, C, E
The patient is presenting with laboratory evidence of diabetic ketoacidosis. Diabetic ketoacidosis is
characterized by hyperglycemia and low bicarbonate levels, low CO2, and low pH. A blood glucose of 43
mg/dL is indicative of hypoglycemia. The reported carbon dioxide level is normal and is not consistent with
acute DKA, for which compensatory tachypnea would be expected along with a low PaCO2.
DIF: Cognitive Level: Analysis REF: p. 556
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. What psychosocial factors may potentially contribute to the development of diabetic ketoacidosis? (Select
all that apply.)
a.
Altered sleep/rest patterns
b.
Eating disorder
c.
Exposure to influenza
d.
High levels of stress
e.
Lack of financial resources
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
359
ANS: A, B, D, E
Psychosocial factors may lead to changes in diabetes self-management practices that precipitate diabetic
ketoacidosis. Eating disorders may complicate 20% of recurrent cases of DKA in young women. Changes in
sleep patterns and psychosocial stressors may lead to increased insulin demands in the face of declining selfcare practices. Financial and time limitations impacted the ability to monitor for changes in control. Exposure
to influenza is a physiological factor; it would not be a psychosocial factor associated with DKA.
DIF: Cognitive Level: Application REF: p. 552
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
5. Factors associated with the development of nephrogenic diabetes insipidus include which of the following?
(Select all that apply.)
a.
Heredity
b.
Medications, including phenytoin (Dilantin) and lithium carbonate
c.
Meningitis
d.
Pituitary tumors
e.
Sickle cell disease
ANS: A, B, E
Nephrogenic diabetes insipidus occurs when adequate amounts of antidiuretic hormone are produced with
limited renal response. Causative factors for nephrogenic diabetes insipidus are heredity, preexisting renal
disease, multisystem diseases such as multiple myeloma and sickle cell disease, chronic electrolyte
disturbances, and medications. Meningitis may result in neurogenic diabetes insipidus. Pituitary tumors may
result in neurogenic diabetes insipidus.
DIF: Cognitive Level: Comprehension REF: p. 565 | Box 18-11
OBJ: Describe the pathophysiology and systemic manifestations of disorders resulting from alterations in
hormones secreted by the pancreas, adrenal, thyroid, and posterior pituitary glands.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse has been assigned the following patients. Which patients require assessment of blood glucose
control as a nursing priority? (Select all that apply.)
a.
18-year-old male who has undergone surgical correction of a fractured femur
b.
29-year-old female who is undergoing evaluation for pheochromocytoma
c.
43-year-old male with acute pancreatitis who is receiving total parenteral nutrition (TPN)
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
62-year-old morbidly obese female who underwent a hysterectomy for ovarian cancer
e.
72-year-old female who is receiving intravenous (IV) steroids for an exacerbation of chronic
obstructive pulmonary disease (COPD)
360
ANS: B, C, D, E
Risk factors for development of stress-induced hyperglycemia are a prior history of diabetes or hyperglycemia;
obesity; pancreatitis; cirrhosis; glucocorticoids; excess epinephrine; advanced age; nutrition support; and
various medications. The young male with the fractured femur is at low risk for stress-induced hyperglycemia.
DIF: Cognitive Level: Analysis REF: p. 545 | Box 18-1
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
7. A patient with long-standing type 1 diabetes presents to the emergency department with a loss of
consciousness and seizure activity. The patient has a history of renal insufficiency, gastroparesis, and
peripheral diabetic neuropathy. Emergency personnel reported a blood glucose of 32 mg/dL on scene. When
providing discharge teaching for this patient and family, the nurse instructs on the need to do which of the
following? (Select all that apply.)
a.
Administer glucagon 1 mg intramuscularly any time the blood glucose is less than 70 mg/dL.
b.
Administer 15 grams of carbohydrate orally for severe episodes of hypoglycemia.
c.
Discontinue the insulin pump by removing the infusion set catheter.
d.
Increase home blood glucose monitoring and report patterns of hypoglycemia to the provider.
e.
Perform blood glucose monitoring before exercising and driving.
ANS: B, D, E
This patient experienced a severe hypoglycemic episode. The patient is at risk for this because of a history of
autonomic neuropathy as evidenced by gastroparesis, which causes erratic gastric emptying and glucose
absorption, and renal insufficiency, which can result in erratic clearance of insulin. Patients with hypoglycemia
unawareness should increase blood glucose monitoring; carry a glucagon emergency kit and instruct a family
member of friend on administration; monitor before high-risk activities such as driving and exercising; and use
caution with alcohol ingestion. Glucagon or 50% dextrose is administered for severe hypoglycemic episodes
when a patient is unconscious or extremely uncooperative. Oral glucose replacement may be dangerous in a
severe reaction because of the risk of aspiration. Mild and moderate hypoglycemic reactions should be
managed with oral glucose replacement. Insulin pump therapy may be suspended temporarily during a
hypoglycemic episode but should not be discontinued. The infusion set catheter should not be removed during
a hypoglycemic episode.
DIF: Cognitive Level: Application REF: p. 564 | Box 18-9 | Box 18-10
OBJ: Formulate plans of care for patients with critical alterations in endocrine function.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
361
Chapter 20: Trauma and Surgical Management
MULTIPLE CHOICE
1. Which of the following best defines the term traumatic injury?
a.
All trauma patients can be successfully rehabilitated.
b.
Traumatic injuries cause more deaths than heart disease and cancer.
c.
Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events.
d.
Trauma mainly affects the older adult population.
ANS: C
Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances.
Rehabilitation potential depends on multiple factors including severity of injury, patient age, and
comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of
predominantly young individuals.
DIF: Cognitive Level: Comprehension REF: p. 588
OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
2. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54
years are most likely to experience which type of trauma incident?
a.
High-speed motor vehicle crashes
b.
Poisonings from prescription or illegal drugs
c.
Violent or domestic traumatic altercations
d.
Work-related falls
ANS: B
People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs
resulting in unintentional injury, followed by motor vehicle crashes (MVCs. MVCs and homicide are the
leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in the
65 years and older population. Domestic violence is not well defined as an age-related trauma incident.
DIF: Cognitive Level: Comprehension REF: p. 588
OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
362
has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center?
a.
Level I
b.
Level II
c.
Level III
d.
Level IV
ANS: A
Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries
related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less
severe injuries can be treated at lower level trauma centers.
DIF: Cognitive Level: Analysis REF: p. 589 | Table 19-1
OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for
infection?
a.
A fall from a 6-foot ladder onto the grass
b.
A shotgun wound to the abdomen
c.
A knife wound to the right chest
d.
A motor vehicle crash in which the driver hits the steering wheel
ANS: B
The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic
energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a
compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which
the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may
include a cardiac contusion is possible following an injury in which the patient hits the steering column.
DIF: Cognitive Level: Analysis REF: p. 594
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
5. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a
blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED:
a.
includes a cervical spine x-ray study to determine the presence of a fracture.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
involves turning the patient from side to side to get a look at his back.
c.
is done quickly in the first few minutes to get a baseline assessment and establish priorities.
d.
is a methodical head-to-toe assessment identifying injuries and treatment priorities.
363
ANS: C
The primary survey is a systematic rapid assessment of the patients airway with cervical spine immobilization,
breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and
exposure/environmental considerations. The secondary survey is more methodical and involves identifying
injuries and specific treatment priorities.
DIF: Cognitive Level: Application REF: p. 594
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient is 22
years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is
most appropriate?
a.
Insert an oral airway to prevent aspiration and to protect the airway.
b.
Offer the patient an emesis basin so that you can measure the amount of emesis.
c.
Prepare to suction the oropharynx while maintaining cervical spine immobilization.
d.
Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.
ANS: C
Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential
elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis and
offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum
analysis.
DIF: Cognitive Level: Analysis REF: pp. 597-598 | Table 19-4
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. Which of the following interventions would not be appropriate for a patient who is admitted with a
suspected basilar skull fracture?
a.
Insertion of a nasogastric tube
b.
Insertion of an indwelling urinary catheter
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Endotracheal intubation
d.
Placement of an oral airway
364
ANS: A
Nasogastric tubes are contraindicated in basilar skull fractures because insertion may result in penetration of
the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the
airway to include placement of an oral airway or endotracheal tube may be indicated.
DIF: Cognitive Level: Analysis REF: p. 601
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
8. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to
a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to
facilitate rapid fluid administration?
a.
Placement of an intraosseous catheter
b.
Placement of a central line placement
c.
Insertion of a femoral catheter by a trauma surgeon
d.
Rapid transfer to the operating room
ANS: A
Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber
venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the
physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to
obtain intravenous access for fluid resuscitation.
DIF: Cognitive Level: Analysis REF: p. 599
OBJ: Describe prehospital care, emergency care, and resuscitation of the trauma patients.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
9. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by:
a.
cardiac contusion.
b.
cardiogenic shock.
c.
hypovolemia.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
365
pericardial tamponade.
ANS: C
Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion
may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated
with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.
DIF: Cognitive Level: Analysis REF: p. 598
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the
medical records review department arrives at the emergency department asking how she can assist. The best
response by a nurse working for the trauma center would be to:
a.
assign the nurse administrative duties, such as obtaining patient demographic information.
b.
assign the nurse to a triage room with another nurse from the emergency department.
c.
thank the nurse but inform her to return to her department as her skill set is not a good match for
patients needs.
d.
have the nurse assist with transport of patients to procedural areas.
ANS: A
A nurse in the medical records department is most likely familiar with the disaster plan and although she
doesnt currently provide direct care to patients, she is a knowledgeable healthcare provider who can help in a
disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such
as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not
known. Asking the nurse to return to her department also may not be appropriate because the nurse offers a
skill set that can be used during the disaster.
DIF: Cognitive Level: Analysis REF: pp. 591-592
OBJ: Describe a system approach to trauma care.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Safe and Effective Care Environment
11. A near-infrared spectroscopy (NIRS) probe is placed in a trauma patient during the resuscitation phase to:
a.
assess severity of metabolic acidosis.
b.
determine intraperitoneal bleeding.
c.
determine tissue oxygenation.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
366
prevent complications of over-resuscitation.
ANS: C
NIRS is a continuous noninvasive technology that uses principles of light transmission to measure skeletal
muscle oxygenation as an indicator of shock. Low oxygenation levels detected by NIRS may suggest
metabolic acidosis but requires laboratory analysis. Poor tissue perfusion determined through NIRS requires
further evaluation of causes of shock, including intraperitoneal bleeding. NIRS would not be helpful in
determining complications associated with over-resuscitation.
DIF: Cognitive Level: Comprehension REF: p. 599
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
12. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending
which of the following tests?
a.
Arterial oxygen saturation
b.
Hourly urine output
c.
Mean arterial pressure
d.
Serum lactate levels
ANS: D
Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial
oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean
arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective
resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by under-perfusion
(under-resuscitation).
DIF: Cognitive Level: Comprehension REF: p. 599
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
13. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of his car. The
patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During
the nurses assessment, the oxygen saturation drops to 80%. The patients blood pressure has dropped from
128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung
fields. The nurse notifies the physician and anticipates:
a.
administration of lactated Ringers solution (1 L) wide open.
b.
chest x-ray study to determine the etiology of the symptoms.
c.
endotracheal intubation and mechanical ventilation.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
d.
367
needle thoracostomy and chest tube insertion.
ANS: D
These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury.
Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray
would delay treatment and is not needed prior to emergent intervention. Administration of IV fluids would not
assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved
to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be
necessary after the tension pneumothorax is relieved to assist with the patients ventilation.
DIF: Cognitive Level: Analysis REF: p. 603
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
14. Which of the following patients have the greatest risk of developing acute respiratory distress syndrome
(ARDS) after traumatic injury?
a.
A patient who has a closed head injury with a decreased level of consciousness
b.
A patient who has a fractured femur and is currently in traction
c.
A patient who has received large volumes of fluid and/or blood replacement
d.
A patient who has underlying chronic obstructive pulmonary disease
ANS: C
During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid
and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid
from the intravascular space into the interstitial spaces (third spacing). As more IV fluids are given to support
systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and
predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute
kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by
traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would be related
to fluid resuscitation and excessive inflammation associated with traumatic injury.
DIF: Cognitive Level: Analysis REF: p. 600
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial
symptom of a suspected compartment syndrome?
a.
Absence of pulse in affected extremity
b.
Pallor in the affected area
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Paresthesia in the affected area
d.
Severe, throbbing pain in the affected area
368
ANS: D
Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury.
Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and
increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment,
pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the
extremity.
DIF: Cognitive Level: Application REF: p. 607
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and
nutritional support are strategies to prevent:
a.
disseminated intravascular coagulation.
b.
multisystem organ dysfunction.
c.
septic shock.
d.
wound infection.
ANS: B
Patients with multisystem injuries are at high risk of developing myriad complications associated with the
overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion
and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to
prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic
shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate
antibiotics and nursing interventions to reduce infection (e.g. hand hygiene).
DIF: Cognitive Level: Application REF: p. 610
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
17. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent:
a.
catheter-associated infection.
b.
venous thromboembolism.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
fat embolism.
d.
nosocomial pneumonia.
369
ANS: B
Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically
contraindicated, patients should receive pharmacological prophylaxis (e.g. heparin or heparin derivatives).
Nurses should encourage ambulation, evaluate the patients overall hydration, and ensure sequential
compression devices are used properly. Prevention of catheter-associated infections is also important through
interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation,
along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures
and early recognition of this complication is essential to treatment.
DIF: Cognitive Level: Application REF: p. 607
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. Which of the following interventions is a strategy to prevent fat embolism syndrome?
a.
Administer lipid-lowering statin medications.
b.
Intubate the patient early after the injury to provide mechanical ventilation.
c.
Provide prophylaxis with lowmolecular weight heparin.
d.
Stabilize extremity fractures early.
ANS: D
Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the
bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on
prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary
system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not
prevent fat embolism; it is for venous thromboembolism prophylaxis.
DIF: Cognitive Level: Application REF: p. 607
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to
achieve urine output of:
a.
30 mL/hr.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
50 mL/hr.
c.
100 mL/hr.
d.
300 mL/hr.
370
ANS: C
Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal
tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr.
Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm
the patient but may create too aggressive a diuresis.
DIF: Cognitive Level: Application REF: p. 607
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
20. Which of the following statements about mass casualty triage during a disaster is true?
a.
Priority treatments and interventions focus primarily on young victims.
b.
Disaster victims with the greatest chances for survival receive priority for treatment.
c.
Once interventions have been initiated, healthcare providers cannot stop the treatment of disaster
victims.
d.
Color-coded systems in which green indicates the patient of greatest need are used during disasters.
ANS: B
Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of
greatest chances for survival matched to resources available for medical intervention. Age is not a
determination in rendering interventions. Patient survival and severity of injury are the priority assessment for
triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to
principles of ethical care. Color-coded systems are frequently used during disasters to signify patients in
greatest need of assistance, with red indicating worse severity of injury and green being most stable.
DIF: Cognitive Level: Comprehension REF: p. 592
OBJ: Describe a system approach to trauma care.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Safe and Effective Care Environment
21. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What
assessment data suggest the patient suffered tissue damage consistent with a blast injury?
a.
Blood pressure 82/60, heart rate 122, respiratory rate 28.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Crackles (rales) on auscultation of bilateral lung fields.
c.
Responsive only to painful stimuli.
d.
Irregular heart rate and rhythm.
371
ANS: B
Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage.
Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer
period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic
membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood
pressure and corresponding tachycardia is more suggestive of hypovolemia. Lack of response to stimuli
suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the
heart (e.g. cardiac contusion).
DIF: Cognitive Level: Analysis REF: p. 594
OBJ: Identify mechanisms of traumatic injury commonly seen in the critical care setting.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Fluid resuscitation is an important component of managing the trauma patient. Which of the following
statements are true regarding the care of a trauma patient? (Select all that apply.)
a.
5% Dextrose is recommended for rapid crystalloid infusion.
b.
IV fluids may need to be warmed to prevent hypothermia.
c.
Massive transfusions should be avoided to improve patient outcomes.
d.
Only fully cross-matched blood products are administered.
ANS: B, C
Lactated Ringers and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia
is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Crossmatched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency.
DIF: Cognitive Level: Analysis REF: p. 594
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Trauma patients are at high risk for multiple complications not only due to the mechanism of injury but also
due to the patients long-term management. Which of the following statements apply to trauma patients? (Select
all that apply.)
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
a.
Indwelling urinary catheters are a source of infection.
b.
Patients often develop infection and sepsis secondary to central line catheters.
c.
Pneumonia is often an adverse outcome of mechanical ventilation.
d.
Wounds require sterile dressings to prevent infection.
372
ANS: A, B, C
Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices
when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care
considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds,
other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for
wound care.
DIF: Cognitive Level: Analysis REF: p. 610
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
3. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings
would increase the nurses suspicion of a pulmonary contusion? (Select all that apply.)
a.
Chest wall ecchymosis
b.
Diminished or absent breath sounds
c.
Pink-tinged or blood secretions
d.
Signs of hypoxia on room air
ANS: A, C, D
Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of
death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody
secretions, and a partial pressure of arterial oxygen (PaO2 of less than 60 mm Hg while breathing room air.
The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath
sounds is more suggestive of atelectasis or a collapsed lung.
DIF: Cognitive Level: Analysis REF: p. 604
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of
the following? (Select all that apply.)
a.
ARDS
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
b.
Coagulopathies
c.
Dysrhythmias
d.
Myocardial dysfunction
373
ANS: B, C, D
Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced
perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a complication
associated with excessive inflammation and over-resuscitation.
DIF: Cognitive Level: Application REF: p. 602
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney
injury associated with rhabdomyolysis? (Select all that apply.)
a.
Crush injury to right arm
b.
Gunshot wound to the abdomen
c.
Lightning strike of the left arm and chest
d.
Pulmonary contusion and rib fracture
ANS: A, C
Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being
struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension.
Acute kidney injury would not have a direct cause associated with a pulmonary contusion.
DIF: Cognitive Level: Analysis REF: p. 607
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. Which interventions can the nurse implement to assist the patients family in coping with the traumatic
event? (Select all that apply.)
a.
Establish a family spokesperson and communication system.
b.
Ask the family about their normal coping mechanisms.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Limit visitation to set times throughout the day.
d.
Coordinate a family conference.
374
ANS: A, B, D
The trauma team can assist the patient and family in crisis by helping them establish a consistent
communication process between the healthcare team and family. Other interventions include exploring the
familys perceptions of the event, support systems, and coping mechanisms. Family conferences early in the
emergent phase and frequently during the critical care phase assist with communication and with
understanding the patients and familys expectations for care. Limiting visitation will not assist the patient or
the familys ability to cope with the traumatic event.
DIF: Cognitive Level: Analysis REF: p. 611
OBJ: Describe assessment and management of common traumatic injuries.
TOP: Nursing Process Step: Assessment | Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity
7. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.)
a.
Prevention of hypothermia
b.
Administration of fresh frozen plasma as ordered
c.
Administration of potassium as ordered
d.
Administration of calcium as ordered
ANS: A, B, D
Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining
normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen
plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium
levels is important for effective cardiac muscle function, not coagulation.
DIF: Cognitive Level: Application REF: p. 598
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Assessment |Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
8. Which of the following findings require immediate nursing interventions related to the assessment of a
patient with a traumatic brain injury? (Select all that apply.)
a.
Mean arterial pressure 48 mm Hg
b.
Elevated serum blood alcohol level
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
c.
Non-reactive pupils
d.
Respiratory rate of 10 breaths per minute
375
ANS: A, C, D
Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain
injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral
perfusion; non-reactive pupils are an abnormal finding and require immediate attention to evaluate the cause.
Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of
10 requires further evaluation. An elevated blood alcohol level interferes with the ability to conduct a
neurological examination but does not require immediate intervention.
DIF: Cognitive Level: Application REF: p. 601
OBJ: Formulate a plan of care for the trauma patient, including prevention of complications.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
COMPLETION
1. The correct order of actions in the management of the postoperative surgical trauma patient who has been
admitted to the critical care unit after surgery is: _______________, _______________,
_______________,_______________. (Put a comma and space between each answer choice.)
a. Connect the patient to bedside monitor and mechanical ventilator.
b. Obtain vital signs, rhythm, oxygen saturation, and neurological status.
c. Assess airway, breathing, and circulation.
d. Reassess and evaluate patency of IV lines, and adjust rate of fluid administration as ordered.
ANS:
C, A, B, D
The initial intervention upon admission to the critical care unit is a rapid assessment of airway, breathing, and
circulation. The nurse quickly connects the patient to the bedside monitor and ventilator, and completes an
assessment of vital signs, cardiac rhythm, pulse oximetry reading, level of consciousness, and pupil reactivity.
The nurse reassesses IV access and evaluates the patency of IV catheters, because they may have become
dislodged during transport. Calculation of medication dosages and rates is completed as part of the initial
assessment. Once the assessment and initial interventions have been completed, the family is contacted to see
the patient.
DIF: Cognitive Level: Analysis REF: p. 608
OBJ: Explain the priorities of care for the postoperative surgical patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Prevention of hypothermia is crucial in caring for trauma patients. The correct order of actions for the
preparation for the trauma patient is: _______________, _______________, _______________,
_______________. (Put a comma and space between each answer choice.
a. Remove wet clothing.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
376
b. Warm fluids and blood products before administration.
c. Cover the patient with an external warming device.
d. Warm the ED or intensive care unit (ICU) room before the patients arrival.
ANS:
D, A, C, B
Before arrival to the ED or ICU, the receiving room needs to be warmed. The patients clothing is removed, and
he or she should be covered to prevent external loss of heat. An external warming device needs to be
immediately available for warming the patient after arrival. Fluids that are administered should be warmed via
active internal devices.
DIF: Cognitive Level: Synthesis REF: p. 602 | Table 19-6
OBJ: Discuss prehospital care, emergency care, and resuscitation of the trauma patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
377
Chapter 21: Burns
MULTIPLE CHOICE
1. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn
treatment is:
a.
blood urea nitrogen.
b.
daily weight.
c.
hourly intake and urine output.
d.
serum potassium.
ANS: C
During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake
and output is most effective in determining the needs for additional fluid infusion than is urine output alone.
Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen
after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume
status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the
optimum measure of intravascular fluid status.
DIF: Cognitive Level: Comprehension REF: p. 636
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn
management. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. In patients with extensive burns, edema occurs in both burned and unburned areas because of:
a.
catecholamine-induced vasoconstriction.
b.
decreased glomerular filtration.
c.
increased capillary permeability.
d.
loss of integument barrier.
ANS: C
Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of
proteins, fluid, and electrolytes resulting in edema (third spacing. Catecholamine-induced vasoconstriction
does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for
the extensive edema seen after burn injury. Loss of integument barrier does not cause edema.
DIF: Cognitive Level: Comprehension REF: p. 626
OBJ: Describe the pathophysiology of burns.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
378
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
3. Tissue damage from burn injury activates an inflammatory response that increases the patients risk for:
a.
acute kidney injury.
b.
acute respiratory distress syndrome.
c.
infection.
d.
stress ulcers.
ANS: C
The loss of skin as the primary barrier against microorganisms and activation of the inflammatory response
cascades results in immunosuppression, placing the patient at an increased risk of infection. A systemic
inflammatory response (SIRS) also increases the risk of acute kidney injury in the presence of poor tissue
perfusion. Acute respiratory distress syndrome is also a potential complication, but the risk of infection is
greater because of the loss of the skin barrier. Catecholamine release and gastrointestinal ischemia are the
causes of stress ulcers.
DIF: Cognitive Level: Comprehension REF: pp. 622-623
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
4. The nurse is caring for a burn-injured patient who weighs 154 pounds, and the burn injury covers 50% of his
body surface area. The nurse calculates the fluid needs for the first 24 hours after a burn injury using a standard
fluid resuscitation formula of 4 mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans
to administer what amount of fluid in the first 24 hours?
a.
2800 mL
b.
7000 mL
c.
14 L
d.
28 L
ANS: C
154 pounds/2.2 = 70 kg
4 70 kg 50 = 14,000 mL, or 14 liters.
DIF: Cognitive Level: Application REF: p. 636 | Box 20-1
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
379
5. The nurse is caring for a patient who has circumferential full-thickness burns of his forearm? A priority in
the plan of care is :
a.
Keeping the extremity in a dependent position
b.
Active and passive range of motion every hour.
c.
Preparing for an escharotomy as a prophylactic measure
d.
Splinting the forearm
ANS: B
Special attention is given to circumferential (completely surrounding a body part) full thickness
burns of the extremities. Pressure from bands of eschar or from edema that develops as resuscitation proceeds
may impair blood flow to underlying and distal tissue. Therefore, extremities are elevated to reduce edema.
Active or passive range-of-motion (ROM) exercises are performed every hour for 5 minutes to increase venous
return and to minimize edema. Peripheral pulses are assessed every hour, especially in circumferential burns of
the extremities, to confirm adequate circulation. If signs and symptoms of compartment syndrome are present
on serial examination, preparation is made for an escharotomy to relieve pressure and to restore circulation.
DIF: Cognitive Level: Application REF: p. 638
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. The patient asks the nurse if the placement of the autograft over his full-thickness burn will be the only
surgical intervention needed to close his wound. The nurses best response would be:
a.
Unfortunately, an autograft skin is a temporary graft and a second surgery will be needed to close
the wound.
b.
An autograft is a biological dressing that will eventually be replaced by your body generating new
tissue.
c.
Yes, an autograft will transfer your own skin from one area of your body to cover the burn wound.
d.
Unfortunately, autografts frequently do not adhere well to burn wounds and a xenograft will be
necessary to close the wound.
ANS: C
The autograft is the only permanent method of grafting and it uses the patients own tissue to cover the burn
wound. Autografting is permanent and does not require a second surgery unless the graft fails. A biological or
biosynthetic graft or dressing is a temporary wound covering. A xenograft is from an animal, usually pig skin
and is a temporary graft.
DIF: Cognitive Level: Application REF: p. 647
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
380
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A patient admitted with severe burns to his face and hands is showing signs of extreme agitation. The nurse
should explore the mechanism of burn injury possibly related to:
a.
excessive alcohol use.
b.
methamphetamine use.
c.
posttraumatic stress disorder.
d.
subacute delirium.
ANS: B
A vague or inconsistent injury history, burns to the face and hands, and signs of agitation or substance
withdrawal should alert the nurse to a potential methamphetamine-related injury.
DIF: Cognitive Level: Application REF: p. 616 OBJ: Compare types of burns.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. The nurse is caring for patient who has been struck by lightning. Because of the nature of the injury, the
nurse assesses the patient for which of the following?
a.
Central nervous system deficits
b.
Contractures
c.
Infection
d.
Stress ulcers
ANS: A
Lightning injury frequently causes cardiopulmonary arrest. However, of those patients who survive, 70% will
have transient central nervous system deficits. Contractures, infection, and stress ulcer risks are no greater than
with other causes of burn injury.
DIF: Cognitive Level: Comprehension REF: p. 617
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn
management. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
9. The nurse is providing care to manage the pain of a patient with burns. The physician has ordered opiates to
be given intramuscularly. The nurse contacts the physician to change the order to intravenous administration
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
381
because:
a.
intramuscular injections cause additional skin disruption.
b.
burn pain is so severe it requires relief by the fastest route available.
c.
hypermetabolism limits effectiveness of medications administered intramuscularly.
d.
tissue edema may interfere with drug absorption of injectable routes.
ANS: D
Edema and impaired circulation of the soft tissue interfere with absorption of medications administered
subcutaneously or intramuscularly. Even though it is true intramuscular injections disrupt tissue, medication
absorption is not effective. Burn pain is severe and intravenous administration is desired to relieve pain, but
this is not the physiological basis for giving medications intravenously. Hypermetabolism affects medication
effectiveness but is not the rationale for administering opioids intravenously.
DIF: Cognitive Level: Comprehension REF: pp. 642-643
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
10. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be
intubated. What is the reasoning for the immediate intubation?
a.
Carbon monoxide poisoning always occurs when soot is visible.
b.
Inhalation injury above the glottis may cause significant edema that obstructs the airway.
c.
The patient will have a copious amount of mucus that will need to be suctioned.
d.
The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways.
ANS: B
In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation
is recommended to protect the airway. Carbon monoxide poisoning may be present, but singed nose hairs are
neither a symptom nor a reason for early intubation. Management of secretions is not an indication for
intubation. Singed hairs and soot are more commonly symptoms of injury above the glottis rather than lower
airway, below-the-glottis, signs and symptoms that will interfere with oxygenation and ventilation.
DIF: Cognitive Level: Comprehension REF: p. 618
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn
management. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
382
11. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine
output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate
and treat the patient for:
a.
acute kidney injury.
b.
acute respiratory distress syndrome.
c.
intraabdominal hypertension.
d.
disseminated intravascular coagulation disorder.
ANS: C
Intraabdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or
edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased
urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid
resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but
not a tense abdomen. Disseminated intravascular disorder may present as a tense abdomen if there is active
bleeding, but it would not present with pulmonary symptoms.
DIF: Cognitive Level: Application REF: p. 639
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn
management. TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
12. An elderly individual from an assisted living facility presents with severe scald burns to the buttocks and
back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and
states that the bath water was too hot and that the patient sat in the water too long. What should the nurse do?
a.
Ask the caregiver at what temperature the water heater is set in the home.
b.
Ask the caregiver to step out while examining the patients burn injury.
c.
Immediately contact the police to report the suspected elder abuse.
d.
Ask the caregiver to describe exactly how the injury occurred.
ANS: B
In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired,
it is important to assess the injured patient separately from the caregiver. While obtaining safety information
on the temperature of the water heater is important, it is not a priority assessment question. The nurse should
follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may
include contacting the police or social services. Asking the caregiver to describe how the injury occurred is
important (e.g., there may be discrepancies in the physical assessment and reported mechanism of burn injury;
however, examining the patient away from the caregiver is a priority.
DIF: Cognitive Level: Application REF: p. 642
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
383
OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. Silver is used as an ingredient in many burn dressings because it:
a.
stimulates tissue granulation.
b.
is effective against a wide spectrum of wound pathogens.
c.
provides topical pain relief.
d.
stimulates wound healing.
ANS: B
Silver is an ingredient in many dressings because it helps prevent infection against a wide spectrum of
common pathogens. Silver does not stimulate tissue granulation; nor does it provide pain relief or stimulate
wound healing processes.
DIF: Cognitive Level: Comprehension REF: p. 645 | Table 20-4
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
14. The nurse understands that negative-pressure wound therapy may be used in the treatment of partialthickness burn wounds to do which of the following?
a.
Maintain a closed wound system to decrease the risk of infection.
b.
Remove excessive wound fluid and promote moist wound healing.
c.
Increase patient mobility with large burn wounds.
d.
Quantify wound drainage amount for more accurate output assessment.
ANS: B
Negative-pressure wound therapy can be used to treat grafts or partial-thickness burns by decompressing
edematous interstitial spaces that enhance local perfusion, optimizing wound healing. This therapy also
provides a moist wound-healing environment. The system is closed and may reduce the risk of infection but
may not prevent infection. Patients are less mobile because the system needs an electrical source to function.
Wound drainage is quantified by using the negative-pressure wound therapy system, but this is not a primary
indication for the therapy.
DIF: Cognitive Level: Comprehension REF: p. 646
OBJ: Formulate a plan of care for the patient with a burn injury.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
384
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. The nurse is caring for a patient with an electrical injury. The nurse understands that patients with electrical
injury are at a high risk for acute kidney injury secondary to:
a.
hypervolemia from burn resuscitation.
b.
increased incidence of ureteral stones.
c.
nephrotoxic antibiotics for prevention of infection.
d.
release of myoglobin from injured tissues.
ANS: D
Myoglobin is released during electrical injury and is a risk factor for rhabdomyolysis and acute kidney injury.
Hypervolemia is not a cause of acute kidney injury. Ureteral stones and nephrotoxic antibiotics may cause
acute kidney injury but is not associated with the electrical injury.
DIF: Cognitive Level: Comprehension REF: p. 636
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
16. The nurse is caring for a patient with a chemical burn injury. The priority nursing intervention is to:
a.
remove the patients clothes and flush the area with water.
b.
apply saline compresses.
c.
contact a poison control center for directions on neutralizing agents.
d.
remove all jewelry.
ANS: A
As long as the chemical remains in contact with the skin, burn damage will result. Priority interventions are to
remove the patients clothes, brush loose chemical away from the skin and apply water for at least 30 minutes.
Water needs to washed away from the body, not be applied as compresses. Contacting poison control may be
helpful in obtaining more information on the systemic effects of the chemical, but it is not a priority
intervention. Jewelry should be removed, but this is not as high a priority as removing the chemical and
stopping the chemical burning process through continuous flushing with water.
DIF: Cognitive Level: Application REF: p. 616, 632
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Implementation
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
385
MSC: NCLEX: Physiological Integrity
17. Patients with burns may have mesh grafts or sheet grafts. Which of the following sites is most likely to
have a sheet graft applied?
a.
Arm
b.
Face
c.
Leg
d.
Chest
ANS: B
A sheet graft is more likely to be used on the face and hands because the cosmetic effects are more optimal.
Meshed grafts are more commonly used elsewhere on the body (e.g., arm, leg, chest, etc.).
DIF: Cognitive Level: Comprehension REF: p. 649 | Table 20-6
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
18. The nurse is caring for a patient who has undergone skin grafting of the face and arms for burn wound
treatment. A primary nursing diagnosis is:
a.
altered nutrition, less than body requirements.
b.
body image disturbance.
c.
decreased cardiac output.
d.
fluid volume deficit.
ANS: B
Burns, scarring, and skin grafting can all affect appearance. Body image disturbances may result. Nutritional
support is started early in management of the patient with burns, and there is no indication that this patient has
a nutritional deficit. Nursing care plan priorities would also continue to focus on nutritional needs to optimize
healing. Decreased cardiac output and fluid volume deficit should not be priority concerns during the wound
closure phase of burn wound management by grafting.
DIF: Cognitive Level: Application REF: p. 650
OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
19. The nurse is assisting the patient to select foods from the menu that will promote wound healing. Which
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
386
statement indicates the nurses knowledge of nutritional goals?
a.
Avoid foods that have saturated fats. Fats interfere with the ability of the burn wound to heal.
b.
Choose foods that are high in protein, such as meat, eggs, and beans. These help the burns to heal.
c.
It is important to choose foods like bread and pasta that are high in carbohydrates. These foods will
give you energy and help you to heal faster.
d.
Select foods that have lots of fiber, such as whole grains and fruits. These will promote removal of
toxins from the body that interfere with healing.
ANS: B
Nutritional therapy must be instituted immediately after burn injury to meet the high metabolic demands of the
body. Oral diets should be high in calories and high in protein to meet the demands of the body.
DIF: Cognitive Level: Application REF: p. 650
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
20. A burn patient in the rehabilitation phase of injury is increasingly anxious and unable to sleep. The nurse
should consult with the provider to further assess the patient for:
a.
acute delirium.
b.
posttraumatic stress disorder.
c.
suicidal intentions.
d.
bipolar disorder.
ANS: B
Burn-injured patients experience psychologically devastating injuries in addition to physical injuries. Burn
patients that demonstrate changes in behavior, anxiety, insomnia, regression, and acting out should be
evaluated for posttraumatic stress disorder. Acute delirium is more likely to occur during the acute phase of
injury. Suicidal ideations should always be addressed if the patient expresses or shows signs of suicidal
thoughts. Burn-injured patients may have an underlying mental health disorder that requires treatment, such as
bipolar disorder or schizophrenia.
DIF: Cognitive Level: Application REF: pp. 650-651
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
21. The nurse is planning care to meet the patients pain management needs related to burn treatment. The
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
387
patient is alert, oriented, and follows commands. The pain is worse during the day when various treatments are
scheduled. Which statement to the physician best indicates the nurses knowledge of pain management for this
patient?
a.
Can we ask the music therapist to come by each morning to see if that will help the patients pain?
b.
The patients pain is often unrelieved. I suggest that we also add benzodiazepines to the opioids
around the clock.
c.
The patients pain is often unrelieved. It would be best if we can schedule the opioids around the
clock.
d.
The patients pain varies depending on the treatment given. Can we try patient-controlled analgesia
to see if that helps the patient better?
ANS: D
Patient-controlled analgesia allows the patient with burns to self-medicate for pain, thus providing
independence with pain management strategies. Nonpharmacological pain strategies may provide helpful
adjuncts to pain interventions. Scheduled pain medications and anxiolytic agents, although helpful, do not put
the control of pain management with the patient.
DIF: Cognitive Level: Application REF: pp. 642-643
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
22. The nurse is conducting an admission assessment of an 82-year-old patient who sustained a 12% burn from
spilling hot coffee on the hand and arm. Which statement is of priority to assist in planning treatment?
a.
Do you live alone?
b.
Do you have any drug or food allergies?
c.
Do you have a heart condition or heart failure?
d.
Have you had any surgeries?
ANS: C
Many variables influence the outcome of elderly burn patient mortality, including preinjury hydration status,
nutrition status, and comorbid diseases, especially heart failure. Assessment questions should include, as a
priority, information about the patients cardiovascular status, including heart failure. Obtaining food or drug
allergy information is also important along with other past medical history, including past surgeries.
Information on the patients living arrangements is an important safety consideration for discharge planning.
DIF: Cognitive Level: Application REF: p. 652
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
388
23. A 63-year-old patient is admitted with new onset fever; flulike symptoms; blisters over her arms, chest, and
neck; and red, painful, oral mucous membranes. The patient should be further evaluated for which possible
nonburn injured skin disorder?
a.
Toxic epidermal necrolysis
b.
Staphylococcal scalded skin syndrome
c.
Necrotizing soft tissue infection
d.
Graft versus host disease
ANS: A
Patients with toxic epidermal necrolysis, Stevens-Johnson Syndrome (SJS), and erythema multiforme present
with acute onset fever and flulike symptoms, with erythema and blisters developing within 24 to 96 hours, skin
and mucous membranes slough, resulting in a significant and painful partial-thickness injury. Staphylococcal
scalded skin syndrome presents predominantly in children. Necrotizing soft tissue infection results from
rapidly invasive bacterial infections. Graft versus host disease is not logical given the clinical information
provided.
DIF: Cognitive Level: Comprehension REF: pp. 652-653
OBJ: Review the anatomy and physiology of the integumentary system.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
24. A(An) ____________________ often produces a superficial cutaneous injury but may cause
cardiopulmonary arrest and transient but severe central nervous system deficits.
a.
chemical burn
b.
electrical burn
c.
heat burn
d.
infection
ANS: B
Tissue damage results from the conversion of electrical energy into heat. Monitor the patient for cardiac
dysrhythmias.
DIF: Cognitive Level: Comprehension REF: pp. 616-617
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
389
1. Which of the following statements about the pain management of a burn victim are true? (Select all that
apply.)
a.
Additional pain medication may be needed because of rapid body metabolism.
b.
Pain medication should be given before procedures such as debridement, dressing changes, and
physical therapy.
c.
Patients with a history of drug and alcohol abuse will require higher doses of pain medication.
d.
The intramuscular route is preferred for pain medication administration.
ANS: A, B, C
The rapid metabolism associated with burn injury may require additional pain medication. Many of the
procedures associated with burn wounds are painful, such as dressing changes. Adequate pain medication
should be given prior to the procedures. Edema in burned patients alters the absorption of medications that are
injected intramuscularly; therefore, drugs must be administered by the IV route.
DIF: Cognitive Level: Application REF: pp. 644-645
OBJ: Relate the nursing diagnoses, outcomes, and interventions for the burned patient.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. Which of the following factors increase the burn patients risk for venous thromboembolism? (Select all that
apply.)
a.
Burn injury less than 10%
b.
Bedrest
c.
Burns to lower extremities
d.
Electrical burn injury
e.
Delayed fluid resuscitation
ANS: B, C, E
Venous thromboembolism (VTE is a significant risk for patients who have thermal injury, venous stasis
associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and
hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use
of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk
for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.
DIF: Cognitive Level: Application REF: p. 638
OBJ: Formulate a plan of care for the patient with a burn injury.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
390
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a patient with burns to the hands, feet, and major joints. The nurse plans care to
include which of the following? (Select all that apply.)
a.
Applying splints that maintain the extremity in an extended position
b.
Implementing passive or active range-of-motion exercises
c.
Keeping the limbs as immobile as possible
d.
Wrapping fingers and toes individually with bandages
ANS: A, B, D
It is important to avoid immobility in patients with burns of the hands, feet, or major joints. Measures must be
taken to maintain the function of the hands, feet, and major joints. Nursing interventions to maintain range of
motion, applying splits to keep the extremities in a position of function, and individually wrapping fingers and
toes are necessary to maintain function of the hands, feet, and joints. Effective pain management is necessary
to encourage mobility.
DIF: Cognitive Level: Application REF: p. 641
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
4. Which of the following infection control strategies should the nurse implement to decrease the risk of
infection in the burn-injured patient? (Select all that apply.)
a.
Apply topical antibacterial wound ointments/dressings.
b.
Change indwelling urinary catheter every 7 days.
c.
Daily assess the need for central IV catheters.
d.
Restrict family visitation.
e.
Maintain strict aseptic technique during burn wound management.
ANS: A, C, E
Nurses can help reduce the risk of infection by using topical antibacterial wound ointments and dressings as
prescribed, daily questioning the need for invasive devices such as central IV access and indwelling urinary
catheters, and maintaining aseptic technique during all care provided to the patient. Changing the indwelling
urinary catheter will not reduce the risk of infection; wound care is achieved by aseptic technique; and
restricting family is not an intervention related to infection prevention.
DIF: Cognitive Level: Application REF: pp. 643-644
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of
burn
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
391
management. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. Which complications may manifest after an electrical injury? (Select all that apply.)
a.
Long bone fractures
b.
Cardiac dysrhythmias
c.
Hypertension
d.
Compartment syndrome of extremities
e.
Dark brown urine
f.
Peptic ulcer disease
g.
Acute cataract formation
h.
Seizures
ANS: A, B, D, E, G, H
Electrical injuries vary in severity of injury by the intensity of energy exposed to the body. Manifestations and
complications may include cardiac dysrhythmias or cardiopulmonary arrest, hypoxia, deep tissue necrosis,
rhabdomyolysis and acute kidney injury, compartment syndrome, long bone fractures, acute cataract
formation, and neurological deficits (including seizures). Hypertension and peptic ulcer disease are not direct
consequences of electrical burn injuries.
DIF: Cognitive Level: Application REF: Box 20-2
OBJ: Compare types of burn injuries. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. An autograft is used to optimally treat a partial- or full-thickness wound that: (Select all that apply.)
a.
involves a joint.
b.
involves the face, hands, or feet.
c.
is infected.
d.
requires more than 2 weeks for healing.
ANS: A, B, D
Autograft skin will allow for faster healing with less scar formation and a shorter hospitalization.
Test Bank - Introduction to Critical Care Nursing 7e (Sole 2016)
392
DIF: Cognitive Level: Comprehension REF: p. 647
OBJ: Formulate a plan of care for the patient with a burn injury.
TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
COMPLETION
1. The correct priority order of actions in prehospital primary survey for burn injuries is: _______________,
_______________, _______________, _______________. (Put a comma and space between each answer
choice.)
a. Assess ABCs and cervical spine.
b. Provide oxygen therapy if smoke inhalation is suspected.
c. Make rapid head-to-toe assessment to rule out additional trauma.
d. Stop the burning process and prevent further injury.
ANS:
D, A, B, C
Early care has a positive impact on recovery. The first priority is to stop the burning process and prevent
further injury. At this point, you initiate the primary survey, which is to assess the ABCs and cervical spine.
Oxygen therapy follows the ABCs. The secondary survey includes further assessment for additional injuries.
DIF: Cognitive Level: Analysis REF: p. 632
OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn
management. TOP: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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