Test Bank for Critical Care Nursing
9th Edition by Urden.
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Test Bank for Priorities in Critical Care Nursing, 9th
Edition, Linda D. Urden, Kathleen M. Stacy, Mary E.
Lough
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Chapter 01: Critical Care Nursing Practice
Urden: Critical Care Nursing, 9th
MULTIPLE
CHOICE
1. During World War II, what type of wards were developed to care for critically
injured patients?
a. Intensive care
b. Triage
c. Shock
d. Postoperative
ANS: C
During World War II, shock wards were established to care for critically injured patients.
Triage wards establish the order in which a patient is seen or treated upon arrival to a
hospital. Postoperative wards were developed in 1900 and later evolved into intensive care
units.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 1
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
2. What type of practitioner has a broad depth of specialty knowledge and expertise and
manages complex clinical and system issues?
Registered nurses
Advanced practice nurses
Clinical nurse leaders
Intensivists
a.
b.
c.
d.
ANS: B
Advanced practice nurses (APNs) have a broad depth of knowledge and expertise in their
specialty area and manage complex clinical and systems issues. Intensivists are medical
practitioners who manage the critical ill patient. Registered nurses (RNs) are generally
direct care providers. Clinical nurse leaders (CNLs) generally do not manage system
issues.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 2
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
3. What type of practitioner is instrumental in ensuring care that is evidence based and
that safety programs are in place?
a. Clinical nurse
specialist b. Advanced
practice nurse c.
Registered nurses
d. Nurse practitioners
ANS: A
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Clinical nurse specialists (CNSs) serve in specialty roles that use their clinical, teaching,
research, leadership, and consultative abilities. They are instrumental in ensuring that care
is evidence based and that safety programs are in place. Advanced practice nurses (APNs)
have
a broad depth of knowledge and expertise in their specialty area and manage complex
clinical and systems issues. Registered nurses are generally direct care providers. Nurse
practitioners (NPs) manage direct clinical care of groups of patients.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 2
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
4. Which professional organization administers critical care certification exams for
registered nurses?
State Board of Registered Nurses
National Association of Clinical Nurse Specialist
Society of Critical Care Medicine
American Association of Critical-Care Nurses
a.
b.
c.
d.
ANS: D
American Association of Critical-Care Nurses (AACN) administers certification exams
for registered nurses. The State Board of Registered Nurses (SBON) does not administer
certification exams. National Association of Clinical Nurse Specialists (NACNS) does
not administer certification exams. Society of Critical Care Medicine (SCCM) does not
administer nursing certification exams for registered nurses.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 3
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
5. Emphasis is on human integrity and stresses the theory that the body, mind, and spirit
are interdependent and inseparable. This statement describes which methodology of
care?
a. Holistic care
b. Individualized care
c. Cultural care
d. Interdisciplinary care
ANS: A
Holistic care focuses on human integrity and stresses that the body, mind, and spirit are
interdependent and inseparable. Individualized care recognizes the uniqueness of each
patient’s preferences, condition, and physiologic and psychosocial status. Cultural diversity
in
health care is not a new topic, but it is gaining emphasis and importance as the world
becomes more accessible to all as the result of increasing technologies and interfaces with
places and peoples. Interdisciplinary care is care among a variety of health care
professionals with the patient’s health as the common goal.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 4
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
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6. The American Association of Critical-Care Nurses (AACN) has developed short
directives that can be used as quick references for clinical use that are known as
a.
b.
c.
d.
Critical Care Protocol.
Practice Policies.
Evidence-Based Research.
Practice Alerts.
ANS: D
The American Association of Critical-Care Nurses (AACN) has promulgated several
evidence-based practice summaries in the form of “Practice Alerts.” Evidence-based
nursing practice considers the best research evidence on the care topic along with clinical
expertise of the nurse and patient preferences. Critical care protocol and practice policies
are established by individual institutions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 3
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
7. What type of therapy is an option to conventional treatment?
a. Alternative
b. Holistic
c. Complementary
d. Individualized
ANS: A
The term alternative denotes that a specific therapy is an option or alternative to what is
considered conventional treatment of a condition or state. The term complementary was
proposed to describe therapies that can be used to complement or support conventional
treatments. Holistic care focuses on human integrity and stresses that the body, mind,
and spirit are interdependent and inseparable. Individualized care recognizes the
uniqueness of each patient’s preferences, condition, and physiologic and psychosocial
status.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 4
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
8. Prayer, guided imagery, and massage are all examples of what type of treatment?
a. Alternative therapy
b. Holistic care
c. Complementary care
d. Individualized care
ANS: C
The term complementary was proposed to describe therapies that can be used to
complement or support conventional treatments. Spirituality, prayer, guided imagery,
massage, and animal- assisted therapy are all examples of complementary care. The term
alternative denotes that a specific therapy is an option or alternative to what is considered
conventional treatment of a condition or state. Holistic care focuses on human integrity and
stresses that the body, mind, and spirit are interdependent and inseparable. Individualized
care recognizes the uniqueness of each patient’s preferences, condition, and physiologic and
psychosocial status.
PTS: 1
DIF:
Cognitive Level: Understanding
REF: p. 4
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OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
9. What is the systematic decision-making model used by nurses termed?
a. Nursing diagnosis
b. Nursing interventions
c. Nursing evaluations
d. Nursing process
ANS: D
The nursing process is a systematic decision-making model that is cyclic, not linear. An
essential and distinguishing feature of any nursing diagnosis is that it describes a health
condition. Nursing interventions constitute the treatment approach to an identified
health alteration. Evaluation of attainment of the expected patient outcomes occurs
formally at intervals designated in the outcome criteria.
PTS: 1
DIF: Cognitive Level: Understanding
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
10. What is a health condition primarily resolved by nursing interventions or therapies called?
a. Nursing diagnosis
b. Nursing interventions
c. Nursing outcomes
d. Nursing process
ANS: A
An essential and distinguishing feature of any nursing diagnosis is that it describes a health
condition. Nursing interventions constitute the treatment approach to an identified health
alteration. Evaluation of attainment of the expected patient outcomes occurs formally at
intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.
PTS: 1
DIF: Cognitive Level: Remembering
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
11. Designing therapeutic activities that move a patient from one state of health to another is
an example of which of the following?
Nursing diagnosis
Nursing interventions
Nursing outcomes
Nursing process
a.
b.
c.
d.
ANS: B
Nursing interventions constitute the treatment approach to an identified health alteration.
An essential and distinguishing feature of any nursing diagnosis is that it describes a health
condition. Evaluation of attainment of the expected patient outcomes occurs formally at
intervals designated in the outcome criteria. The nursing process is a systematic decisionmaking model that is cyclic, not linear.
PTS: 1
DIF: Cognitive Level: Remembering
REF: n/a
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
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12. A patient was admitted to a rural critical care unit in Montana. Critical care nurses are
assisting with monitoring and care of the patient from the closest major city. What is this
type of practice termed?
a. Tele-nursing
b. Tele-ICU
c. Tele-informatics
d. Tele-hospital
ANS: B
Tele-ICU is a form of telemedicine. Telemedicine was initially used in outpatient areas,
remote rural geographic locations, and areas where there was a dearth of medical
providers. Currently, there are tele-ICUs in areas where there are limited resources
onsite. However, experts (critical care nurses, intensivists) are located in a central distant
site.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 5
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
13. Which core competency for interprofessional practice can be described as working with
individuals of other professions to maintain a climate of mutual respect and shared
values? a. Interprofessional teamwork and team-based care
b. Values and ethics for interprofessional practice
c. Interprofessional communication
d. Roles and responsibilities for collaborative practice
ANS: B
Values and ethics for interprofessional practice mean working with individuals of other
professions to maintain a climate of mutual respect and shared values. Roles and
responsibilities for collaborative practice include using knowledge of one’s own role and
the roles of other professions to appropriately assess and address the health care needs of
the patients and populations served. Interprofessional communication includes
communicating with patients, families, communities, and other health professionals in a
responsive and responsible manner that supports a team approach to maintaining health
and treatment of disease. Interprofessional teamwork and team-based care means applying
relationship- building values and principles of team dynamics to perform effectively in
different team roles
to plan and deliver patient population-centered care that is safe, timely, efficient, effective,
and equitable.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 5|Box 1-5
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
14. What is the stepwise decision-making flowchart for a specific care process
named?
a.
b.
c.
d.
Algorithm
Practice guideline
Protocol
Order set
ANS: A
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An algorithm is a stepwise decision-making flowchart for a specific care process or
processes. A practice guideline is usually created by an expert panel and developed by a
professional organization. Protocols are more directive and rigid than guidelines, and
providers are not supposed to vary from a protocol. An order set consists of preprinted
provider orders that are used to expedite the order process after a standard has been
validated through analytic review of practice and research.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 6
OBJ: Nursing Process Step: Intervention TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
15. Which nursing intervention continues to be one of the most error-prone for critical
care nurses?
a. Inappropriate care
b. Intimidating and disruptive clinician behavior
c. Injury to patients by falls
d. Medication administration
ANS: D
Medication administration continues to be one of the most error-prone nursing
interventions for critical care nurses. Intimidating and disruptive clinician behaviors can
lead to errors and preventable adverse patient outcomes. Patient safety has been described
as an ethical imperative and one that is inherent in health care professionals’ actions and
interpersonal processes; examples include inappropriate care and injury to patients by
falls.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 7
OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
16. A practitioner and nurse are performing a dressing change on an unresponsive patient in
room
14. The practitioner asks the nurse for an update on the patient in room 13. Which
action should the nurse take next?
a. Give the update to the practitioner.
b. Refuse to give the update because of Health Insurance Portability and
Accountability Act (HIPAA)
requirements.
c. Give the update because the is patient’s unconscious.
d. Refuse to give the update because of Occupational Safety and Health
Administration (OSHA) requirements.
ANS: B
Most specific to critical care clinicians is the privacy and confidentiality related to
protection of health care data. This has implications when interacting with family members
and others and the often very close work environments, tight working spaces, and
emergency situations. A patient’s unconscious state is not a reason for another patient’s care
to be discussed in his or her presence. Research shows hearing is the last sense to
deteriorate. Occupational Safety and Health Administration (OSHA) has to do with safety
in the workplace, not privacy and confidentiality.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 8
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
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=
MULTIPLE
RESPONSE
1. What considerations are taken into account in evidence-based nursing practice? (Select
all that apply.)
Clinical expertise of the nurse
Availability of staff and facility equipment
Research evidence on the topic
Patient knowledge of the disease
Patient preference regarding care
a.
b.
c.
d.
e.
ANS: A, C, E
Evidence-based nursing practice considers the best research evidence on the care topic
along with clinical expertise of the nurse and patient preferences. For instance, when
determining the frequency of vital sign measurement, the nurse would use available
research and nursing judgment (stability, complexity, predictability, vulnerability, and
resilience of the patient). Availability of staff and facility equipment and the patient’s
knowledge of the disease do not factor into evidence-based nursing practices.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 3
OBJ: Nursing Process Step: Assessment TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
2. The concept of diversity encompasses what thoughts and actions? (Select all that apply.)
a.
Sensitivity to ethnic
differences b.
Openness to
different lifestyles c. Openness to
different values
d. Reticence to different beliefs
e. Lack of concern regarding different opinions
ANS: A, B, C
Diversity includes not only ethnic sensitivity but also sensitivity to openness to
difference lifestyles, opinions, values, and beliefs. Reticence and lack of concern are not
part of the concept of diversity.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 4
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
3. According to American Association of Critical-Care Nurses, what are the responsibilities of
a critical care nurse? (Select all that apply.)
Respecting the values, beliefs, and rights of the patient
Intervening when the best interest of the patient is in question
Helping the patient obtain necessary care
Making decisions for the patient and patient’s family
Monitoring and safeguarding the quality of care the patient receives
Acting as a gatekeeper for the patient, the patient’s family, and other health
care professionals
a.
b.
c.
d.
e.
f.
ANS: A, B, C, E
American Association of Critical-Care Nurses (AACN) critical care nurse role
responsibilities include respecting the values, beliefs, and rights of the patient; intervening
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when the best interest of the patient is in question; helping the patient obtain necessary care;
and monitoring and safeguarding the quality of care the patient receives. The nurse is not to
make decisions
for the patient or the patient’s family but should support their decisions. The nurse should
act as a liaison, not a gatekeeper, for the patient and the patient’s family and other health
care professionals.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 2|Box 1-1
OBJ: Nursing Process Step: N/A
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
4. According to Kupperschmidt, what factors are needed to become a skilled
communicator? (Select all that apply.)
Becoming candid
Becoming reflective
Setting goals
Surveying the team
Becoming aware of self-deception
a.
b.
c.
d.
e.
ANS: A, B, E
Kupperschmidt and colleagues posed a five-factor model for becoming a skilled
communicator: becoming aware of self-deception, becoming authentic, becoming candid,
becoming mindful, and becoming reflective, all of which lead to being a skilled
communicator. The HWE model was offered by Blake, who suggested five steps: rallying
the
team, surveying the team, establishing work groups, setting goals and developing action
steps, and celebrating successes along the way.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 9
OBJ: Nursing Process Step: General
TOP: Critical Care Nursing Practice
MSC: NCLEX: Safe and Effective Care Environment
Chapter 02: Ethical
Issues
Urden: Critical Care Nursing, 9th EditionEdition
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MULTIPLE
CHOICE
1. What is the difference between ethics and morals?
a. Ethics is more concerned with the “why” of behavior.
b. Ethics provides a framework for evaluation of the behavior.
c. Ethics is broader in scope than morals.
d. Ethics concentrates on the right or wrong behavior based on religion and
culture values.
ANS: A
Ethics are concerned with the basis of the action rather than whether the action is right
or wrong, good or bad.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 12
2. A patient’s wife has been informed by the practitioner that her spouse has permanent
quadriplegia. The wife states that she does not want anyone to tell the patient about his
injury. The patient asks the nurse about what has happened. The nurse has conflicting
emotions about how to handle the situation. What is the nurse experiencing?
a. Autonomy
b. Moral distress
c. Moral doubt
d. Moral courage
ANS: B
The nurse has been placed in a situation initially causing moral distress and is struggling
with determining the ethically appropriate action to take. Moral courage is the freedom to
advocate for oneself, patients, and peers. Autonomy is an ethical principle. Moral doubt is
not part of the American Association of Critical-Care Nurses (AACN) framework. The 4A’s
to Rise
Above Moral Distress.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 12
3. By what action can critical care nurses can best enhance the principle of autonomy?
a. Presenting only the information to prevent relapse in a patient
b. Assisting with only tasks that cannot be done by the patient
c. Providing the patient with all of the information and facts
d. Guiding the patient toward the best choices for care
ANS: C
Patients and families must have all the information about a certain situation to make
an autonomous decision that is best for them.
PTS: 1
DIF:
Cognitive Level: Applying
REF: pp. 15-16
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
4. Which ethical principle is most important when soliciting informed consent from a patient?
a. Nonmaleficence
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b. Fidelity
c. Beneficence
d. Veracity
ANS: D
Veracity is important when soliciting informed consent because the patient needs to be
aware of all potential risks of and benefits to be derived from specific treatments or their
alternatives.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 15
5. The principle of respect for persons incorporates what additional
a.
b.
c.
d.
concepts?
Confidentiality and privacy
Truth and reflection
Autonomy and justice
Beneficence and nonmaleficence
ANS: A
Confidentiality of patient information and privacy in patient interactions must be
protected and honored by health care providers out of respect for persons. Confidentiality
is a right involving the sharing of patient information with only those involved in the
patient’s care. Privacy includes confidentiality but goes further to include the right to
privacy of person and personal space, such as ensuring that a patient is adequately
covered during a procedure.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 16
6. Which action best reflects the concept of beneficence within the critical care setting?
a. Advocating for equitable health care
b. Promoting for safe patient care
c. Ensuring equal access for those with the same condition or diagnosis
d. Confirming technologic advances are available to all in a given community
ANS: B
Advocating for patient safety is an example of beneficence. The other actions are examples
of justice.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 15|Box 2-2
7. Which statement best describes the concept of paternalism?
a. Encouraging the patient to ambulate after surgery
b. Demanding the patient get out of bed to sit in a chair
c. Following the patient’s advance directive despite family objections
d. Administering antibiotics for a viral infection
ANS: B
Encouraging the patient to ambulate after surgery is an example of beneficence. Demanding
the patient get out of bed to sit in a chair is an example of paternalism. Following the
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patient’s advance directive despite family objections is an example of autonomy.
Administering antibiotics for a viral infection is an example of physiologic futility.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 18
8. Which statement regarding the Code of Ethics for Nursing is
accurate?
a. The Code of Ethics for Nurses is usurped by state or federal laws.
b. It allows the nurse to focus on the good of society rather than the uniqueness of
the patient.
c. The Code of Ethics for Nurses was recently adopted by the American Nurses
Association.
d. It provides society with a set of expectations of the nursing profession.
ANS: D
The Code of Ethics for Nursing provides a framework for the nurse to follow in
ethical decision making and provides society with a set of expectations of the
profession.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 19
9. Ethical decisions are best made by performing which
a.
b.
c.
d.
action?
Following the guidelines of a framework or model
Having the patient discuss alternatives with the practitioner or nurse
Prioritizing the greatest good for the greatest number of persons
Studying by the Ethics Committee after all diagnostic data are reviewed
ANS: A
To facilitate the ethical decision-making process, a model or framework must be used so
that all involved will consistently and clearly examine the multiple ethical issues that arise
in critical care.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 20
10. What is the first step of the ethical decision-making
a.
b.
c.
d.
process?
Consulting with an authority
Identifying the health problem
Delineating the ethical problem from other types of problems
Identifying the patient as the primary decision maker
ANS: B
Step one involves identifying the major aspects of the patient’s medical and health
problems. Consulting an authority is not always necessary in the process. Delineating the
ethical problem from other types of problems may not be necessary. Identification of the
patient as primary decision maker is not part of the process.
PTS: 1
DIF:
Cognitive Level: Remembering
REF: p. 20
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OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
11. Truth-telling is an example of what ethical
a.
b.
c.
d.
principle?
Justice
Beneficence
Autonomy
Nonmaleficence
ANS: C
Truth telling is an example of autonomy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Psychosocial Integrity
REF: p. 15|Box 2-2
12. A practitioner is suggesting treatments to a patient that are contrary to the
patient’s preferences. What is this practice called?
Invaluable deficiency
Physiologic uselessness
Ethical futility
Situational insufficiency
a.
b.
c.
d.
ANS: C
Ethical futility is treatment that will not serve the underlying interests, values, and
preferences of the patient such as when a practitioner’s idea of benefit is contrary to the
values and preferences of the patient.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 18
13. Institutional ethics committees (IECs) review ethical cases that are problematic for
the practitioner. What is the major function of an IEC?
a. Consultation with purely binding recommendations
b. Support and education to health care providers
c. Conflict resolution for moral dilemmas
d. Recommendations that are binding in all cases
ANS: B
The Institutional Ethics Committee (IEC) can function in a variety of ways, serving as
consultants, providing education, and helping resolve ethical conflicts or dilemmas for
health care providers. Recommendations from the formal IEC may or may not be binding
and are relative to the situation at hand.
PTS: 1
DIF:
Cognitive Level: Remembering
REF: p. 22
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
14. Developing an organizational policy that supports unobstructed access to the ethics
committee by health care team members is one example of a proactive approach to dealing
with what issue?
a. Moral distress
b. Surrogate decision-makers
c. Paternalism
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d. Patient advocacy
ANS: A
Every organization must develop policies that support unobstructed access to resources
such as the ethics committees to mitigate the harmful effects of moral distress in the
pursuit of creating a healthy work environment.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: pp. 12-13|Box 2-1
15. A patient’s wife has been informed by the practitioner that her spouse has permanent
quadriplegia. The wife states that she does not want anyone to tell the patient about his
injury. The patient asks the nurse about what has happened. Based on which ethical
principles does the nurse answer the patient’s questions?
a. Veracity
b. Justice
c. Autonomy
d. Nonmaleficence
ANS: C
Autonomy is a freedom of choice or a self-determination that is a basic human right. It can
be experienced in all human life events.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: pp. 15-16
16. The nurse is using the SFNO approach to case analysis to facilitate ethical decision making.
What justification criteria may be used to help explain the reasons for selection of one
option over another?
a. Effectiveness
b. Usefulness
c. Legal ramifications
d. Economics
ANS: A
Justification criteria may be helpful in explaining the reasons for selecting one or two
options as superior. These include necessity, effectiveness, proportionality, least
infringement, and proper process. Usefulness, legal ramifications, and economics are not
part of the criteria.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
REF: p. 21|Box 2-8
MSC: NCLEX: Safe and Effective Care Environment
17. The nurse is using the SFNO approach to case analysis to facilitate ethical decision making.
Which question is important to ask when considering stakeholders?
Are there reasons to give priority to one stakeholder over another?
Will the stakeholders abide by the decision?
Will the stakeholders want to be present during the ethics consultation?
Do the stakeholders understand how to use the SFNO model?
a.
b.
c.
d.
ANS: A
In the SFNO model, questions about stakeholders include:
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• Who has a stake in the decision being made?
Why?
• Who will be significantly affected by the decision made? Why? Please be
specific.
• Are there reasons to give priority to one stakeholder over
another? The other questions are not relevant to this process.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: General
TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 21|Box 2-8
MULTIPLE RESPONSE
1. Which of the following is/are criteria for defining an ethical dilemma? (Select all that
apply.)
a. An awareness of different options
b. An issue in which only one viable option exists
c. The choice of one option compromises the option not chosen
d. An issue that has different options
ANS: A, C, D
The criteria for identifying an ethical dilemma are threefold: (1) an awareness of the
different options, (2) an issue that has different options, and (3) the choice of one option
over another compromises the option not chosen.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Ethics
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 21|Box 2-8
2. Which situations are early signs of an ethical dilemma? (Select all that apply.)
a. Disagreements among health care team members
b. Failure to discuss end-of-life issues with patient
c. Aggressive pain management
d. Belief that treatment is harmful
e. Following the patient’s advance directive despite family objections
f. Providing hope to the patient’s family
ANS: A, B, D
Disagreements among health care team members, failure to discuss end-of-life issues with
patient, and belief that treatment is harmful are early signs or indicators of an ethical
dilemma.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: General
TOP: Ethics
REF: p. 19|Box 2-5
MSC: NCLEX: Safe and Effective Care Environment
Chapter 03: Legal Issues
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE
CHOICE
1. What is the legal standard of care for a nurse's
actions?
a. Minimal competency under the state Nurse Practice Act
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b. The ability to distinguish what is right or wrong for the patient
c. The demonstration of satisfactory knowledge of policies and procedures
d. The care that an ordinary prudent nurse would perform under the
same circumstances
ANS: D
The legal standard of care for nurses is established by expert testimony and is generally
“the care that an ordinarily prudent nurse would perform under the same circumstances.”
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27
2. A patient is admitted with chest pain, and his electrocardiogram shows elevated ST
segments.
The nurse bases her plan of care on the nursing diagnosis of pneumonia. What type
of negligence may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: B
Basing nursing care on an erroneous diagnosis is a failure in planning. Standards of care
include assessment, the collection of relevant data pertinent to the patient’s health or
situation; diagnosis, analysis of the assessment data in determining diagnosis and care
issues; implementation, coordinating care delivery and plan and using strategies to promote
health
and a safe environment; and evaluation, evaluation of the progress of the patient
toward attaining outcomes.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 27|p. 30|Box 3-3
3. What is an injury resulting from the failure to meet an ordinary duty called?
a.
Negligence b.
Malpractice
c. Assault
d. Battery
ANS: A
Injury resulting from the failure to meet an ordinary duty or standard of care is
negligence. Malpractice is a specialized form of negligence. Assault and battery are
examples of intentional acts.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: pp. 27-28
4. A night nurse is notified by the laboratory that the patient has a critical magnesium level of
1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not notify the
practitioner because of the patient’s code status. In doing so, the nurse is negligent for
what? a. Failure to analyze the level of care needed by the patient
b. Failure to respect the patient’s wishes
c. Wrongful death
d. Failure to take appropriate action
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ANS: D
Nurses caring for acutely and critically ill patients must appropriately notify physicians of
situations warranting treatment actions. Furthermore, the full no-code, do-not-resuscitate
order does not exclude this patient from receiving treatment to correct the critical
laboratory value. Failure to take appropriate action in cases involving acutely and
critically ill patients
has included not only physician-notification issues but also failure to follow physician
orders, failure to properly treat, and failure to appropriately administer medication.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 28-29
OBJ: Nursing Process Step: Assessment | Nursing Process Step: Implementation
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
5. Two nurses are talking about a patient’s condition in the cafeteria. In doing so, these
nurses could be accused of what?
Failure to take appropriate action
Failure to timely communicate patient findings
Failure to preserve patient privacy
Failure to document patient information
a.
b.
c.
d.
ANS: C
Nurses have a duty to preserve patient privacy, and failure to do so is a breach of patient
confidentiality and failure to preserve patient privacy. Nurses should also refrain from
having discussions about specific patients with anyone except other health care
professionals involved in the care of the patient. When discussing specific patients with
other health care professionals, it is imperative that patient-specific discussions occur in
non-public settings. Discussions about specific patients are never appropriate in public
areas such as elevators, cafeterias, gift shops, and parking lots.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 31
6. What is negligence called when it applies to an individual who is a
professional?
a.
b.
c.
d.
Breach
Malpractice
Duty
Harm
ANS: B
Whereas negligence claims may apply to anyone, malpractice requires the alleged
wrongdoer to have special standing as a professional. If a nurse caring for acutely and
critically ill
patients is accused of failing to act in a manner consistent with the standard of care, that
nurse is subject to liability for professional malpractice (negligence applied to a
professional).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 28
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7.
A nurse fails to recognize an intubated patient’s need for suctioning. The endotracheal
tube becomes clogged, and the patient has a respiratory arrest. What type of negligence
may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: A
Nurses have a duty to assess and analyze the care required by each patient they care for.
Failure to do so puts the nurse at risk for negligence related to failure to assess the
patient’s needs.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
8. What element of malpractice is based on the existence of a nurse–patient relationship?
a. Duty
b. Breach
c. Damages
d. Harm caused by the breach
ANS: A
Duty to the injured party is the first element of a malpractice case and is premised on the
existence of a nurse–patient relationship. Breach is failure to act consistently within
applicable standards of care. Harm caused by the breach occurs when the patient sustained
injuries because of the breach of duty. Damages are derived from the harm or injury
sustained by the acutely or critically ill patient and are calculated as a dollar amount.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 28
9. A patient is getting heparin by intravenous infusion. The nurse received an order to
increase the heparin infusion rate and obtain a partial thromboplastin time (PTT) in 1 hour.
The PTT was drawn correctly and revealed a critically elevated level. The nurse was busy
with another patient and failed to report the critical result to the physician within 30
minutes according to the facility’s policy. Subsequently, the patient sustained a massive
intracerebral bleed. What type of negligence may be present?
a. Assessment failure
b. Planning failure
c. Implementation failure
d. Evaluation failure
ANS: C
Failure to communicate and document patient findings in a timely manner is a form of
failure to implement appropriate action.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
10. On the way to surgery, a patient expresses doubt about proceeding with the planned
procedure. The patient states that the doctor did not explain it very well and she would like
to talk to her again before starting the procedure. The nurse knows the surgery schedule is
very tight, reassures the patient that everything will be all right, and administers the
preoperative sedation. This scenario describes what possible type of negligence?
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a.
b.
c.
d.
Assessment failure
Planning failure
Implementation failure
Evaluation failure
ANS: D
The nurse has a duty to act as a patient advocate, in this case by holding the preoperative
sedation until the doctor and the patient can speak and the patient is satisfied that she has
the necessary information to make this decision.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 31
11. Which statement is accurate regarding a nurse’s job description?
a. As long as the nurse follows the American Nurses Association Standards of
Care, the job description is irrelevant in a negligence allegation.
b. Job descriptions must be reflective of the accepted standard of care.
c. Institution-specific job descriptions are not legally acceptable.
d. Job descriptions should be vague in describing nursing functions to avoid claims
of negligence.
ANS: B
Although job descriptions can be institution specific, they should be reflective of the
national and community standards of care. Job descriptions are based on professional
accountability as outlined by state boards of nursing and standards of practice.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 29
12. The ability to practice as a licensed professional nurse is a privilege granted by what entity?
a. Employee contract
b. State legislature
c. State boards of nursing
d. Congress
ANS:
B
The very ability to practice as a licensed professional nurse is a privilege granted by the
state and is a function of each state’s authority to promote and protect the health and welfare
of its citizens. State boards of nursing (BON) are administrative bodies created by—and that
operate under—state statutes, or more generally written state laws created by state
legislatures and signed by the governor. In turn, the BONs develop more specific rules (or
regulations) for obtaining and maintaining licensure.
PTS: 1
DIF: Cognitive Level: Understanding
24
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC:
NCLEX: Safe and Effective Care
Environment
REF: p.
13. Why is restraining a competent patient against his or her wishes considered an
intentional tort?
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a. The nurse did not document the patient’s need for restraints.
b.
The nurse failed to get a physician’s order for
restraints.
c.
The nurse touched the patient in an unauthorized
manner.
d. The nurse do not inform the patient that the restraints were needed.
ANS:
C
Assault and battery are examples of intentional torts that are frequently brought against health
care providers. Battery occurs if the health care professional actually touches the patient in
an unauthorized manner. The act of restraining a patient without consent is battery.
PTS: 1
DIF: Cognitive Level: Understanding
32
OBJ:
Nursing Process Step: Intervention
TOP:
Legal
MSC:
NCLEX: Safe and Effective Care
Environment
REF: p.
14. What is the best action a nurse could take to prevent allegations of malpractice?
a.
Carrying malpractice
insurance
b.
Clarifying orders with the nursing
supervisor
c.
Delegating care to nursing
assistants
d.
Providing care according to standards of
practice
ANS:
D
Maintaining standards of practice is the best way to reduce risk. The hallmark of risk
reduction is knowledge of the professional standards of care, delivery and documentation
of that care, and consistent demonstration that the standards are met. Nurses caring for
acutely and critically ill patients may be alleged to have acted in a manner that is
inconsistent with standards of care or standards of professional practice and may find
themselves involved in civil litigation that focuses in whole or in part on the alleged
failure.
PTS: 1
DIF: Cognitive Level: Understanding
24
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC:
NCLEX: Safe and Effective Care
Environment
REF: p.
15. While participating in rounds, a nurse is interrupted by the wife of a ventilated patient,
who informs the nurse that her husband is having difficulty breathing. The patient is
found to be disconnected from the ventilator and unresponsive when the nurse enters the
room after rounds. The alarm mode on the ventilator had been turned off. This situation
an example of what legal situation?
a.
Assault
b.
Battery
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c.
Injury
d. Malpractice
ANS: D
All four elements of negligence are present: duty and standard of care, breach of duty,
causation, and injury. If a nurse caring for acutely and critically ill patients is accused of
failing to act in a manner consistent with the standard of care, that nurse is subject to
liability for professional malpractice (negligence applied to a professional). Assault occurs
if the patient fears harmful or offensive touching. Battery is any intentional act that brings
about actual harmful or offensive contact with the plaintiff.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: pp. 27-28
16. After admission a patient shares with the nurse a concern that her adult children will not
be able to reach agreement on what to do if she is no longer able to make decisions for
herself. The nurse informs the patient that it is possible to grant authority to one person to
make decision through which mechanism?
a. Court-appointed guardian
b. Do-not-resuscitate order
c. Durable power of attorney for health care
d. Living will
ANS: C
A durable power of attorney for health care includes legally binding documents that allow
individuals to specify a variety of preferences, particular treatments he or she wants to
avoid, and circumstances in which he or she wishes to avoid them. The durable power of
attorney for health care is a directive through which a patient designates an “agent,”
someone who will make decisions for the patient if the patient becomes unable to do so. A
living will specifies that if certain circumstances occur, such as terminal illness, the patient
will decline specific treatments, such as cardiopulmonary resuscitation and mechanical
ventilation.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 36
17. In which situation did the nurse disregard the patient’s right to privacy?
a. Informing the physician that the patient was verbalizing suicidal thoughts
b. Notifying the health department of a patient’s tuberculosis diagnosis
c. Reporting possible dependent-adult abuse to the police
d. Warning a visitor to wear gloves when giving a back rub because the patient is HIV
positi
ve
ANS: D
Telling a visitor of the patient’s HIV status violated the patient’s right to privacy. The
nurse could have ensured the visitor’s safety by providing gloves and explaining
universal precautions.
PTS: 1
DIF:
Cognitive Level: Analyzing
REF: p. 31
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
18. Which statement best describes the definition of
assault?
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a.
b.
c.
d.
An intentional act that causes the patient to believe that harm may have been done
A statement that causes injury to the patient’s standing in the community
Negligence that results in harm to a spousal relationship
An intentional act that brings about harm or offensive contact with the patient
ANS: A
Assault occurs if the patient fears harmful or offensive touching. Battery is defined as
an intentional act that brings about harm or offensive contact with the patient.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 32
19. During transport to the operating room for mitral valve replacement, a patient with a
signed consent form says that she does not want to go through with the surgery and asks to
be returned to her room. What is the best response from the nurse?
a. “The operating room is prepared; let’s not keep the surgeon waiting.”
b. “You have the right to cancel surgery, but it could be weeks before you
are rescheduled.”
c. “You sound frightened; tell me what you are thinking.”
d. “Your preoperative medications will have you feeling more relaxed in a minute;
it will be OK.”
ANS: C
The patient has the right to withdraw consent at any time. The nurse must listen and
then clarify whether that is really what the patient desires. If it is, the surgeon should
then be notified.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 34
20. Which situation would be considered a failure of proper implementation?
a. Not identifying and analyzing symptoms appropriately
b. Not documenting the patient’s response to pain medication
c. Not recognizing a malfunctioning chest tube
d. Not asking the patient about code or no code wishes
ANS: B
Nurses caring for acutely and critically ill patients are required not only to take appropriate
action but also to accurately document their findings, interventions performed, and patients’
response to those interventions. Failure to thoroughly and accurately document any aspect
of care gives rise to negligence causes of action.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
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21. Which agency is responsible for maintaining the expectations and limits of nursing practice?
a. State Hospital Association
b. Court system
c. State Board of Nursing
d. State Department of Health
ANS: C
State Boards of Nursing (SBONs) maintain expectations for and limits of nursing practice
in each state through the licensure of nurses and also through challenges to non-nurses
engaged in professional activities that intrude upon the nursing scope of practice.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 24
OBJ: Nursing Process Step: N/A
TOP: Nurse Practice Act
MSC: NCLEX: Safe and Effective Care Environment
22. A nurse providing care for a patient with a recent tracheostomy notes the presence of an
ulceration or wound at the tracheotomy site. The nature of the ulceration or wound clearly
indicates it has been present for at least several days. The nurse finds no documentation
regarding the ulceration or wound since the insertion of the tracheostomy tube 12 days
earlier. This situation an example of what legal situations?
a. Assessment and implementation failure
b. Failure to appropriately diagnose
c. Failure to follow practitioners orders
d. Planning and evaluation failure
ANS: A
This situation is an example of the prior nurses’ failure to assess and implement
appropriately. Assessment and implementation failures are related to a failure to assess and
analyze a care need, communicate findings to a physician, take appropriate action, and
document.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: N/A
TOP: Legal
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 30
23. The patient received a blood transfusion based on test results of critically low hemoglobin.
The nurse records vital signs (VS) per hospital protocol. One hour after the transfusion
was started, the nurse records VS as temperature (T) 102F, pulse (P) 110, respirations (R)
24, blood pressure (BP) 136/88. The nurse continues to administer the blood. This
situation an example of what legal situation?
a. Malpractice
b.
Assault
c.
Battery
d. Libel
ANS: A
To avoid liability associated with administration of blood and blood products, nurses must
carefully follow organizational procedures and protocols that govern these interventions.
Battery is any intentional act that brings about actual harmful or offensive contact with the
plaintiff. Assault occurs if the patient fears harmful or offensive touching. Libel is defined
as publishing false statements that are damaging to a person’s reputation.
PTS: 1
DIF:
Cognitive Level: Analyzing
REF: pp. 33-34
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OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. What elements or criteria must be present for negligence cases to go forward? (Select all
that apply.)
a. Duty to another person
b. Acknowledgement of wrong doing
c. Harm that would not have occurred in the absence of the breach
d. Breach of duty
e. Damages that have a monetary value
ANS: A, C, D, E
There are four criteria or elements for all negligence cases: (1) duty to another person; (2)
breach of that duty; (3) harm that would not have occurred in the absence of the breach
(causation); and (4) damages that have a monetary value. All four elements must be
satisfied for a case to go forward. Acknowledgement of wrong doing is not required.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
REF: pp. 27-28
2. Which actions by a nurse demonstrate the act of battery? (Select all that
apply.)
a. Performing cardiopulmonary resuscitation (CPR) on a patient with a dob.
c.
d.
e.
not- resuscitate (DNR) order
Threatening to punch someone
Sexual misconduct with a patient
Drawing blood without the patient’s consent
Threatening to restrain a patient for not using his or her call light for
mobility assistance
ANS: A, C, D
Battery is any intentional act that brings about actual harmful or offensive contact with the
plaintiff. Battery occurs if the health care professional actually touches the patient in an
unauthorized manner. Assault occurs if the patient fears harmful or offensive touching.
Assault may be alleged if the patient was aware that he or she was going to be touched in a
manner not authorized by informed consent. Threatening to punch someone and threatening
to restrain a patient for not using his or her call light for mobility assistance are examples of
assault.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Legal Issues
MSC: NCLEX: Safe and Effective Care Environment
REF: p. 32
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Chapter 04: Genetic
Issues
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE
CHOICE
1. What is a genetic variant that exists in greater than 1% of the population termed?
a. Genetic mutation
b. Genetic polymorphism
c. Genetic deletion
d. Tandem repeat
ANS: B
When a genetic variant occurs frequently and is present in 1% or more of the population, it
is described as a genetic polymorphism. The term genetic mutation refers to a change in the
DNA genetic sequence that can be inherited that occurs in less than 1% of the population.
Genetic material in the chromosome can also be deleted and new information from another
chromosome can be inserted or can be a tandem repeat (multiple repeats of the same
sequence).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 43
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
2. Which type of genetic disorder occurs when there is an interaction between genetic
and environmental factors such as that which occurs with type 2 diabetes?
Chromosome
Mitochondrial
Multifactorial disorders
Allele dysfunction
a.
b.
c.
d.
ANS: C
In multifactorial disorders there is an interaction between vulnerable genes and the
environment. Cardiovascular atherosclerotic diseases and type 2 diabetes are examples of
multifactorial disorders that result from an interaction of genetic and environmental
factors.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 46
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
3. Prader-Willi syndrome (PWS) is a rare genetic disorder in which genes on chromosome
15 (q11.2-13) are deleted. What type of disorder is PWS?
a. Chromosome disorder
b. Mitochondrial
disorder c. Complex
gene disorder d.
Multifactorial disorder
ANS: A
Prader-Willi syndrome (PWS) is a chromosome disorder as a result of several missing genes
on chromosome 15. In chromosome disorders, the entire chromosome or very large
segments of the chromosome are damaged, missing, duplicated, or otherwise altered.
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PTS: 1
DIF: Cognitive Level: Applying
REF: p. 45
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
4. A family pedigree is used to determine whether a disease has a genetic component. What
does a proband indicate in a family pedigree?
The disease being mother related or father related
The first person in the family who was diagnosed with the disorder
Who in the family is the xy band
The disease genotype including locus
a.
b.
c.
d.
ANS: B
For nurses, it is important to ask questions that elucidate which family members are affected
versus those who are unaffected and then to identify the individuals who may carry the
gene in question but who do not have symptoms (carriers). The proband is the name given
to the
first person diagnosed in the family pedigree. Homozygous versus heterozygous determines
if the disorder is carried by a gene from one or both parents. The xy band determines if the
disorder is carried through the sex genes. A disease locus is the genetic address of the
disorder.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 46
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
5. Philadelphia translocation is a specific chromosomal abnormality that occurs
from a reciprocal translocation between chromosomes 9 and 22, where parts of
these two chromosomes switch places. This abnormality is associated with which
disease?
a. Hemophilia A
b. Chronic myelogenous leukemia
c. Obesity
d. Marfan syndrome
ANS: B
Philadelphia chromosome or Philadelphia translocation is a specific chromosomal
abnormality associated with chronic myelogenous leukemia. It occurs from a reciprocal
translocation between chromosomes 9 and 22, where parts of these two chromosomes
switch places. Hemophilia A is a sex-linked inheritance. Obesity is being studied with the
FTO gene on chromosome 16. Marfan syndrome is classified as a single-gene disorder.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 42
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
6. What was the goal of the Human Genome
a.
b.
c.
d.
Project?
Identifying haplotype tags
Exposing untaggable SNPs and recombination hot spots
Producing a catalog of human genome variation
Mapping all the human genes
ANS: D
The Human Genome Project was a huge international collaborative project that began in
1990 with the goal of making a map of all the human genes (the genome). The final genome
sequence was published in 2003. The HapMap project was to identify haplotype tags. The
Genome-Wide Association Studies was used to expose untaggable SNPs and recombination
hot spots. The 1000 Genomes project was used to map all the human genes.
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PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 49
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
7. The patient is placed under general anesthesia for a carotid endarterectomy. During the
surgery, the patient develops muscle contracture with skeletal muscle rigidity, acidosis,
and elevated temperature. What is a possible cause for malignant hyperthermia?
a. Polymorphism in RYR1 at chromosome 19q13.1
b. Variant in the VKOR1 gene
c. Variant in the cytochrome P450 enzyme CYP2C9 gene
d. Halothane overdose
ANS: A
Individuals with polymorphisms in the ryanodine receptor gene (RYR1) at chromosome
19q13.1 are at risk of a rare pharmacogenetic condition known as malignant hyperthermia.
In affected individuals, exposure to inhalation anesthetics and depolarizing muscle
relaxants during general anesthesia induces life-threatening muscle contracture with
skeletal muscle rigidity, acidosis, and elevated temperature. Warfarin is being researched as
a variant in the VKOR1 gene and in the cytochrome P450 enzyme CYP2C9 gene.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 53|Box 4-3
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
8. What is the study of heredity particularly as it relates to the transfer heritable
physical characteristics called?
a.
Chromatids
b.
Karyotype c.
Genetics
d. Histones
ANS: C
Genetics refers to the study of heredity, particularly as it relates to the ability of individual
genes to transfer heritable physical characteristics. Each somatic chromosome, also called
an autosome, is made of two strands, called chromatids, which are joined near the center.
A karyotype is the arrangement of human chromosomes from largest to smallest. A
specialized class of proteins called histones organizes the double-stranded DNA into what
looks like a tightly coiled telephone cord.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 54
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
9. Each chromosome consists of an unbroken strand of DNA inside the nucleus of the cell.
What is the arrangement of human chromosomes termed?
a.
Chromatids
b.
Karyotype c.
Genomics
d. Histones
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ANS: B
A karyotype is the arrangement of human chromosomes from largest to smallest. Each
somatic chromosome, also called an autosome, is made of two strands, called chromatids,
which are joined near the center. Genomics refers to the study of all of the genetic material
within cells and encompasses the environmental interaction and impact on biologic and
physical characteristics. A specialized class of proteins called histones organizes the doublestranded DNA into what looks like a tightly coiled telephone cord.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 39
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
10. What is the study of all the genetic material within the cell and its impact on biologic
and physical characteristics called?
a.
Chromatids
b.
Karyotype c.
Genomics
d. Histones
ANS: C
Genomics refers to the study of all of the genetic material within cells and encompasses the
environmental interaction and impact on biologic and physical characteristics. Each
somatic chromosome, also called an autosome, is made of two strands, called chromatids,
which are joined near the center. A karyotype is the arrangement of human chromosomes
from largest to smallest. A specialized class of proteins called histones organizes the
double-stranded DNA into what looks like a tightly coiled telephone cord.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 39
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
11. A specialized class of proteins that organizes the double-stranded DNA into what looks
like a tightly coiled telephone cord is known which of the following?
a.
Chromatids
b.
Karyotype c.
Genomics
d. Histones
ANS: D
A specialized class of proteins called histones organizes the double-stranded DNA into
what looks like a tightly coiled telephone cord. Genomics refers to the study of all of the
genetic material within cells and encompasses the environmental interaction and impact
on biologic and physical characteristics. Each somatic chromosome, also called an
autosome, is made of two strands, called chromatids, which are joined near the center. A
karyotype is the arrangement of human chromosomes from largest to smallest.
PTS: 1
DIF:
Cognitive Level: Remembering
REF: p. 39
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
12. To achieve a consistent distance across the width of the DNA strand, the nucleotide
base guanine (G) can only be paired with what other genetic material?
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a.
Adenine
b.
(A)
Thymine (T) c.
Cytosine (C)
d. Sex chromosome X
ANS: C
Four nucleotide bases—adenine (A), thymine (T), guanine (G), and cytosine (C)—comprise
the “letters” in the genetic DNA “alphabet.” The bases in the double helix are paired T with
A and G with C. The nucleotide bases are designed so that only G can pair with C and only
T can pair with A to achieve a consistent distance across the width of the DNA strand. The
TA and GC combinations are known as base pairs.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 40
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
13. Why are monozygotic twins separated at birth used to study the effects of genetics
versus environment?
They share an identical genome.
They have different sex chromosomes.
They have mirror chromosomes.
They have identical health issues.
a.
b.
c.
d.
ANS: A
Studies of identical twins offer a unique opportunity to investigate the association of
genetics, environment, and health. Identical twins are monozygotic and share an identical
genome. Monozygotic twins are the same sex. Studies occur much less frequently today
because tremendous efforts are made to keep siblings together when they are adopted.
Genetics can be stable in a study group, but the environment and health issues are dynamic
even in a
controlled study group.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 48
OBJ: Nursing Process Step: General
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
14. The process that is used to make polypeptide chains that constitute proteins can be written
as:
a. RNA
DNA protein.
b.
DNA
RNA
protein. c. Protein RNA
DNA. d.
Protein
DNA
RNA.
ANS: B
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The nucleotides A, T, C, and G can be thought of as “letters” of a genetic alphabet that are
combined into three-letter “words” that are transcribed (written) by the intermediary of
ribonucleic acid (RNA). The RNA translates the three-letter words into the amino acids
used to make the polypeptide chains that constitute proteins. This process may be written
as DNA
RNA protein.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 41
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
15. What are the studies called that are done on large, extended families who have several
family members affected with a rare disease?
Genetic association
Genetic epidemiology
Kinships
Phenotypes
a.
b.
c.
d.
ANS: C
In genetic epidemiologic research of a rare disease, it can be a challenge to find enough
people to study. One method is to work with large, extended families, known as kinships,
which have several family members affected with the disease. Genetic association studies
are usually conducted in large, unrelated groups based on demonstration of a phenotype
(disease trait or symptoms) and associated genotype. Genetic epidemiology represents the
fusion of epidemiologic studies and genetic and genomic research methods. Phenotypes are
different at different stages of a disease and are influenced by medications, environmental
factors, and gene–gene interaction.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 48
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
16. What is an example of direct-to-consumer genomic testing?
a. Genetic testing through amniocentesis
b. Paternity testing from buccal swabs of the child and father
c. Biopsy of a lump for cancer
d. Drug testing using hair follicles
ANS: B
An example of direct-to-consumer testing is paternity testing from buccal swabs of the
child and father. Genetic testing can be done through biopsies and amniocentesis, but they
are performed in a facility by a medical professional. Drug testing and genomic testing are
two different tests and are unrelated.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 53
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
17. What was the Genetic Information Nondiscrimination Act (GINA) of 2008 designed
to prevent from happening?
a. Abuse of genetic information in employment and health insurance decisions
b. Genetic counselors from reporting results to the health insurance companies
c. Mandatory genetics testing of all individuals with certain diseases
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d. Information sharing between biobanks that are studying the same genetic disorders
ANS: A
The Genetic Information Nondiscrimination Act (GINA) of 2008 is an essential piece of
legislation designed to prevent abuse of genetic information in employment and health
insurance decisions in the United States. One of the paramount concerns in the genomic era
is to protect the privacy of individuals’ unique genetic information. Many countries have
established biobanks as repositories of genetic material, and many tissue samples are stored
in medical center tissue banks. Some people who may be at risk for a disorder disease will
not be tested because they fear that a positive result may affect their employability. GINA
also mandates that genetic information about an individual and his or her family has the
same protections as health information.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 53
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which patients would be candidates for genetic testing for long QT syndrome
(LQTS)? (Select all that apply.)
Patients with prolonged QT interval during a cardiac and genetic work-up
Family history of positive genotype and negative phenotype
Patients diagnosed with torsades de pointes
Family history of sudden cardiac death
Family history of bleeding disorders
Family history of obesity
a.
b.
c.
d.
e.
f.
ANS: A, B, C, D
Clinical genetic testing is available for long QT syndrome (LQTS). Genetic testing is very
helpful within families of patients with LQTS. If the family member has a prolonged QTc
interval, the reasonable assumption during the cardiac and genetic work-up is that the
person has the mutation. It is also important to test family members with normal QTc
intervals because up to 50% have “concealed” LQTS, meaning they have a positive
genotype and negative phenotype (normal QT on the resting ECG). This is because of a
genetic concept termed penetrance, in which the same gene does not have the same
phenotypic effect on
everyone who is affected. If a person carries the genetic mutation but has a normal QT
interval at rest, he or she may still be vulnerable during exercise or physiologic stress.
Frequently patients are identified after a syncopal episode, a life-threatening dysrhythmia
such as torsades de pointes, or sudden cardiac death. Hemophilia A and B are associated
with bleeding disorders. The FTO gene is associated with obesity.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 51
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
2. Which disorders are classified as a single-gene disorder? (Select all that
apply.)
a. Down syndrome
b. Marfan syndrome
c. Cystic fibrosis
d. Type 2 diabetes
e. Sickle cell disease
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f.
Cardiovascular atherosclerotic diseases
ANS: B, C, E
Cystic fibrosis, sickle cell disease, hemophilia A, and Marfan syndrome are examples of
single-gene disorders. Down syndrome is a chromosome disorder (extra chromosome 21),
and cardiovascular atherosclerotic disease and type 2 diabetes are examples of complex
gene disorders that result from an interaction of genetic and environmental factors.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: pp. 45-46
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
3. Hemophilia A is an inherited disease. Which statements would be determined by the
family pedigree regarding hemophilia A? (Select all that apply.)
It is an X-linked disorder.
Sons have a 50% chance of having hemophilia.
It is a Y-linked disorder.
Daughters have a 50% chance of being a carrier of the trait.
Sons have a 25% chance of having hemophilia.
Daughters have a 50% chance of having hemophilia.
a.
b.
c.
d.
e.
f.
ANS: A, B, D
In an X-linked disorder, each son has a 50% chance of having the disorder and each daughter
has a 50% chance of being a carrier. In a family pedigree, the absence of direct male-tomale transmission makes this condition identifiable as an X-linked disorder.
PTS: 1
DIF: Cognitive Level: Evaluating
REF: p. 46
OBJ: Nursing Process Step: Diagnosis
TOP: Genetics in Critical Care
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 05: Sleep Alterations
Test Bank
MULTIPLE
CHOICE
1. Which stage of NREM sleep is associated with anabolic processes?
a.
N1 b.
N2 c.
N3 d.
N4
ANS: C
In stage N3 sleep, slow waves continue to develop until 50% of the EEG waveforms are
slow wave. This stage of sleep is often referred to as slow-wave sleep. The release of other
hormones, such as prolactin and testosterone, suggests that anabolism occurs during the
slow- wave sleep of stage N3. N1 sleep is a transitional, lighter sleep state from which the
patient can be easily aroused by light touch or by softly calling his or her name. Stage N2
sleep occupies about 45% to 55% of the night, with sleep deepening and a higher arousal
threshold being required to awaken the patient. N4 sleep does not exist.
2. What occurs physiologically during REM sleep?
a. Growth hormone is secreted.
b. Metabolic needs are decreased.
c. Sympathetic nervous system predominates.
d. Heart rate and blood pressure decrease.
ANS: C
The sympathetic nervous system predominates during REM sleep. Oxygen consumption
increases, and cardiac output, blood pressure, heart rate, and respiratory rate may become
erratic. NREM sleep is dominated by parasympathetic nervous system. Blood pressure,
heart and respiratory rates, and the metabolic rate return to basal levels. About 80% of total
daily growth stimulating hormone is released in NREM sleep.
3. Interventions to help with circadian synchronization include
a. opening the window blinds.
b. encouraging the patient to take frequent naps during the day.
c. administering sedatives at bedtime.
d. keeping the patient awake during the early morning hours.
ANS: A
Nursing interventions that maintain normal rhythm of the day–night cycle, such as
opening window blinds, should be encouraged.
4. The patient has been in the critical care unit for 3 weeks and has been on an intra-aortic
balloon pump for the past 3 days. The patient’s condition has been serious, and hourly
assessments and vital signs have been necessary. The nursing staff has noted that the
patient has been unable to achieve sleep for more than 30 minutes at a time. The patient
has been given diazepam (Valium) prn. The anticipated effect of diazepam on the
patient’s sleep is
a. a decrease in NREM stage 1.
b. an increase in NREM stage 3.
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c. total NREM suppression.
d. REM suppression in larger doses.
ANS: D
Diazepam increases NREM stage 1 and reduces NREM stages 3 and REM. REM
suppression is dose related.
5. The patient has been in the critical care unit for 3 weeks and has been on the intra-aortic
balloon pump for the past 3 days. The patient’s condition has been serious, and hourly
assessments and vital signs have been necessary. The nursing staff has noted that the
patient has been unable to achieve sleep for more than 30 minutes at a time. The patient
has been given diazepam (Valium) prn. Which techniques may assist in assessing the
patient’s sleep pattern?
a. Correlating sleep time with vital signs
b. Documenting sleep periods of more than 90 minutes
c. Assessing degree of arousal on hourly checks
d. Observing the length of NREM sleep periods
ANS: B
Keeping a sleep chart for 48 to 72 hours and documenting sleep periods greater than 90
minutes, the number and length of awakenings, and the total possible sleep time can
help assess sleep patterns in the critical care unit.
6. Where are EMG leads placed to detect muscle atonia?
a. Scalp
b. Intercostal
c. Anterior tibialis
d. Chin
ANS: D
Electromyography involves leads placed over various muscle groups. When placed over the
chin, the leads can help detect muscle atonia associated with REM sleep. Intercostal leads
detect respiratory effort, and leads over the anterior tibialis detect leg movements that may
be causing the patient to arouse. Electroencephalographic electrodes are attached to the
patient’s scalp to measure brain waves.
7. Hypnotic benzodiazepines
a. promote deeper sleep stages.
b. can produce prolonged effects in older adults.
c. are metabolized more rapidly in the presence of steroids.
d. enhance short-term recall.
ANS: B
Hypnotic benzodiazepines have a high lipophilicity, resulting in increased half-life in older
adults. They also promote lighter sleep stages, are potentiated by steroids, and cause
memory failure.
8. Which of the following patients would the nurse most strongly suspect of having
obstructive sleep apnea?
a. A severely obese woman with diabetes
b. A moderately obese man who snores
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c. A nonobese woman with hypertension
d. A severely obese man with renal dysfunction
ANS: B
Obesity associated with snoring is a hallmark of obstructive sleep apnea.
9. Which of the following older patients demonstrates changes in sleep patterns attributable
to central sleep apnea?
A patient who wakes up two to three times per night and is tired during the day
A patient who reports sleeping less soundly and not feeling rested
A patient who consistently awakens at 4 AM and goes to bed at 7 PM
A patient who has irregular respiration during sleep and whose inspiratory
muscles intermittently fail
a.
b.
c.
d.
ANS: D
Inspiratory muscle paralysis is a symptom of central sleep apnea. The other answers are
associated with lifestyle habits that should be modified or changed to enhance sleep
hygiene.
10. Sleep deprivation can result from which of the following?
a. CPAP machine use
b. Mechanical ventilation
c. Use of nonbenzodiazepine short-acting hypnotics
d. Use of analgesic medications to control pain
ANS: B
Not surprisingly, mechanical ventilation and the required care associated with it contribute
to sleep disturbances. CPAP treats the obstruction and the snoring, choking, and gasping
that accompany it, and it provides cardiovascular benefits. Hypnotics and analgesic
medications may aid sleep. Nurses have a responsibility to administer these medications in
the most efficient manner to promote sleep and to monitor effectiveness.
11. During a sleep study, which of the following groups of information are gathered?
a. Airflow, snoring, and tonsil size
b. Electroencephalogram, electrocardiogram, and end-tidal carbon dioxide
c. Oxygen saturation, number of arousals, and airflow
d. Frequency of awakenings, REM speed, and apnea–hypopnea index
ANS: C
Polysomnography is used to determine the number and length of apnea episodes and
sleep stages, number of arousals, airflow, respiratory effort, and oxygen desaturation.
12. A patient with mild obstructive sleep apnea (OSA) can expect treatment to consist of
a. medical management with protriptyline.
b. weight loss, elimination of alcohol before bedtime, and side sleeping.
c. immediate use of continuous positive airway pressure (CPAP).
d. surgical intervention with uvulopalatopharyngoplasty (UPPP).
ANS: B
For patients with mild OSA (apnea–hypopnea index of 5 to 10), weight loss, sleeping on the
side (if apnea is associated with sleeping on the back), avoidance of sedative medications
and alcohol before bedtime, and avoidance of sleep deprivation may be all that is necessary.
CPAP would be the next treatment choice.
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13. The primary determinant in the efficacy of CPAP in patients with OSA is
a. compliance.
b. weight.
c. tonsil size.
d. respiratory effort.
ANS: A
CPAP, although the treatment of choice, is effective only if the patient is compliant
with therapy. Regular attendance at CPAP clinics can improve patient compliance.
14. A patient was given the diagnosis of congestive heart failure (CHF) 2 years ago. The patient
complains of increased daytime sleepiness and states his support system has been
complaining more and more about snoring. Central sleep apnea is suspected. Treatment
depends on
whether the patient has hypercapnic or nonhypercapnic central sleep apnea. Which of
the following indicates a diagnosis of nonhypercapnic central sleep apnea (CSA)?
a. Polysomnography with absence of airflow for at least 5 seconds
b. Apnea–hypopnea index of 10
c. Peripheral edema, polycythemia, and obesity
d. Insomnia, awakenings accompanied by choking, and normal body mass index
ANS: D
Nonhypercapnic central sleep apnea characteristics include daytime sleepiness, insomnia
or poor sleep, mild or intermittent snoring, and awakenings accompanied by choking or
feeling short of breath; frequently, patients are of normal body weight. CSA can be seen
on polysomnography as an absence of airflow and respiratory effort for at least 10
seconds.
15. A patient was given the diagnosis of congestive heart failure (CHF) 2 years ago. The patient
complains of increased daytime sleepiness and states his support system has been
complaining more and more about snoring. Central sleep apnea is suspected. Treatment
depends on
whether the patient has hypercapnic or nonhypercapnic central sleep apnea. The
patient’s primary treatment plan should include
a. CPAP.
b.
bilevel positive airway pressure
(BiPAP). c.
acetazolamide and
medroxyprogesterone. d. modafinil and
zolpidem.
ANS: A
One treatment for the nonhypercapnic or heart failure patients is nasal CPAP, which also
may provide a beneficial cardiovascular effect. Nocturnal oxygen supplementation may be
effective as well. If CPAP is not tolerated, pharmacologic management may be tried.
16.
a.
b.
c.
d.
is a diagnostic test used to determine sleep disturbances.
Electrooculography
Electromyography
Electroencephalography
Polysomnography
ANS: D
Polysomnography uses electroencephalography, electrooculography, myography,
and electrocardiography to assess the quality of sleep.
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17.
a.
b.
c.
d.
is used during polysomnography to determine when the patient enters REM sleep.
Electrooculography
Electromyography
Electroencephalography
Polysomnography
ANS: A
Electrooculography is used during polysomnography to determine when the patient enters
REM sleep.
18.
a.
b.
c.
d.
is the external element that has the most significant effect on circadian rhythms.
Lower body temperature
Light
Melatonin cycle
Background noise
ANS: B
Light is the external element that has the most significant effect on circadian rhythms.
Lower body temperature and melatonin cycles are internal elements that help with the
sleep–wake cycle. Background noise can influence the circadian rhythms but not as
significantly as light.
19. Sleep disturbance in critically ill patients is defined as insufficient duration or stages of
sleep that results in
less sleep that promotes recovery.
discomfort and interferes with quality of life.
adaptation of the environment to promote sleep.
more sleep that promotes recovery.
a.
b.
c.
d.
ANS: B
Sleep disturbance in critically ill patients is defined as insufficient duration or stages of
sleep that result in discomfort and interferes with quality of life. When ill, most people
need more sleep than usual, and sleep seems to promote recovery.
20. Identify the usual cycle of sleep onset.
a. NR1, NR2, NR3, NR2, REM
b. NR1, NR2, NR3, REM
c. NR1, NR2, NR3, NR1, REM
d. NR1, NR2, NR3, REM, NR3
ANS: A
Sleep onset usually occurs in stage 1 sleep, progressing through stages 2 and 3 and then
going back to stage 2, at which time the person usually enters REM.
21. REM sleep comprises what percent of the sleep cycle?
a.
70% to
75% b. 45%
to 65% c.
15% to 20% d.
20% to 25%
ANS: D
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NREM sleep usually occupies 70% to 75% of the sleep cycle, with REM sleep comprising
20% to 25%.
22. A sufficient amount of sleep has been achieved when a person
a.
b.
c.
d.
awakens
after 8 to 10 hours of uninterrupted sleep.
with external stimuli and gets through the day without feeling sleepy.
without external stimuli and gets through the day without feeling sleepy.
feeling rested in the morning and takes a nap in the afternoon.
ANS: C
A sufficient amount of sleep has been achieved when one awakens without external stimuli
and gets through the day without feeling sleepy. The amount of sleep required is uncertain.
No set number of hours has been established.
MULTIPLE
RESPONSE
1. Which of the following occur during REM sleep stages? (Select all that
a.
b.
c.
d.
e.
apply.)
Vital signs remain at basal levels.
Dreams occur.
Myocardial infarction often occurs.
Sweating or shivering is common.
Growth hormone is released.
ANS: B, C
The sympathetic nervous system predominates during REM sleep. Vital signs remain at
basal levels, sweating or shivering commonly occurs with extreme temperature changes,
and releases of growth hormone are parasympathetic nervous system responses.
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Chapter 06: Nutritional
Alterations
Test Bank
MULTIPLE
CHOICE
1. A patient with poorly controlled diabetes mellitus is to be started on enteral tube feeding.
What type of formula would be most appropriate?
Whole proteins and glucose polymers
Concentrated in calories
Low sodium
High fat, low carbohydrate
a.
b.
c.
d.
ANS: D
Individuals with diabetes mellitus whose blood sugar is poorly controlled with standard
formulas should be given a glucose intolerance formula that is high in fat and low in
carbohydrate. High protein is associated with polymeric formulas. Concentrated calories
is associated with renal failure. Low sodium is associated with hepatic failure.
2. Most of the energy produced from carbohydrate metabolism is used to form what substance?
a. Galactose
b. Glycogen
c. Adenosine triphosphate
d. Antibodies
ANS: C
Most of the energy produced from carbohydrate metabolism is used to form adenosine
triphosphate (ATP), the principal form of immediately available energy within all body
cells. One gram of carbohydrate provides approximately 4 kcal of energy. Through the
process of digestion, carbohydrates are broken down into glucose, fructose, and galactose.
Antibodies are produced through the immune system.
3. A patient has a new order for intermittent nasogastric feedings every 4 hours. The
nasogastric tube is placed by the nurse. The best method for confirming the placement of
the tube before feeding would be to
a. obtain radiography of the abdomen.
b. check the pH of fluid aspirated from the tube.
c. auscultate the left upper quadrant of the abdomen while injecting air into the tube.
d. auscultate the right upper quadrant of the abdomen while injecting air into the tube.
ANS: A
After the tube has been placed, correct location must be confirmed before feedings are
started and regularly throughout the course of enteral feedings. Radiographs are the most
accurate way of assessing tube placement.
4. A person with a BMI of 28 would be considered
a. obese.
b. overweight or pre-obese.
c. of normal weight.
d. underweight.
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ANS: B
A body mass index between 25 and 30 is considered overweight or pre-obese. The other
BMIs are underweight = 2; normal = 18.5 to 24.99 kg/m2; overweight = ?5=25 kg/m2; preobese =
25 to 29.99 kg/m2; obese class I = 30 to 34.99 kg/m2; obese class II = 35 to 39.99 kg/m2;
and obese class III = ?5=40 kg/m2.
5. Diet therapy for a person with hypertension 1 day after a myocardial infarction would
include
a. three meals a day with two snacks.
b. a low-protein diet.
c. a low-salt, low-cholesterol diet.
d. a high-carbohydrate diet.
ANS: C
Because fluid accompanies sodium, limitation of sodium is necessary to reduce fluid
retention. Specific interventions include limiting salt intake, usually to 2 g a day or less,
and limiting fluid intake because appropriate meal size, caffeine intake, and food
temperatures are some of the dietary factors that are of concern. Small, frequent snacks are
preferable to larger meals for patients with severe myocardial compromise or postprandial
angina.
6. Two types of protein-caloric malnutrition are kwashiorkor and marasmus. Kwashiorkor
results in
weight loss and muscle wasting.
low levels of serum proteins, low lymphocyte count, and hair loss.
elevated serum albumin and increased creatinine excretion in the urine.
hyperpigmentation and a hard, easily palpated liver margin.
a.
b.
c.
d.
ANS: B
Kwashiorkor results in low levels of serum proteins, low lymphocyte count, low
immunity and edema from low plasma oncotic pressure, and hair loss. Marasmus is
recognizable by weight loss, loss of subcutaneous fat, and muscle wasting.
7. The patient history plays an important role in assessing the patient’s nutritional status.
Significant laboratory and clinical findings in the patient with cardiovascular disease include
low levels of high-density lipoprotein (HDL) cholesterol and transferrin.
elevated low-density lipoprotein (LDL) cholesterol and decreased subcutaneous fat.
elevated sodium levels and a soft, fatty liver on palpation.
normal triglyceride levels and the presence of S3 on auscultation.
a.
b.
c.
d.
ANS: B
Laboratory and clinical findings in patients with cardiovascular disease include elevated
total cholesterol and triglycerides as well as cardiac cachexia (muscle and subcutaneous
fat wasting).
8. Proteins serve the function of
a. maintaining osmotic
pressure. b. providing minerals
in the body. c. maintaining
blood glucose.
d. providing a stored source of energy.
ANS: A
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Proteins are the basis for lean body mass and are important for chemical reactions,
transportation of other substances, preservation of immune function, and maintenance
of osmotic pressure (albumin) and blood neutrality (buffers) in the body. Carbohydrates
help with maintaining osmotic pressure, gluconeogenesis, and providing minerals to the
body. Lipids provide source of energy.
9. The loss of exocrine function of pancreatitis results
in
a.
b.
c.
d.
anorexia.
obesity.
malabsorption.
hyperglycemia.
ANS: C
The loss of exocrine function leads to malabsorption and steatorrhea. In chronic
pancreatitis, the loss of endocrine function results in impaired glucose intolerance. Anorexia
is the result of an inability to eat or not eating. Obesity would result from consuming more
than the RDA of calories based on one’s body type.
10. Obtaining height and weight measurements for the critically ill patient
a. should be deferred until the medical condition stabilizes.
b. should be measured rather than obtained through patient or family report.
c. requires consistent weights in pounds.
d. requires weight, but height can be deferred.
ANS: B
Height and current weight are essential anthropometric measurements that should be
measured rather than obtained through patient or family report. The most important reason
for obtaining anthropometric measurements is to detect changes in the measurements over
time (e.g., response to nutritional therapy). Weight is measured in kilograms and height in
meters. BMI values are independent of age and gender and are used for assessing health
risk.
11. A patient on mechanical ventilation is receiving total parenteral nutrition (TPN). Which of
the following is true?
Excessive calorie intake can cause an increase in PaCO2.
The patient’s head should remain elevated at 45 degrees to avoid aspiration.
Lipid intake should be maintained at greater than 2 g/kg/day.
TPN is preferred over the use of enteral feeding to avoid the complication
of aspiration.
a.
b.
c.
d.
ANS: A
Excessive calorie intake can raise PaCO2 sufficiently to make it difficult to wean a
patient from the ventilator. A balanced regimen with both lipids and carbohydrates
providing the nonprotein calories is optimal for patients with respiratory compromise,
and these patients need to be reassessed continually to ensure that caloric intake is not
excessive.
12. A primary nutritional intervention for hypertension is
a. decreasing carbohydrates.
b. limiting salt.
c. increasing protein.
d. increasing fluids.
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ANS: B
For hypertensive cardiac disease, sodium chloride restriction is recommended.
Some individuals are more salt sensitive than others, and this salt sensitivity
contributes to hypertension.
13. Patients with coronary artery disease should be taught about cholesterol. Which situation
is most desirable?
Low levels of HDL
cholesterol b.
Low levels of
c.
LDL
cholesterol
Hypocholesterolemia
d. Low levels of both HDL and LDL cholesterol
a.
ANS: B
Interventions for patients with coronary artery disease are geared toward lowering the LDL
cholesterol to desirable levels.
14. An effect of malnutrition on respiratory function is
a. decreased surfactant.
b. increased vital capacity.
c. decreased PaCO2.
d. tachypnea.
ANS: A
Malnutrition has extremely adverse effects on respiratory function, decreasing both
surfactant production and vital capacity. Excessive lipid intake can impair capillary gas
exchange in the lungs, although this is not usually sufficient to produce an increase in
PaCO2 or decrease in PaO2; this results in decreased respiratory function.
15. What is the rationale for careful intake and output for patients with pulmonary alterations?
a. Fluid retention occurs with tachypnea.
b. Hemodilution may cause deleterious hypernatremia.
c. Fluid volume excess can lead to right-sided heart failure.
d. Excessive fluid losses may lead to dehydration and hypovolemic shock.
ANS: C
Pulmonary edema and failure of the right side of the heart may result from fluid
volume excess, which can further worsen the status of patients with respiratory
compromise.
16. A patient who has sustained a head injury has increased nutritional needs related to the
a. decrease in metabolism as a result of coma.
b. decrease in blood sugar from a lack of dietary supplementation.
c. anabolism and wound healing.
d. hypermetabolism and catabolism associated with the injury.
ANS: D
Patients with neurologic alterations have increased needs because of hypermetabolism
and catabolism after head injury. Poor food intake is related to altered state of
consciousness, dysphagia or other chewing or swallowing difficulties, or ileus resulting
from spinal cord injury or use of pentobarbital.
17. The patient is receiving corticosteroid treatment for neurologic alterations. The nurse
should assess the patient for episodes of
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a.
b.
c.
d.
hyponatremia.
hyperalbuminemia.
hyperkalemia.
hyperglycemia.
ANS: D
Hyperglycemia is a common complication in patients receiving corticosteroids. Needs
for protein and calories are increased by infection and fever, as may occur in the patient
with encephalitis or meningitis. Needs for protein, calories, zinc, and vitamin C are
increased during wound healing, as occurs in trauma patients and patients with pressure
ulcers.
18. Which of the following nutritional interventions is a priority for the patient with renal
disease who is receiving dialysis?
Increase fluids to replace losses.
Encourage potassium-rich foods to replace losses.
Ensure an adequate amount of protein to prevent catabolism.
Limit all nutrients to account for altered renal excretion.
a.
b.
c.
d.
ANS: C
Proteins and amino acids are removed during peritoneal dialysis, creating a greater
nutritional requirement for protein. The renal patient must receive an adequate amount of
protein to prevent catabolism of body tissues to meet energy needs. Approximately 1.5 to
2.0 g protein/kg/day is required. Certain nutrients such as potassium and phosphorus are
restricted because they are excreted by the kidney. The patient has no specific requirement
for the fat- soluble vitamins A, E, and K because they are not removed in appreciable
amounts by dialysis, and restriction generally prevents development of toxicity.
19. Prevention of pulmonary aspiration is best accomplished
a.
b.
c.
d.
by
administering intermittent feedings.
adding thickening agents to the tube feeding solution.
suctioning the patient hourly.
elevating the head of the bed 30 to 45 degrees.
ANS: D
To reduce the risk of pulmonary aspiration during enteral tube feeding, keep the patient’s
head elevated at least 30 to 45 degrees during feedings unless contraindicated.
20. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic
failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and
TPN is started. For which of the following complications should the patient be evaluated
immediately after insertion of the catheter?
a. Pneumothorax
b. Hypoglycemia
c. Central venous thrombosis
d. Pulmonary aspiration
ANS: A
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Central vein TPN carries an increased risk of sepsis as well as potential insertion-related
complications such as pneumothorax and hemothorax. Repeated traumatic catheterizations
are most likely to result in thrombosis. To prevent hypoglycemia, administer oral
carbohydrates or an IV bolus of dextrose. Elevate the head of bed 30 to 45 degrees to
prevent pulmonary aspiration after the infusion has begun.
21. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic
failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and
TPN is started. On the third day of infusion, the patient develops symptoms of fever and
chills. Which of the following complications should be suspected?
a. Air embolism
b. Pneumothorax
c. Central venous thrombosis
d. Catheter-related sepsis
ANS: D
Because TPN requires an indwelling catheter in a central vein, it carries an increased risk
for sepsis and potential insertion-related complications such as pneumothorax and
hemothorax. Signs and symptoms of catheter-related sepsis include fever, chills, glucose
intolerance, and positive blood cultures. Air embolism is also more likely with central
vein TPN.
22. A patient is admitted to the critical care unit with severe malnutrition as a result of hepatic
failure. A triple-lumen central venous catheter is placed in the right subclavian vein, and
TPN is started. Which of the following dietary restrictions should be maintained for the
patient?
a. Fat and magnesium
b. Protein and sodium
c. Carbohydrate and potassium
d. Protein and calcium
ANS: B
Protein should be restricted because it contributes to the development of encephalopathy;
sodium should be restricted because it contributes to the development of edema. Release of
lipids from their storage depots is accelerated, but the liver has decreased ability to
metabolize them for energy. Moreover, inadequate production of bile salts by the liver
results in malabsorption of fat from the diet.
23. Which of the following medical interventions may be initiated with the onset
of hyperglycemia?
Discontinuing the infusion
Adding insulin to the TPN
Weaning from the TPN over a 6-hour period
Starting an infusion of 0.9% normal saline
a.
b.
c.
d.
ANS: B
One method for controlling hyperglycemia in a patient receiving TPN is to add insulin to
the infusion. Rapid cessation of TPN may not lead to hypoglycemia; however, tapering the
infusion over 2 to 4 hours is recommended. Slow advancement of the rate of TPN (25
mL/hr) to the goal rate allows pancreatic adjustment to the dextrose load.
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24. A patient is mechanically ventilated and is receiving enteral nutrition via a nasogastric tube.
To help ensure feeding tolerance, the nurse checks residual volumes every 4 hours.
During a residual check later in the shift, the nurse aspirates a total residual volume of
350 mL. The nurse will
a. stop the tube feeding, wait 1 hour, and recheck the residual.
b. discontinue the feeding tube and tube feeding and call the physician for TPN
orders.
c. continue the tube feeding, if no other gastrointestinal symptoms exist, and
reassess the patient with the next residual check.
d. continue the tube feeding and place the patient in the left lateral decubitus
position to facilitate gastric emptying.
ANS: C
There is little evidence to support a correlation between gastric residual volumes and
tolerance to feedings, gastric emptying, and potential aspiration. Except in selected highrisk patients, there is little evidence to support holding tube feedings in patients with gastric
residual volumes less than 400 mL.
25. A tracheostomy patient is experiencing regurgitation of tube feeding formula. The nurse’s
first priority should be
a. checking to make sure the tracheostomy cuff is inflated during tube feedings.
b. placing the patient in the right lateral decubitus position to promote
gastric emptying.
c. discussing the use of metoclopramide to facilitate gastric motility with
the physician.
d. placing the patient in prone position to improve draining from mouth.
ANS: A
When regurgitation of formula is an issue, the following interventions can be used as
appropriate: keep the cuff of the endotracheal or tracheostomy tube inflated during feedings
to prevent aspiration; elevate the head to 30 to 45 degrees during feedings unless
contraindicated; if head cannot be raised, position the patient in the right lateral position
or prone position to improve drainage of vomitus from the mouth; and consider giving
metoclopramide to improve gastric emptying.
26. The patient’s feeding tube is occluded and cannot be flushed. The nurse knows that the
best irrigant for feeding tube occlusion is
a. cola.
b. pancreatic enzyme.
c. water.
d. juice.
ANS: C
Although cranberry juice or cola beverages are sometimes used to reduce the incidence
of tube occlusion, water is the preferred irrigant because it has been shown to be
superior in maintaining tube patency.
27. The nutritional alteration most frequently encountered in hospitalized patients is
a. respiratory quotient (RQ).
b. protein-calorie malnutrition.
c. fat-calorie malnutrition.
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d. gluconeogenesis.
ANS: B
The nutritional alteration most frequently encountered in the hospitalized patient is proteincalorie malnutrition. The respiratory quotient (RQ) is equal to the VCO2 divided by the
VO2. Fat, protein, and carbohydrates each have a unique RQ; thus, RQ identifies which
substrate is being preferentially metabolized and may provide target goals for calorie
replacement. This process of manufacturing glucose from nonglucose precursors is called
gluconeogenesis. Gluconeogenesis is carried out at all times, but it becomes especially
important in maintaining a source of glucose in times of increased physiologic need and
limited supply. Fat is used as a source of energy.
28. Sodium and fluid restrictions ordered for the patient with heart failure are primarily aimed
at reducing
a. use of medications.
b. weight.
c. cardiac workload.
d. serum lipids.
ANS: C
Myocardial infarction, nutrition interventions, and education are designed to reduce
angina, cardiac workload, and the risk of dysrhythmia. Sodium restriction applies in the
treatment of patients with heart failure because water follows sodium. Fluids should be
restricted to 1500 to 2000 mL/day. Weight is an anthropometric measurement and is a
long-term goal. Serum lipids is a biochemical data and is a long-term goal. Medications
are used to control fluid levels in the body and prevention of angina and dysrhythmia.
MULTIPLE
RESPONSE
1. Which of the following signs would alert the nurse to possible nutritional alterations?
(Select all that apply.)
Impaired wound healing
Edema
Nail growth
Muscle atrophy
diaphoresis
a.
b.
c.
d.
e.
ANS: A, B, D
Impaired wound healing, edema, and muscle wasting atrophy are indicative of impaired
nutrition. Nail growth would indicate normal caloric intake. Diaphoresis refers to
sweating and is indicated with exercising and infection.
2. A patient was admitted with ESRD and on hemodialysis. Which of the following
elements should be restricted? (Select all that apply.)
Fluid
Protein
Carbohydrates
Fats
Phosphorus
a.
b.
c.
d.
e.
ANS: A, B, E
The kidneys are responsible for the balance of fluids, protein, and other nutrients. When the
kidneys are functioning suboptimally, dietary intake of those substances must be restricted.
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Chapter 07: Gerontological Alterations
Test Bank
MULTIPLE
CHOICE
1. A 68-year-old patient has been admitted to the coronary care unit after an inferior
myocardial infarction. Age-related changes in myocardial pumping ability may be
evidenced by
a. increased contractility.
b. decreased contractility.
c. decreased left ventricle afterload.
d. increased cardiac output.
ANS: B
Collagen is the principal noncontractile protein occupying the cardiac interstitium.
Because myocardial collagen content increases with age, increased myocardial collagen
content
renders the myocardium less compliant and may be responsible for increased loading of
blood vessels.
2. Age-related pulmonary changes that may affect this patient include
a. increased tidal volumes.
b. weakening of intercostal muscles and the diaphragm.
c. improved cough reflex.
d. decreased sensation of the glottis.
ANS: B
Respiratory muscle function is affected by skeletal muscle and peripheral muscle
strength. During aging, skeletal muscle progressively atrophies, and its energy
metabolism decreases, which may partially explain the declining strength of the
respiratory muscles.
3. A 68-year-old patient has been admitted to the coronary care unit after an inferior
myocardial infarction. Dopamine 3 mcg/kg/min has been ordered for this patient. What
nursing implications should be considered when administering this drug to an older patient?
a. No changes are noted in older patients with this drug.
b. Drug effect is enhanced by increased receptor site action.
c. Increased breakdown by liver hepatocytes occurs, increasing dosage requirements.
d. Drug metabolism and detoxification are slowed, increasing the risks of
drug toxicity.
ANS: D
Reduced drug-metabolizing capacity is caused by a decline in activity of the drugmetabolizing enzyme system, microsomal ethanol oxidizing system, and decrease in total
liver blood flow. Medications that depend on the cytochrome P450 group of liver enzymes
are most affected because age-associated changes cause as much as a 50% decline in
enzymatic function.
4. A 68-year-old patient has been admitted to the coronary care unit after an inferior
myocardial infarction. When caring for this patient, the nurse will give increased attention
to skin
integrity because of the
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a. thickening of the epidermal skin layer.
b. loss of sebaceous glands.
c. increased fragility from loss of protective subcutaneous layers.
d. decreased melanocyte production.
ANS: C
Ecchymotic areas may be seen because of decreased protective subcutaneous tissue layers,
increased capillary fragility, and flattening of the capillary bed, predisposing older adults to
developing ecchymoses. Medications and physiologic factors may result in an augmented
bleeding tendency and appearance of ecchymotic areas; nevertheless, consideration should
be given to the possibility of older adult abuse if ecchymosis is widespread or in unusual
areas.
5. An older patient is admitted to the hospital with an acute onset of mental changes and
recent falls. The nurse knows that the most common cause of mental changes is
a. hypoxia.
b. infection.
c. cerebrovascular accident.
d. electrolyte imbalance.
ANS: B
Some slight memory dysfunction is common with increasing age, but a significant decline
may represent a change in individual need and may be a result of acute or chronic
conditions. Acute mental status changes caused by infection, metabolic imbalances, or
medications are usually reversible after identification and treatment.
6. A nurse is teaching an older patient about the signs and symptoms of a myocardial
infarction.
Which statement by the patient would indicate that the teaching was effective?
a. “The pain in my chest may last a long time.”
b. “I will feel like I have an elephant sitting on the center of my chest.”
c. “The chest pain will be sharp and over the center of my chest.”
d. “The pain may not be severe and may not be in my chest.”
ANS: D
Myocardial infarction in older adults is often associated with ST-segment depression
rather than ST elevation. Sensation of chest pain may be altered and may be less intense
and of shorter duration. Other atypical symptoms may include dyspnea, confusion, and
failure to thrive, which results in unrecognized signs and symptoms of cardiac problems
and delays in diagnosis and treatment.
7. An older patient is starting a new medication that is metabolized in the liver and excreted
by the kidneys. Which is the best assessment to monitor the patient’s ability to tolerate the
medication?
a. Liver function tests
b. Drug side effects experienced by the patient
c. Kidney function tests
d. Therapeutic drug levels
ANS: B
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Adverse drug effects and medication interactions may be related to pharmacokinetics or
the manner in which the body absorbs, distributes, metabolizes, and excretes a drug. The
aging process is associated with changes in gastric acid secretion, which can alter
ionization or solubility of a drug and hence its absorption. Medication distribution
depends on body composition and on physiochemical drug properties. With advancing
age, a patient’s fat content increases, lean body mass decreases, and total body water
decreases, which can alter drug disposition.
8. An older patient is receiving a nephrotoxic medication. Which of the following would
be a priority for the nurse to monitor?
Electrocardiogram
Lung sounds
Blood pressure
Level of consciousness
a.
b.
c.
d.
ANS: C
Decrease in number and size of nephrons begins in the cortical regions and progresses
toward the medullary portions of the kidney. This decrease in number of nephrons
corresponds to a
20% decrease in weight of the kidneys between 40 and 80 years of age. Initially, this loss
of nephrons does not appreciably alter renal function because of the large renal reserve
and a simultaneous decrease in lean muscle mass.
9. Which of the following can be a normal assessment finding for an older patient?
a. Asymptomatic dysrhythmias
b. Decreased urine output
c. Increased respiratory effort
d. Difficulty problem solving
ANS: A
The incidence of asymptomatic cardiac dysrhythmias increases in older patients. The most
common dysrhythmia is the premature ventricular contraction. Other common types are
atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia and
atrioventricular conduction disturbances. All of the other findings are abnormal.
10. Chemical changes in a drug that renders it active or inactive is known as
a.
absorption. b.
metabolism.
c. excretion.
d. distribution.
ANS: B
Metabolism is the chemical change in a drug that renders it active or inactive. Absorption is
the receptor-coupled or diffusional uptake of drug into the tissue. Distribution is the
theoretic space (tissue) or body compartment into which free form of a drug distributes.
Excretion is the removal of a drug through an eliminating organ, often the kidneys; some
drugs are excreted in bile or feces, in saliva, or through the lungs.
11. Which of the following nonsteroidal anti-inflammatory drugs (NSAIDs) has the side effect
of renal failure, HTN, heart failure, and GI bleed in the elderly population?
a. Indomethacin
b. Ketorolac
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c. Aspirin greater than 325 mg
d. Naproxen
ANS: D
Possible side effects of select NSAIDs include indomethacin: central nervous system (CNS)
effects (highest of all NSAIDs); ketorolac: asymptomatic gastrointestinal conditions
(ulcers); aspirin (>325 mg): asymptomatic gastrointestinal conditions (ulcers); and
naproxen: gastrointestinal bleeding, renal failure, high blood pressure, and heart failure.
MULTIPLE
RESPONSE
1. An older patient is started on amitriptyline to control depression. The nurse knows to
monitor for (Select all that apply)
impaired psychomotor function.
irregular heart rate.
polyuria.
pulmonary edema.
a.
b.
c.
d.
ANS: A, B, C
Tricyclic antidepressants (amitriptyline and amitriptyline compounds) have strong
anticholinergic effects; may lead to ataxia, impaired psychomotor function, syncope,
falls; cardiac arrhythmias (QT interval changes); may produce polyuria or lead to urinary
incontinence; may exacerbate chronic constipation
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Chapter 08: Pain and Pain Management
Test Bank
MULTIPLE
CHOICE
1. The subjective characteristic implies that pain is
a. an uncomfortable experience present only in the patient with an intact
nervous system.
b. an unpleasant experience accompanied by crying and tachycardia.
c. activation of the sympathetic nervous system from an injury.
d. whatever the patient experiencing it says it is, occurring when that patient
says it does.
ANS: D
Pain is described as an unpleasant sensory and emotional experience associated with actual
or potential tissue damage or described in terms of such damage. This definition emphasizes
the subjective and multidimensional nature of pain. More specifically, the subjective
characteristic implies that pain is whatever the person experiencing it says it is and that it
exists whenever
he or she says it does.
2. The neural processes of encoding and processing noxious stimuli necessary but not
sufficient for pain is known as
a.
perception. b.
nociception. c.
transduction.
d.
transmission.
ANS: B
Nociception represents the neural processes of encoding and processing noxious stimuli
necessary, but not sufficient, for pain. Transduction refers to mechanical (e.g., surgical
incision), thermal (e.g., burn), or chemical (e.g., toxic substance) stimuli that damage
tissues. As a result of transduction, an action potential is produced and is transmitted by
nociceptive nerve fibers in the spinal cord that reach higher centers of the brain. This is
called transmission, and it represents the second process of nociception. Pain sensation
transmitted by the NS pathway reaches the thalamus, and the pain sensation transmitted
by the PS pathway reaches brainstem, hypothalamus, and thalamus. These parts of the
CNS contribute to the initial perception of pain.
3. Which of the following assessment findings might indicate respiratory depression after
opioid administration?
a. Flushed, diaphoretic skin
b. Shallow respirations with a rate of 24 breaths/min
c. Tense, rigid posture
d. Sleep apnea
ANS: D
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Opioids may cause this complication because they reduce the responsiveness of carbon
dioxide chemoreceptors in the respiratory center located in the medulla. Risk factors for
opioid-induced respiratory depression include advanced age, obesity, sleep apnea, impaired
kidney/lung/liver/heart function, patients in whom pain is controlled after a period of poor
control, patients who are opioid naïve (i.e., receiving opioids for less than a week),
concurrent use of central nervous system depressants, and postoperative day 1 were
described. In addition to side effects common to all opioids, morphine may stimulate
histamine release from mast cells, resulting in cardiac instability and allergic reactions.
4. The patient is admitted to the CCU with hemodynamic instability and an allergy to
morphine.
The nurse anticipates that the physician will order which medication for severe pain?
a. Hydromorphone
b. Codeine
c. Fentanyl
d. Methadone
ANS: C
Fentanyl is a synthetic opioid preferred for critically ill patients with hemodynamic
instability or morphine allergy. Hydromorphone is a semisynthetic opioid that has an onset
of action and a duration similar to those of morphine. It is more potent than morphine.
Hydromorphone produces an inactive metabolite (i.e., hydromorphone-3-glucuronide),
making it the opioid of choice for use in patients with end-stage renal disease. Codeine has
limited use in the management of severe pain. It is rarely used in critical care units. It
provides analgesia for mild to moderate pain. It is usually compounded with a nonopioid.
Methadone is a synthetic opioid with morphine-like properties but less sedation. It is
longer acting than morphine and has a long half-life. This makes it difficult to titrate in the
critical care patient.
5. Which of the following combinations of drugs has been found to be effective in managing
the pain associated with musculoskeletal and soft tissue inflammation?
Nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids
NSAIDs and antidepressants
Opioid agonists and opioid antagonists
Adjuvants and partial agonists
a.
b.
c.
d.
ANS: A
The use of NSAIDs in combination with opioids is indicated in patients with
acute musculoskeletal and soft tissue inflammation.
6. A patient underwent a thoracotomy 12 hours ago. The patient currently has an epidural
catheter in place and is receiving continuous epidural analgesia with morphine. In addition
to respiratory depression, the patient should be monitored for which of the following
complications?
a. Urinary retention, undue somnolence, itching, nausea, and vomiting
b. Urinary incontinence, photophobia, headache, and skin rash
c. Apprehension, anxiety, restlessness, sadness, anger, and myoclonus
d. Gastric bleeding, nasal discharge, cerebrospinal fluid leak, and calf pain
ANS: A
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Epidural analgesia is commonly used in critical care units after major abdominal surgery,
nephrectomy, thoracotomy, and major orthopedic procedures. Monitor for adverse
reactions, including respiratory depression, urinary retention, undue somnolence, itching,
seizures, nausea, and vomiting.
7. Acute pain usually corresponds to
a. the healing process but should not exceed 9 months.
b. the healing process but should not exceed 6 months.
c. persistent pain more than 6 months after the healing process.
d. damage to the patient’s nervous system unrelated to the initial injury.
ANS: B
Acute pain has a short duration, and it usually corresponds to the healing process (30 days)
but should not exceed 6 months. It implies tissue damage that is usually from an identifiable
cause. If undertreated, acute pain may bring a prolonged stress response and lead to
permanent damage to the patient’s nervous system. In such instance, acute pain can become
chronic.
8. A patient complains of pain at his incision site. The nurse is aware that four processes
are involved in nociception. The proper order of the processes is
transmission, perception, modulation, and
transduction. b. perception, modulation, transduction,
and transmission. c.
modulation, transduction,
transmission, and perception. d.
transduction,
transmission, perception, and modulation.
a.
ANS: D
Four processes are involved in nociception: transduction, transmission, perception,
and modulation.
9. Using a specific pain intensity scale in the CCU
a. eliminates the need for the subjectivity of the patient.
b. allows for one tool for all patient types.
c. provides consistency of assessment and documentation.
d. is not necessary because all pain is treated equally in the CCU.
ANS: C
Many CCUs use a specific pain intensity scale because a single tool provides consistency
of assessment and documentation. A pain intensity scale is useful in the critical care
environment. Asking the patient to grade his or her pain on a scale of 0 to 10 is a
consistent
method and aids the nurse in objectifying the subjective nature of the patient’s pain.
However, the patient’s tool preference should be considered.
10. The patient is sedated and breathing with the use of mechanical ventilation. The patient is
unable to communicate any aspects of his pain to the nurse. The nurse knows that the best
tool for pain assessment for this patient is
a. FLACC.
b. Wong-Baker FACES.
c. BIS.
d. BPS or CPOT.
ANS: D
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The BPS and the CPOT are supported by experts in critical care and are suggested for use
in medical, postoperative, and nonbrain trauma critically ill adults unable to self-report in
the clinical guidelines of the Society of Critical Care Medicine (SCCM). FLACC is a
pediatric pain assessment tool. The Wong-Baker FACES tool requires the patient to
associate a level of pain to a facial representation. BIS is as an objective measure of
sedation levels during neuromuscular blockade in the ICU.
11. A patient states that he has been taking Demerol 50 mg tablets four times a day for the
past 5 years, but they are not working like they use to. The nurse is concerned that the
patient has developed
a. addiction to Demerol.
b. physical dependence and tolerance.
c. physical dependence and addiction.
d. a method to withdraw himself off the medication.
ANS: B
Addiction is defined by a pattern of compulsive drug use that is characterized by an
incessant longing for an opioid and the need to use it for effects other than pain relief.
Tolerance is defined as a diminution of opioid effects over time. Physical dependence and
tolerance to opioids may develop if the medication is given over a long period. Physical
dependence is manifested by withdrawal symptoms when the opioid is abruptly stopped.
12. The use of PCA infusion pumps allows the patient to
a. act preemptively by administering a bolus of medication when pain begins.
b. choose between the use of opioids or NSAID medication to control pain.
c. decrease the risk of respiratory depression.
d. control pain medication in 2-hour increments.
ANS: A
The patient can self-administer a bolus of medication the moment the pain begins, acting
preemptively. Allowing the patient to self-administer opioid doses does not diminish the
role of the critical care nurse in pain management. The nurse advises about necessary
changes to the prescription and continues to monitor the effects of the medication and
doses. The patient is closely monitored during the first 2 hours of therapy and after every
change in the prescription. If the patient’s pain does not respond within the first 2 hours of
therapy, a total reassessment of the pain state is essential. If the patient is pressing the
button to bolus medication more often than the prescription, the dose may be insufficient
to maintain pain control. Naloxone must be readily available to reverse adverse opiate
respiratory effects.
13. Relaxation, distraction, guided imagery, and music therapy are all examples of
a. physical techniques for pain management.
b. cognitive-behavioral techniques for pain management.
c. PCA management of pain.
d. equianalgesic management of pain.
ANS: B
Using the cortical interpretation of pain as the foundation, several interventions can reduce
the patient’s pain report. These modalities include cognitive techniques such as relaxation,
distraction, guided imagery, and music therapy.
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MULTIPLE RESPONSE
1. Which of the following statements are true regarding pain assessment and management?
(Select all that apply.)
a. The single most important assessment tool available to the nurse is the
patient’s self-report.
b. The only way to assess pain in patients unable to verbalize because of
mechanical ventilation is through observation of behavioral indicators.
c. The concept of equianalgesia uses morphine as a basis for dosage comparison
for other medications.
d. Transcutaneous electrical nerve stimulation and application of heat or cold
therapy stimulate the nonpain sensory fibers.
e. Meperidine, a synthetic form of morphine, is much stronger and is given at
lower doses at less frequent intervals.
ANS: A, C, D
Appropriate pain assessment is the foundation of effective pain treatment. Because pain is
recognized as a subjective experience, the patient’s self-report is considered the most valid
measure for pain and should be obtained as often as possible. Unfortunately, in critical care,
many factors, such as the administration of sedative agents, the use of mechanical
ventilation, and altered levels of consciousness, may impact communication with patients.
These obstacles make pain assessment more complex. Meperidine (Demerol) is a less
potent opioid with agonist effects similar to those of morphine. It is considered the weakest
of the opioids, and it must be administered in large doses to be equivalent in action to
morphine. Because the duration of action is short, dosing is frequent. Equianalgesic means
approximately the same pain relief. Dosages in the equianalgesic chart for moderate to
severe pain are not necessarily starting doses. The doses suggest a ratio for comparing the
analgesia of one medication with another.
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Chapter 09: Sedation, Agitation and Delirium Management
Test Bank
MULTIPLE
CHOICE
1. To achieve ventilator synchrony in a mechanically ventilated patient with acute
respiratory distress syndrome (ARDS), which level of sedation might be most effective?
a. Light
b.
Moderate c.
Conscious
d. Deep
ANS: D
Deep sedation is used when the patient must be unresponsive to deliver necessary care
safely.
2. A patient has been taking benzodiazepines and suddenly develops respiratory depression
and hypotension. After careful assessment, the nurse determines that the patient is
experiencing benzodiazepine overdose. What is the nurse’s next step?
a. Decrease benzodiazepines to half the prescribed dose.
b. Increase IV fluids to 500 cc/hr for 2 hours.
c. Administer flumazenil (Romazicon).
d. Discontinue benzodiazepine and start propofol.
ANS: C
The major unwanted side effects associated with benzodiazepines are dose-related respiratory
depression and hypotension. If needed, flumazenil (Romazicon) is the antidote used to
reverse benzodiazepine overdose in symptomatic patients.
3. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress
syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The
patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has
been frequently triggered. The nurse's first intervention for this patient would be to
a. administer midazolam (Versed) 5 mg by intravenous push immediately.
b. assess the patient to see if a physiologic reason exists for his agitation.
c. obtain a stat arterial blood gas level; his agitation indicates he is
becoming increasingly hypoxic.
d. apply soft wrist restraints to keep him from pulling out the endotracheal tube.
ANS: B
The first step in determining the need for sedation is to assess the patient quickly for
any physiologic causes that can be quickly reversed. In this case, endotracheal
suctioning may solve the high-pressure alarm problem.
4. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress
syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The
patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has
been frequently triggered. The patient continues to be very agitated, and the nurse can find
nothing physiologic to account for the high-pressure alarm. The next step should be to
a. administer midazolam 5 mg by intravenous push immediately.
b. eliminate noise and other stimuli in the room and speak softly and reassuringly to
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him.
c. obtain a stat arterial blood gas level; his agitation indicates he is
becoming increasingly hypoxic.
d. call respiratory therapy to replace this obviously malfunctioning ventilator.
ANS: B
Optimizing the environment, speaking calmly, explaining things to the patient, and
providing distractions are all nonpharmacologic means to decrease anxiety.
5. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress
syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The
patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has
been frequently triggered. Despite the nurse’s actions, the patient continues to be agitated,
triggering the high-pressure alarm on the ventilator. Which of the following medications
would be appropriate for sedation?
a. Midazolam 2 to 5 mg intravenous push (IVP) every 5 to 15 minutes until
the patient is no longer triggering the alarm
b. Haloperidol 5 mg IVP stat
c. Propofol 5 mcg/kg/min by IV infusion
d. Fentanyl 25 mcg IVP over a 15-minute period
ANS: A
Midazolam is the recommended drug for use in alleviating acute agitation. Propofol can
be used for short- and intermediate-term sedation. Haloperidol is indicated for dementia.
Fentanyl is a narcotic and is not appropriate for use as a sedative.
6. A 56-year-old patient is admitted to the critical care unit with acute respiratory distress
syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The
patient is becoming increasingly agitated, and the high-pressure alarm on the ventilator has
been frequently triggered. After the patient’s agitation is controlled, which of the following
drugs would be most appropriate for long-term sedation?
a. Morphine 2 mg/hr continuous IV drip
b. Haloperidol 15 mcg/kg/min continuous IV infusion
c. Propofol 5 mcg/kg/min by IV infusion
d. Lorazepam 0.01 to 0.1 mg/kg/hr by IV infusion
ANS: D
Propofol may be used for ongoing sedation for short- and intermediate-term sedation (1–
3 days) and should be coupled with a short-acting opioid analgesic. Morphine is an
opioid analgesic and is not sedation. Lorazepam infusion (0.01–0.1 mg/kg/hr) is
recommended for long-term sedation.
7. When administering propofol over an extended period, it is important to monitor which of
the following?
Serum triglyceride level
Sodium and potassium levels
Platelet count
Acid–base balance
a.
b.
c.
d.
ANS: A
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Prolonged use of propofol may cause an elevated triglyceride level because of its high
lipid content.
8. A major side effect of benzodiazepines is
a. hypertension.
b. respiratory depression.
c. renal failure.
d. phlebitis at the IV site.
ANS: B
The major side effects of benzodiazepines include hypotension and respiratory
depression. These side effects are dose related.
9. The major advantage of using propofol for short-term sedation is that it
a. has fewer side effects.
b. is slow to cross the blood–brain barrier.
c. has a shorter half-life and rapid elimination rate.
d. is an excellent amnesiac.
ANS: C
Propofol is an effective short-term anesthetic agent, useful for rapid “wake-up” of patients
for assessment; if continuous infusion is used for many days, emergence from sedation can
take hours or days; sedative effect depends on the dose administered, depth of sedation, and
length of time sedated.
10. Which of the following drugs is used for sedation in patients experiencing
withdrawal syndrome?
a. Dexmedetomidine
b. Hydromorphone
c. Diazepam
d. Clonidine
ANS: D
Clonidine (often prescribed as a Catapres patch) is a central
recommended for sedation during withdrawal syndrome.
-agonist and is
11. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from
mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her
room and pulling at her gown. You suspect this patient is
a. experiencing delirium or “ICU psychosis.”
b. experiencing confusion caused by increased hypoxia.
c. hypocalcemic.
d. acting out to receive the attention she was getting while intubated.
ANS: A
Delirium is represented by a global impairment of cognitive processes, usually of sudden
onset, coupled with disorientation, impaired short-term memory, altered sensory
perceptions (hallucinations), abnormal thought processes, and inappropriate behavior.
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12. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from
mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her
room and pulling at her gown. The drug of choice for treating this patient is
a. diazepam.
b.
haloperidol.
c.
lorazepam. d.
propofol.
ANS: B
Haloperidol is the drug of choice when treating delirium. Lorazepam has been associated with
an increased incidence of delirium. Propofol is indicated for sedation use. Diazepam is not an
appropriate choice for this patient.
13. A patient was admitted into the critical care unit 3 days ago. She has just been weaned from
mechanical ventilation. She suddenly becomes confused, seeing nonexistent animals in her
room and pulling at her gown. Which of the following interventions is indicated to
adequately monitor the patient during haloperidol use?
a. Continuous bispectral index (BIS) monitoring
b. Continuous electrocardiographic (ECG) monitoring
c. Continuous pulse oximetry
d. Continuous electrocardiogram (ECG) monitoring
ANS: B
ECG monitoring is recommended because haloperidol use can produce dose-dependent
QTc- interval prolongation, with an increased incidence of ventricular dysrhythmias. BIS
monitoring is indicated for deep sedation use.
14. The most common contributing factor to the development of delirium in critically ill
patients is
sensory overload.
hypoxemia.
electrolyte disturbances.
sleep deprivation.
a.
b.
c.
d.
ANS: D
Delirium is frequently associated with critical illness. Provision of adequate sleep and
early mobilization are recommended to reduce the incidence of delirium.
15. Which benzodiazepine has a greater advantage for treatment of alcohol withdrawal
syndrome
(AWS) because of its longer half-life and high lipid solubility?
a. Ativan
b. Midazolam
c. Propofol
d. Valium
Management of alcohol withdrawal involves close monitoring of AWS-related agitation
and administration of IV benzodiazepines, generally diazepam (Valium) or lorazepam
(Ativan). Diazepam has the advantage of a longer half-life and high lipid solubility.
Lipid-soluble medications quickly cross the blood–brain barrier and enter the central
nervous system to rapidly produce a sedative effect. Midazolam is the recommended drug
for use in alleviating acute agitation but is known to cause seizures with AWS because of
rapid withdrawal. Propofol is indicated for sedation use.
16. Risk factors for delirium include
a. hypertension, alcohol abuse, and benzodiazepine administration.
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b. coma, hypoxemia, and trauma.
c. dementia, hypertension, and pneumonia.
d. coma, alcohol abuse, hyperglycemia
ANS: A
Risk factors for delirium risk include dementia, hypertension, alcohol abuse, high severity
of illness, coma, and benzodiazepine administration.
17. The two scales that are recommended for assessment of agitation and sedation in
adult critically ill patients are the
a. Ramsay Scale and Riker Sedation-Agitation Scale (SAS).
b. Ramsay Scale and Motor Activity Assessment Scale (MAAS).
c. Riker Sedation-Agitation Scale (SAS) and the Richmond Agitation-Sedation Scale
(RASS).
d. Richmond Agitation-Sedation Scale (RASS) and Motor Activity Assessment Scale
(MAAS).
ANS: C
The two scales that are recommended for assessment of agitation and sedation in
adult critically ill patients are the SAS and the RASS.
18. For sedation and analgesia management of mechanically ventilated critical care patients,
put the following steps in the appropriate order in which the nurse should perform them.
1. Using an accepted pain scale, assess the patient's level of pain, and if the
patient is hemodynamically stable, medicate appropriately with morphine sulfate.
2. Assess the degree of agitation and anxiety with an appropriate sedation scale and select
an appropriate medication treatment.
3. Attempt nonpharmacologic treatments; optimize the environment.
4. Reassess the level of sedation, agitation and anxiety, and pain minimally every 2 hours or
as indicated per facility standards.
5. Rule out and correct reversible causes.
6. Assess the patient’s level of comfort.
a. 1, 2, 6, 5, 3, 4
b. 6, 5, 1, 2, 3, 4
c. 6, 5, 3, 1, 2, 4
d. 4, 1, 2, 6, 5, 3
ANS: C
Pain and sedation scales should be used to accurately assess the patient's needs;
adequate interventions should be applied and the patient frequently reassessed.
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MULTIPLE
RESPONSE
1. Causes of delirium in critically ill patients include (Select all that apply.)
a. hyperglycemia.
b. meningitis.
c. cardiomegaly.
d. pulmonary embolism.
e. alcohol withdrawal syndrome.
f. hyperthyroidism.
ANS: B, E, F
The causes of delirium in critically ill patients include metabolic causes (acid–base
disturbance, electrolyte imbalance, hypoglycemia), intracranial causes (epidural or subdural
hematoma, intracranial hemorrhage, meningitis, encephalitis, cerebral abscess, tumor),
endocrine causes (hyperthyroidism or hypothyroidism, Addison disease,
hyperparathyroidism, Cushing syndrome), organ failure (liver encephalopathy, kidney
encephalopathy, septic
shock), respiratory causes (hypoxemia, hypercarbia), and medication-related causes
(alcohol withdrawal syndrome, benzodiazepines, heavy metal poisoning).
2. Which of the following complications can result from oversedation? (Select all that apply.)
a. Pressure
ulcers b.
Thromboemboli
c. Diarrhea
d. Nosocomial pneumonia
e. Delayed weaning from mechanical ventilation
f. Hypertension
ANS: A, B, D, E
Oversedation can result in a multitude of complications. Prolonged deep sedation is
associated with significant complications of immobility, including pressure ulcers,
thromboemboli,
gastric ileus, nosocomial pneumonia, and delayed weaning from mechanical ventilation.
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Chapter 10: End-of-Life Care
Test Bank
MULTIPLE
CHOICE
1. 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 patient’s 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 only treatments that do not cause pain or
other discomfort to the patient.
2.
is a powerful influence when the decision-making process is dealing with recovery or
a peaceful death.
a. Hope
b.
Religion
c.
Culture d.
Ethics
ANS: A
Hope is a powerful influence on decision making, and a shift from hope for recovery to
hope for a peaceful death should be guided by clinicians with exemplary communication
skills. Ethics, religion, and culture can influence the decision process regarding care and
end-of-life decisions.
3. The patient’s condition has deteriorated to the point where she can no longer make
decisions about her own care. Which of the following nursing interventions would be most
appropriate? a. Obtain a verbal DNR order from the physician.
b. Continue caring for the patient as originally ordered because she obviously
wanted this.
c. Consult the hospital attorney for recommendations on how to proceed.
d. Discuss with the family what the patient’s wishes would be if she could make
those decisions herself.
ANS: D
If the patient is not able to make end-of-life decisions for herself, her family members
should be approached to discuss the next steps because they may have insight into what
her wishes would be.
4. The two basic ethical principles underlying the provision of health care are
a. beneficence and nonmaleficence.
b. veracity and beneficence.
c. fidelity and nonmaleficence.
d. veracity and fidelity.
ANS: A
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The two basic ethical principles underlying the provision of health care are beneficence
and nonmaleficence.
5. A patient was admitted to the critical care unit several weeks ago with an acute myocardial
infarction and subsequently underwent coronary artery bypass grafting surgery. Since a
cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram
shows no meaningful brain activity. The patient does not have an advance directive. Which
of the following statements would be the best way to approach the family regarding his
ongoing care?
a. “I will refer this case to the hospital ethics committee, and they will contact
you when they have a decision.”
b. “What do you want to do about the patient’s care at this point?”
c. “Dr. Smith believes that there is no hope at this point and recommends DNR
status.”
d. “What would the patient want if he knew he were in this situation?”
ANS: D
Approaching the family and asking what they know about the patient’s wishes and
preferences is the best way to begin this discussion. Emotional support for the patient and
the family is important as they discuss advance care planning in the critical care setting.
6. A patient was admitted to the critical care unit several weeks ago with an acute myocardial
infarction and subsequently underwent coronary artery bypass grafting surgery. Since a
cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram
shows no meaningful brain activity. After a family conference, the physician orders a DNR
order,
and palliative care is begun. This means
a. the patient will continue to receive the same aggressive treatment short
of resuscitation if he has another cardiac arrest.
b. all treatment will be stopped, and the patient will be allowed to die.
c. all attempts will be made to keep the patient comfortable without prolonging
his life.
d. the patient will be immediately transferred to hospice.
ANS: C
When palliative care is begun, the primary goal is to keep the patient comfortable by
continuing assessments and managing symptoms that might cause pain, anxiety, or
distress.
7. A patient was admitted to the critical care unit several weeks ago with an acute myocardial
infarction and subsequently underwent coronary artery bypass grafting surgery. Since a
cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram
shows no meaningful brain activity. The patient is placed on a morphine drip to alleviate
suspected operative pain and assist in sedation. The patient continues to grimace and fight
the ventilator. What nursing intervention would be appropriate?
a. Increase the morphine dosage until no signs of pain or discomfort are present.
b. Increase the morphine drip, but if the patient’s respiratory rate drops below
10 breaths/min, return to the original dosage.
c. Gradually decrease the morphine and switch to Versed to avoid
respiratory depression.
d. Ask the family to leave the room because their presence is causing undue stress to
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the patient.
ANS: A
Even though opiates can cause respiratory depression, the goal in palliative care is to
alleviate pain and suffering. A bolus dose of morphine (2–10 mg IV) and a continuous
morphine infusion at 50% of the bolus dose per hour is recommended. Because many
critical care patients are not conscious, assessment of pain and other symptoms becomes
more difficult. Gélinas and colleagues recommended using signs of body movements,
neuromuscular signs, facial expressions, or responses to physical examination for pain
assessment in patients with altered consciousness.
8. A patient was admitted to the critical care unit several weeks ago with an acute myocardial
infarction and subsequently underwent coronary artery bypass grafting surgery. Since a
cardiac arrest 5 days ago, the patient has been unresponsive. An electroencephalogram
shows no meaningful brain activity. The decision is made to remove the patient from the
ventilator. Which of the following statements is most accurate?
a. The cardiac monitor should be left on so everyone will know when the patient
has died.
b. Opioids, sedatives, and neuromuscular blocking agents should be discontinued
just before removing the ventilator.
c. The family and health care team should decide the best method for removing
the ventilator: terminal wean versus immediate extubation.
d. If terminal weaning is selected, the family should be sent to the waiting room
until the ventilator has actually been removed.
ANS: C
The choice of terminal wean as opposed to extubation is based on considerations of access
for suctioning, appearance of the patient for the family, how long the patient will survive
off the ventilator, and whether the patient has the ability to communicate with loved ones at
the bedside.
9. A patient was admitted to the critical care unit after having a CVA and MI. The patient has
poor activity tolerance, falls in and out of consciousness, and has poor verbal skills. The
patient has been resuscitated four times in the past 6 hours. The patient does not have
advance directives. Family members are at the bedside. Who should the physician approach
to discuss decisions of care and possible DNR status?
a. The patient
b. The family
c. The hospital legal system
d. The hospital ethics committee
ANS: A
Patients’ capacity for decision making is limited by illness severity; they are too sick or
are hampered by the therapies or medications used to treat them. When decision making
is required, the patient is the first person to be approached.
10. Organ donation
a. is a choice only the patient can make for him- or herself.
b. is mandated by legal and regulatory agencies.
c. must be requested by the nurse caring for the dying patient.
d. is controlled by individual institutional policies.
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ANS: B
The Social Security Act Section 1138 requires that hospitals have written protocols for the
identification of potential organ donors. The Joint Commission has a standard on organ
donation. The nurse must notify the organ procurement official to approach the family with
a donation request.
11. Hospice care can help families
a.
b.
c.
d.
with
organ donations.
aggressive symptom management and family support.
writing advance directives and living wills.
legal euthanasia.
ANS: B
Health professionals can assist patients and families by providing information about the
hospice benefit, particularly regarding the aggressive symptom management and family
support. Organ donations must follow Social Security Act Section 1138 regarding written
protocols for identification of potential organ donors and notification of organ recovery
agencies. Advance directives can be taken care of at the hospital or legal firm. Euthanasia
is also known as assisted suicide and is legal in Oregon, Washington, and Montana.
12. Disagreement and distress among physicians, nurse practitioners, and critical care nurses
can lead to
emotional distress only.
ethical distress only.
emotional and ethical distress.
pessimistic opinions of care.
a.
b.
c.
d.
ANS: C
Nurses and doctors frequently disagree about the futility of interventions. Sometimes nurses
consider withdrawal before physicians and patients do, and they then believe the care they
are giving is unnecessary and possibly harmful. This issue is a serious one for critical care
nurses because emotional and ethical distress can lead to burnout.
13. Antiemetics should be used to treat
a. dyspnea.
b. nausea and vomiting.
c. anxiety.
d. edema.
ANS: B
Nausea and vomiting are common and should be treated with antiemetics. Dyspnea is best
managed with close evaluation of the patient and the use of opioids, sedatives, and
nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).
Benzodiazepines, especially midazolam with its rapid onset and short half-life, are
frequently used to treat anxiety.
14. Haloperidol is recommended as useful treatment of
a.
anxiety b.
dyspnea c.
.
delirium
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d. pain
ANS: C
Delirium is commonly observed in critically ill patients and in those approaching death.
Haloperidol is recommended as useful, and restraints should be avoided. Dyspnea is best
managed with close evaluation of the patient and the use of opioids, sedatives, and
nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).
Benzodiazepines, especially midazolam with its rapid onset and short half-life, are
frequently used to treat anxiety. Morphine is the most common drug used for pain
management.
15. A patient tells the nurse to call his family and tell them they need to come so they can say
their goodbyes. The patient is sure he will not be here tomorrow because his grandparent is
waiting for him. This is an example of
a. signs and symptoms of anxiety.
b. signs and symptoms of delirium.
c. the need for hospice care.
d. near-death awareness.
ANS: D
The same behaviors may be seen in conscious critical care patients near death. Having
an awareness of the phenomenon enables more careful assessment of behaviors that
may be interpreted as delirium, acid–base imbalance, or other metabolic
derangements. These behaviors include communicating with someone who is not
alive, preparing for travel, describing a place the patient can see, or even knowing
when death will occur.
16. Recommendations for creating a supportive atmosphere during withdrawal
discussions include
telling the family when and where the procedure will occur.
beginning the conversation by inquiring about the emotional state of the family.
ending the conversation by inquiring about the emotional state of the family.
recommendations that the family not be present when the procedure occurs.
a.
b.
c.
d.
ANS: B
Recommendations for creating a supportive atmosphere during withdrawal discussions
include taking a moment at the beginning of the conversation to inquire about the
family’s emotional state. During the family meeting in which a decision to withdraw
life support is made, a time to initiate withdrawal is usually established.
17. Family members become dissatisfied and stressed because of a lack of
among
health care providers.
care provided
communication
patient’s prognosis
patient’s outcome
a.
b.
c.
d.
ANS: B
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Family members have reported dissatisfaction with communication and decision making.
Increasing the frequency of communication and sharing concerns early in the
hospitalization will make subsequent discussions easier for the patient, family, and health
professional. Based on the level of communication and patient understanding of care,
prognosis and outcomes will influence the satisfaction of services being provided to their
family member and decrease
stress levels.
MULTIPLE
RESPONSE
1. Which of the following are considerations when making the decision to allow family at
the bedside during resuscitation efforts? (Select all that apply.)
a. The patient’s wishes
b. Experience of the staff
c. The family’s need to participate in all aspects of the patient’s care
d. State regulatory issues
e. Seeing the resuscitation may confirm the impact of decisions made or delayed
ANS: E
The decision to allow family members at the bedside during resuscitative efforts should
be made by the family and caregivers and be based on needs and experiences. The family
may become more aware of what is involved in decisions if they are present during
procedures or resuscitative attempts. Seeing the steps of resuscitation may make clearer
the impact of decisions made or delayed.
2. According to the Society for Critical Care Medicine, which of the following are among
the most important needs of the family of the dying patient? (Select all that apply.)
To be helpful
To stay informed
To achieve a sense of control
To vent emotions
To be fed, hydrated, and rested
a.
b.
c.
d.
e.
ANS: A, B, D, E
The needs of the patient and the needs of the family may be very different during this
stressful time.
3. Which of the following statements apply to DNR orders? (Select all that apply.)
a. DNR orders are often delayed because of difficulty predicting the time of death.
b. The patient’s wishes are often not known or are vaguely stated.
c. A DNR order indicates that all care should be stopped.
d. End-of-life care skills are not emphasized in medical curricula.
e. DNR orders do not address pain management.
ANS: A, B, D, E
A do-not-resuscitate (DNR) order is intended to prevent the initiation of life-sustaining
measures such as endotracheal intubation or CPR. Families should be assured that
patients will continue to receive care but that aggressive measures to extend life will not
be used.
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Chapter 11: Cardiovascular Anatomy and Physiology
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE CHOICE
1.Which structure is the primary or natural pacemaker of the heart?
a.
Ventricular tissue
b.
Atrioventricular node
c.
Sinoatrial node
d.
Purkinje fibers
ANS: C
With an intrinsic rate of 60 to 100 beats/min, the sinoatrial node is the primary
pacemaker in a healthy heart. The atrioventricular node beats
40 to 60 beats/min. Ventricular tissue must have an electrical impulse to
contract. Purkinje fibers beat 15 to 40 beats/min.
2.The atrioventricular (AV) node delays the conduction impulse from the atria
(0.8–1.2 seconds) for what reasons?
a.
To limit the amount of blood that fills the
ventricle from the atria
b.
To provide time for the ventricles to fill
during diastole
c.
To limit the number of signals the
ventricles receive in some rhythms
d.
To allow the atria to rest between signals
ANS: B
The atrioventricular (AV) node delays the conduction impulse from the atria
(0.8–1.2 seconds) to provide time for the ventricles to fill during diastole.
3.Why do many patients with very high heart rates frequently have chest pain and
shortness of breath?
a.
Patients with heart disease fre- quently
have an anxiety disorder as well.
b.
The rapid pounding of the heart in the
chest wall causes the physical pain.
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c.
The heart muscle gets tired from the
increased work.
The decreased diastolic time de- creases
oxygen delivery to the myocardium.
d.
ANS: D
The coronary arteries are perfused during diastole. When the heart rate
increases, the diastolic time decreases as each contraction has less time to be
completed. This decreases the time the coronary arter- ies have to deliver
oxygenated blood to the myocardium. The symp- toms described are caused
by a lack of oxygen in the myocardium.
4.A patient reports feeling dizzy after standing quickly. Which finding could provide
a clue regarding the cause?
a.
Hemoglobin level of 14.0 g/dL
and hematocrit level of 42.3%
b.
Poor skin turgor with extended tenting
c.
Supine blood pressure of 146/93 mm Hg
d.
Resting heart rate of 96
beats/min
ANS: B
Poor skin turgor could suggest dehydration. Dehydration can cause or- thostatic
hypotension because of low capacitance reserves from hypo- volemia. Supine
blood pressure of 146/93 mm Hg would be considered hypertensive, and the
patient would most likely experience a headache rather than dizziness. A
resting heart rate of 96 beats/min is still con- sidered a normal value.
5.A patient presents with atrial fibrillation, a heart rate of 156 beats/min, and a
blood pressure of 124/76 mm Hg. The practitioner orders dilti- azem, a calcium
channel blocker, to be given slowly by intravenous push. Why did the
practitioner choose this medication to treat this pa- tient’s atrial
tachyarrhythmia?
a.
Diltiazem decreases the calcium influx
into the atrioventricular (AV) nodal tissue
and decreases the speed of impulse
conduction.
b.
Diltiazem increases the calcium influx
into the AV nodal tissue
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c.
d.
and decreases the speed of im- pulse
conduction.
Diltiazem decreases the calcium influx
into the myocardial tissue and decreases
the strength of heart contraction.
Diltiazem increases the calcium influx
into the myocardial tissue and decreases
the strength of heart contraction.
ANS: A
Calcium channel–blocking drugs, such as verapamil and diltiazem, in- hibit the
inward Ca++ current into pacemaker tissue, especially the atrioventricular (AV)
node. For this reason, they are used therapeuti- cally to slow the rate of atrial
tachydysrhythmias and protect the ven- tricle from excessive atrial impulses.
6.What is one hemodynamic effect of a pericardial effusion?
a.
Increased ventricular ejection
b.
Decreased ventricular filling
c.
Myocardial ischemia
d.
Increased afterload
ANS: B
If the fluid collection in the sac (pericardial effusion) impinges on ven- tricular
filling, ventricular ejection, or coronary artery perfusion, a clini- cal emergency
may exist that necessitates removal of the excess peri- cardial fluid to restore
normal cardiac function. Myocardial ischemia is damage of the myocardium
muscle as the result of a heart attack.
7.What percentage of volume does atrial kick contribute to ventricular fill- ing?
a.
10%
b.
20%
c.
5%
d.
45%
ANS: B
Atrial contraction, also known as “atrial kick,” contributes approxi- mately
20% of blood flow to ventricular filling; the other 80% occurs passively
during diastole.
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8.What is the function of the atrioventricular (AV) valves?
a.
Prevent backflow of blood into the atria
during ventricular con- traction
b.
Prevent blood regurgitation back into the
ventricles
c.
Assist with blood flow to the lungs
and aorta
d.
Contribute to ventricular filling by atrial
kick
ANS: A
The atrioventricular (AV) valves are open during ventricular diastole (filling)
and prevent backflow of blood into the atria during ventricular systole
(contraction). Semilunar valves prevent the backflow of pul- monic and aortic
blood back into the ventricles.
9.Which step of impulse conduction is most conducive to atrial kick?
a.
The firing of the sinoatrial node, which
results in atrial depolariza- tion
b.
The conduction delay at the atrioventricular (AV) node, allowing time for
filling
c.
Conduction through the bundle of His,
enhancing ventricular de- polarization
d.
Conduction to the Purkinje fibers, allowing
for ventricular contrac- tion
ANS: B
The conduction delay at the atrioventricular (AV) node allows adequate time for
ventricular filling from atrial contraction.
10.Which is an example of a physiologic shunt?
a.
A ventricular septal defect
b.
Blood returning from the inferior vena
cava to the right atrium
c.
A septal infarct
d.
The thebesian vessels returning
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deoxygenated blood to the left
ventricle
ANS: D
The thebesian vessels return blood to the left ventricle. The mixing of
unoxygenated blood with freshly oxygenated blood is called a physio- logic
shunt. A ventricular septal defect (VSD) allows mixing of blood from both
ventricles. The clinical impact depends on the size of the in- tracardiac shunt. A
VSD is a congenital opening between the ventri- cles; a ventricular septal
rupture can occur as a complication of a large anterior wall myocardial
infarction.
11.What is the name of outermost layer of an artery?
a.
Tunica
b.
Intima
c.
Adventitia
d.
Media
ANS: C
The adventitia is the outermost layer of the artery that helps strengthen and
shape the vessel. The media is the middle layer that is made up of smooth
muscle and elastic tissue. The intima is the inner- most layer consists of a thin
lining of endothelium and a small amount of elastic tissue.
12.Which of the following is most descriptive of the capillary?
a.
Large diameter, low pressure b.
Small diameter, high pressure c.
Large
diameter, high pressure d.
Small
diameter, low pressure
ANS: D
The diameter of a capillary is less than that of an arteriole, but the pressure is
relatively low as a result of the large cross-sectional area of the branching
capillary bed.
13.Depolarization of one myocardial cell will likely result in what physiologic
response?
a.
Completion of the action poten- tial in that
cell before a new cell can accept an
impulse
b.
Quick depolarization and spread to all of
the heart
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c.
Depolarization of only cells supe- rior to
the initial depolarization
Quick depolarization of only cells inferior
to the initial depolariza- tion
d.
ANS: B
The cardiac muscle is a functional syncytium in which depolarization started
in any cardiac cell is quickly spread to all of the heart.
14.What is the normal resting membrane potential of a myocardial cell?
a.
10 to 20 mV
b.
30 to 40 mV
c.
–20 to –30 mV
d.
–80 to –90 mV
ANS: D
In a myocardial cell, the normal resting membrane potential is –80 to –
90 mV.
15.Which phase is the final repolarization phase of the action potential?
a.
Phase 1 b.
Phase 2 c.
Phase 3
d.
Phase 4
ANS: C
The final repolarization phase is phase 3 of the action potential. Phases
1 and 2 (partial repolarization) occur as the AP slope returns toward zero. The
plateau that follows is described as phase 2. In phase 4 the AP returns to an
RMP of –80 to –90 mV.
16.Which statement regarding the autonomic nervous system’s role in the
regulation of heart rate is true?
a.
Parasympathetic influences in- crease
heart rate.
b.
Sympathetic influences are predominantly present.
c.
Parasympathetic influences are only
compensatory.
Both sympathetic and parasym-
d.
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pathetic influences are normally
active.
ANS: D
The parasympathetic nervous system and the sympathetic nervous system
operate to create a balance between relaxation and fight-or- flight readiness.
They affect cardiovascular function by slowing the heart rate during periods of
calm and increasing it in response to sym- pathetic stimulation.
17.A patient is admitted with a diagnosis of acute myocardial infarction. The monitor
pattern reveals bradycardia. Occlusion of which coronary artery most likely
resulted in bradycardia from sinoatrial node is- chemia?
a.
Right
b.
Left anterior descending
c.
Circumflex
d.
Dominant
ANS: A
The right coronary artery provides the blood supply to the sinoatrial and
atrioventricular (AV) nodes in more than half the population. The left coronary
artery is a short but important artery that divides into two large arteries, the
left anterior descending and the circumflex arteries. These vessels serve the
left atrium and most of the left ventricle. The term dominant coronary artery is
used to describe the artery that sup- plies the posterior part of the heart.
18.An echocardiogram reveals an ejection fraction of 55%. On the basis of this
information, how would the patient’s cardiac function be de- scribed?
a.
Adequate
b.
Mildly decreased
c.
Moderately decreased
d.
Severely decreased
ANS: A
Ejection fraction is expressed as a percent, with normal being at least greater
than 50%. An ejection fraction of less than 35% indicates poor ventricular
function (as in cardiomyopathy), poor ventricular filling, ob- struction to outflow
(as in some valve stenosis conditions), or a combi- nation of these.
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19.Which of the following values reflects a normal cardiac output at rest?
a.
2.5 L/min b.
5.8 L/min c.
d.
7.3 L/min
9.6 L/min
ANS: B
Cardiac output is normally expressed in liters per minute (L/min). The normal
cardiac output in the human adult is approximately 4 to 8
L/min. It is approximately 4 to 6 L/min at rest and increases with exercise.
20.A patient is admitted with right- and left-sided heart failure. The nurse’s
assessment reveals that the patient has 3+ pitting edema on the sacrum, blood
pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is
experiencing shortness of breath and chest dis- comfort. On the basis of this
information, how would the nurse evalu- ate the patient’s preload status?
a.
b.
The patient is hypovolemic and has too
little preload.
The patient is experiencing con- gestive
heart failure (CHF) and has too little
preload.
c.
The patient is experiencing heart failure
and has too much preload.
d.
The patient is hypertensive and the
preload is not a factor.
ANS: C
Whereas a patient with hypovolemia has too little preload, a patient with
heart failure has too much preload.
21.A patient is admitted with right- and left-sided heart failure. The nurse’s
assessment reveals that the patient has 3+ pitting edema on the sacrum, blood
pressure of 176/98 mm Hg, and bilateral crackles in the lungs. The patient is
experiencing shortness of breath and chest dis- comfort. Increased afterload is
probably present related to the pa- tient’s blood pressure. Which therapeutic
measure will most likely de- crease afterload in this patient?
a.
Administration of vasodilators
b.
Placement in high Fowler position
c.
Elevation of extremities
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d.
Increasing intravenous fluids
ANS: A
Therapeutic management to decrease afterload is aimed at decreasing the work
of the heart with the use of vasodilators. Placing the patient
in high Fowler position will cause an increase in the workload of the
heart. Elevation of the extremities will ease the venous return back to the heart.
Increasing IV fluids will cause an increased workload on the heart.
22.What are the two important proteins contained within the cardiac cells that
contribute to contraction?
a.
Z-disk and A-band
b.
Actin and myosin
c.
I-band and M-band
d.
Renin and angiotensin
ANS: B
Actin and myosin form cross-bridges, allowing myocardial contraction
to take place. Z-disk, A-band, I-band, and M-band are all portions of the
sarcomere functional unit to promote contraction in the heart. Renin converts
the protein angiotensinogen to angiotensin I. When an- giotensin I passes
through the pulmonary vascular bed, it is activated by angiotensin-converting
enzyme to become angiotensin II.
23.What is the name of the valve that allows blood flow into pulmonary artery?
a.
Aortic
b.
Tricuspid
c.
Mitral valve
d.
Pulmonic valves
ANS: D
The pulmonic valve allows blood flow into the pulmonary artery, and the aortic
valve allows blood flow into the aorta. The tricuspid (right) and mitral valves
(left) are located between the atria and the ventri- cles.
24.Place the following components of the cardiac conduction pathway in the correct
anatomic order.
1. Atrioventricular node
2. Bundle branches
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3.
4.
5.
6.
Bundle of His
Internodal pathways
Purkinje fibers
Sinoatrial node
a.
6, 1, 4, 3, 2, 5
b.
6, 1, 3, 2, 4, 5
c.
6, 1, 4, 2, 3, 5
d.
4, 3, 2, 5, 6, 1
ANS: A
The three main areas of impulse propagation and conduction are (1) the
sinoatrial node, (2) the atrioventricular node, and (3) the conduc- tion fibers
within the ventricle, specifically the bundle of His, the bun- dle branches, and
the Purkinje fibers. Interruption or malfunction of
any part of the conduction pathway can result in dysrhythmias specific to that
structure.
MULTIPLE RESPONSE
1.Which factors influence stroke volume? (Select all that apply.)
a.
Afterload
b.
Cardiac output
c.
Contractility
d.
Heart rate
e.
Preload
ANS: A, C, E
Stroke volume (SV) as a value is influenced by three primary factors: preload,
afterload, and contractility. Cardiac output (CO) is determined by SV × HR = CO.
Preload is the volume of blood in the left ventricle at the end of diastole.
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Chapter 13: Cardiovascular Diagnostic Procedures
Urden: Critical Care Nursing, 9th
EditionEdition
MULTIPLE CHOICE
1. A patient with a serum potassium level of 6.8 mEq/L may exhibit what type of
electrocardiographic changes?
a. A prominent U wave b. Tall,
peaked T waves c. A narrowed
QRS
d. Sudden ventricular dysrhythmias
ANS: B
Normal serum potassium levels are 3.5 to 4.5 mEq/L. Tall, narrow peaked T waves are usually,
although not uniquely, associated with early hyperkalemia and are followed by prolongation of the
PR interval, loss of the P wave, widening of the QRS complex, heart block, and asystole. Severely
elevated serum potassium (greater than 8 mEq/L) causes a wide QRS tachycardia.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 269
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. A patient with heart failure may be at risk for hypomagnesemia as a result of which factor?
a. Pump failure
b. Diuretic use
c. Fluid overload
d. Hemodilution
ANS: B
Hypomagnesemia can be caused by diuresis. Diuretic use with heart failure often contributes to low
serum magnesium levels.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 270
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. Which diagnostic test is most effective for measuring overall heart size?
a. 12-lead electrocardiography
b. Echocardiography
c. Chest radiography
d. Vectorcardiography
ANS: C
Chest radiography is the oldest noninvasive method for visualizing images of the heart, and it
remains a frequently used and valuable diagnostic tool. Information about cardiac anatomy and
physiology can be obtained with ease and safety at a relatively low cost. Radiographs of the chest
are used to estimate the cardiothoracic ratio and measure overall heart size.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 277|Figure 13-88
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
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4. ST segment monitoring for ischemia has gained increasing importance with the advent of
thrombolytic therapy. What is the most accurate method for monitoring the existence of true ischemic
changes?
a. Biomarkers
b. Echocardiogram
c. 5-lead ECG
d. 12-lead ECG
ANS: D
Cardiac biomarkers are proteins that are released from damaged myocardial cells. The initial elevation
of cTnI, cTnT, and CK-MB occurs 3 to 6 hours after the acute myocardial damage. This means that if
an individual comes to the emergency department as soon as chest pain is experienced, the biomarkers
will not have risen. For this reason, it is clinical practice to diagnose an acute myocardial infarction by
12-lead electrocardiography and clinical symptoms without waiting for elevation of cardiac
biomarkers.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 244
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
5. Which criteria are representative of the patient in normal sinus rhythm?
a. Heart rate, 64 beats/min; rhythm regular; PR interval, 0.10 second; QRS, 0.04 second
b. Heart rate, 88 beats/min; rhythm regular; PR interval, 0.18 second; QRS, 0.06 second
c. Heart rate, 54 beats/min; rhythm regular; PR interval, 0.16 second; QRS, 0.08 second
d. Heart rate, 92 beats/min; rhythm irregular; PR interval, 0.16 second; QRS, 0.04 second
ANS: B
The parameters for normal sinus rhythm are heart rate, 60 to 100 beats/min; rhythm, regular; PR
interval, 0.12 to 0.20 second; and QRS, 0.06 to 0.10 second.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 250-251
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. What is the major factor influencing the patient’s response to atrial flutter?
a. Atrial rate
b. Ventricular response rate
c. PR interval
d. QRS duration
ANS: B
The major factor underlying atrial flutter symptoms is the ventricular response rate. If the atrial rate is
300 and the atrioventricular (AV) conduction ratio is 4:1, the ventricular response rate is 75 beats/min
and should be well tolerated. If, on the other hand, the atrial rate is 300 beats/min but the AV
conduction ratio is 2:1, the corresponding ventricular rate of 150 beats/min may cause angina, acute
heart failure, or other signs of cardiac decompensation.
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PTS: 1
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REF: p. 255
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. What characteristic is associated with junctional escape rhythms?
a. Irregular rhythm
b. Rate greater than 100 beats/min c. P
wave may be present or absent d. QRS
greater than 0.10 seconds
ANS: C
Characteristics of a junctional escape rhythm include a rate of 40 to 60 beats/min, regular rhythm,
present or absent P waves, PR less than 0.12 seconds, and QRS between 0.06 and
0.10 seconds.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 259|Table 13-12
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. When assessing a patient with PVCs, the nurse knows that the ectopic beat is multifocal because
it appears in what way?
a. In various shapes in the same lead
b. With increasing frequency c. Wider
than a normal QRS d. On the T wave
ANS: A
If the ventricular ectopic beats are of various shapes in the same lead, they are multifocal.
Multifocal ventricular ectopics are more serious than unifocal ventricular ectopics because they
indicate a greater area of irritable myocardial tissue and are more likely to deteriorate into
ventricular tachycardia or fibrillation.
PTS: 1
DIF: Cognitive Level: Understanding
Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
REF: p. 260|Figure 13-67B OBJ:
9. What major clinical finding present in a patient with ventricular fibrillation (VF)?
a. Hypertension
b. Bradycardia
c. Diaphoresis
d. Pulselessness
ANS: D
In ventricular fibrillation (VF), the patient does not have a pulse, no blood is being pumped forward,
and defibrillation is the only definitive therapy. No forward flow of blood or palpable pulse is present
in VF.
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REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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10. Which portion of the electrocardiogram (ECG) is most valuable in diagnosing atrioventricular
(AV) conduction disturbances?
P wave
PR interval
QRS complex
QT interval
a.
b.
c.
d.
ANS: B
The PR interval is an indicator of atrioventricular nodal function. The P wave represents atrial
depolarization. The QRS complex represents ventricular depolarization, corresponding to
phase 0 of the ventricular action potential. The QT interval is measured from the beginning of the QRS
complex to the end of the T wave and indicates the total time interval from the onset of depolarization
to the completion of repolarization.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 267
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
11. Which findings would be reasons to abort an exercise stress test?
a. Ventricular axis of +90 degrees
b. Increase in blood pressure
c. Inverted U wave
d. ST segment depression or elevation
ANS: D
Signs that can alert the nurse to stop the test include ST segment elevation equal to or greater than
1.0 mm (one small box) or ST depression equal to or greater than 2.0 mm (2 small boxes). Blood
pressure is expected to rise during exercise, but a systolic blood pressure greater than 250 mm Hg or
a diastolic blood pressure greater than 115 mm Hg is considered high enough to stop the test.
Parameters for ventricular axis in degrees are –30 to +90. Left- axis deviation is present if the axis
falls between –30 and –90 degrees.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 280
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. What is the rationale for giving the patient additional fluids after a cardiac catheterization?
a. Fluids help keep the femoral vein from clotting at the puncture site.
b. The patient had a nothing-by-mouth order before the procedure.
c. The radiopaque contrast acts as an osmotic diuretic.
d. Fluids increase cardiac output.
ANS: C
Fluid is given for rehydration because the radiopaque contrast acts as an osmotic diuretic. Fluid is
also used to prevent contrast-induced nephropathy or damage to the kidney from the contrast dye
used to visualize the heart structures.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 276
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. Pulsus paradoxus may be noted on the bedside monitor when what is observed?
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a.
b.
c.
d.
A decrease of more than 10 mm Hg in the arterial waveform during inhalation
A single, nonperfused beat on the electrocardiogram (ECG) waveform
Tall, tented T waves on the ECG waveform
An increase in pulse pressure greater than 20 mm Hg on exhalation
ANS: A
Pulsus paradoxus is a decrease of more than 10 mm Hg in the arterial waveform that occurs during
inhalation. It is caused by a fall in cardiac output (CO) as a result of increased negative intrathoracic
pressure during inhalation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 205
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. When assessing the pulmonary arterial waveform, the nurse notices dampening. After tightening
the stopcocks and flushing the line, the nurse decides to calibrate the transducer. What are two
essential components included in calibration?
a. Obtaining a baseline blood pressure and closing the transducer to air
b. Leveling the air–fluid interface to the phlebostatic axis and opening the transducer to air
c. Having the patient lay flat and closing the transducer to air
d. Obtaining blood return on line and closing all stopcocks
ANS: B
Ensuring accuracy of waveform calibration of the system includes opening the transducer to air and
leveling the air–fluid interface of the transducer to the phlebostatic axis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 199
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
15.
a.
b.
c.
d.
What is the formula for calculating mean arterial pressure (MAP)?
Averaging three of the patient’s blood pressure readings over a 6-hour period
Dividing the systolic pressure by the diastolic pressure
Adding the systolic pressure and two diastolic pressures and then dividing by 3
Dividing the diastolic pressure by the pulse pressure
ANS: C
The mean arterial pressure is one-third systole and two-thirds diastole.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 202
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. What is the physiologic effect of left ventricular afterload reduction?
a. Decreased left atrial tension
b. Decreased systemic vascular resistance
c. Increased filling pressures
d. Decreased cardiac output
ANS: B
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Afterload is defined as the pressure the ventricle generates to overcome the resistance to ejection
created by the arteries and arterioles. After a decrease in afterload, wall tension is lowered. The
technical name for afterload is systemic vascular resistance (SVR). Resistance to ejection from the
right side of the heart is estimated by calculating the pulmonary vascular resistance (PVR). The PVR
value is normally one-sixth of the SVR.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 215
OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17.
a.
b.
c.
d.
What parameter is used to assess the contractility of the left side of the heart?
Pulmonary artery occlusion pressure
Left atrial pressure
Systemic vascular resistance
Left ventricular stroke work index
ANS: D
Contractility of the left side of the heart is measured by the left ventricular stroke work index.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 217
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. Which intervention should be strictly followed to ensure accurate cardiac output readings?
a. Inject 5 mL of iced injectate at the beginning of exhalation over 30 seconds. b. Inject
10 mL of warmed injectate into the pulmonary artery port three times. c. Ensure at least
5° C difference between injectate and the patient temperature. d. Administer the injectate
within 4 seconds during inspiration.
ANS: D
To ensure accurate readings, the difference between injectate temperature and body temperature must
be at least 10° C, and the injectate must be delivered within 4 seconds, with minimal handling of the
syringe to prevent warming of the solution. This is particularly important when iced injectate is used.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 222
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. Why is mixed venous oxygen saturation (SVO2) monitoring helpful in the management of the
critically ill patient?
a. It facilitates oxygen saturation monitoring at the capillary level.
b. It can detect an imbalance between oxygen supply and metabolic tissue demand.
c. It assesses the diffusion of gases at the alveolar capillary membrane.
d. It estimates myocardial workload during heart failure and acute pulmonary edema.
ANS: B
Continuous venous oxygen monitoring permits a calculation of the balance achieved between arterial
oxygen supply (
) and oxygen demand at the tissue level by sampling desaturated venous blood
from the PA catheter distal tip.
PTS: 1
DIF:
Cognitive Level: Understanding
REF: p. 222|Figure 14-22
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OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
20. A patient reports that he has been having “indigestion” for the last few hours. Upon further review the
nurse suspects the patient is having of chest pain. Cardiac biomarkers and a 12-lead electrocardiogram
(ECG) are done. What finding is most significant in diagnosing an acute coronary syndrome (ACS)
within the first 3 hours?
a. Inverted T waves
b. Elevated troponin I
c. Elevated B-type natriuretic peptide (BNP)
d. Indigestion and chest pain
ANS: B
The troponins are biomarkers for myocardial damage. The elevation of Troponin I and troponin T
occurs 3 to 6 hours after acute myocardial damage. Because troponin I is found only in cardiac
muscle, it is a highly specific biomarker for myocardial damage. B-type natriuretic peptide (BNP)
are usually drawn when heart failure is suspected, not acute coronary syndrome (ACS). Usually
within 4 to 24 hours from the onset of the infarction, abnormal Q waves begin to develop in the
affected leads, and T waves begin to invert.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 271
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. Which serum lipid value is a significant predictor of future acute myocardial infarction (MI)
in persons with established coronary artery atherosclerosis?
High-density lipoprotein (HDL) b.
c.
Low-density
lipoprotein
(LDL)
Triglycerides
d. Very-low-density lipoprotein
a.
ANS: B
Both the LDL-C and total serum cholesterol levels are directly correlated with risk for coronary
artery disease, and high levels of each are significant predictors of future acute myocardial
infarction in persons with established coronary artery atherosclerosis. LDL-C is the major
atherogenic lipoprotein and thus is the primary target for cholesterol-lowering efforts.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 274
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Which of the electrocardiogram (ECG) findings would be positive for an inferior wall
myocardial infarction (MI)?
a. ST segment depression in leads I, aVL, and V2 to V4
b. Q waves in leads V1 to V2
c. Q waves in leads II, III, and aVF
d. T-wave inversion in leads V4 to V6, I, and aVL
ANS: C
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Abnormal Q waves develop in leads overlying the affected area. An inferior wall infarction is seen
with changes in leads II, III, and aVF. Leads I and aVF are selected to detect a sudden change in
ventricular axis. If ST segment monitoring is required, the lead is selected according to the area of
ischemia. If the ischemic area is not known, leads V3 and III are recommended
to detect ST segment ischemia.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 246
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. A patient’s bedside electrocardiogram (ECG) strips show the following changes: increased PR
interval; increased QRS width; and tall, peaked T waves. Vital signs are temperature 98.2° F; heart
rate 118 beats/min; blood pressure 146/90 mm Hg; and respiratory rate 18 breaths/min. The patient is
receiving the following medications: digoxin 0.125 mg PO every day; D51/2 normal saline with 40
mEq potassium chloride at 125 mL/hr; Cardizem at 30 mg PO q8h; and aldosterone at 300 mg PO
q12h. The practitioner is notified of the ECG changes. What orders should the nurse expect to
receive?
a. Change IV fluid to D51/2 normal saline and draw blood chemistry.
b. Give normal saline with 40 mEq of potassium chloride over a 6-hour period.
c. Hold digoxin and draw serum digoxin level.
d. Hold Cardizem and give 500 mL normal saline fluid challenge over a 2-hour period.
ANS: A
The electrocardiographic (ECG) changes are most consistent with hyperkalemia. Removing the
potassium from the intravenous line and drawing laboratory values to check the potassium level is the
best choice with the least chance of further harm. Digoxin toxicity can be suspected related to the
prolonged PR interval, but hyperkalemia explains all the ECG changes. The patient is not
hypotensive or bradycardic, so holding the Cardizem is not indicated.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 269
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
24. A patient with a potassium level of 2.8 mEq/L is given 60 mEq over a 12-hour period. A repeat
potassium level is obtained, and the current potassium level is 3.2 mEq/L. In addition to
administering additional potassium supplements, what intervention should now be considered?
a. Discontinue spironolactone
b. Drawing a serum magnesium level
c. Rechecking the potassium level
d. Monitoring the patient’s urinary output
ANS: B
The patient should have serum magnesium level drawn. Hypomagnesemia is commonly associated
with other electrolyte imbalances, most notably alterations in potassium, calcium, and phosphorus.
Low serum magnesium levels can result from many causes.
PTS: 1
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REF: pp. 270-271
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
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MSC: NCLEX: Physiologic Integrity
25.
a.
b.
c.
d.
Which cardiac biomarker is elevated in decompensated heart failure?
Triglycerides
Troponin I
Troponin T
B-type natriuretic peptide (BNP)
ANS: D
In decompensated heart failure, ventricular distension from volume overload or pressure overload
causes myocytes in the ventricle to release B-type natriuretic peptide (BNP). With greater
ventricular wall stress, more natriuretic peptide is released from the myocardium, reflected as an
elevated BNP level. The BNP value is combined with the physical
examination, the 12-lead ECG, and a chest radiograph to increase the accuracy of heart failure
diagnosis. Troponins are elevated with acute coronary syndrome. Triglycerides are not a biomarker
and are reflective of lipids in the bloodstream.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 272
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. The physician is going to place a central venous catheter. Which anatomic site is associated with a
lower risk of infection?
a. Subclavian vein
b.
External jugular vein c.
Internal jugular vein d. Femoral
vein
ANS: A
The subclavian site should be used for insertion rather than jugular or femoral insertion sites to
minimize infection risk.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 209
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
27. Most chest radiographs of critically ill patients are obtained using a portable chest radiograph machine.
What is the difference between a chest radiograph taken in the radiology department and one taken in
the critical care unit?
a. Portable chest radiographs are usually clearer.
b. Only posterior views can be obtained in the critical care unit.
c. The sharpness of the structures is decreased with a portable chest radiograph.
d. Chest radiographs taken in radiology enlarge some thoracic structures.
ANS: C
In the supine radiograph with the patient lying flat on the bed, the x-ray tube can be only
approximately 36 inches from the patient’s chest because of ceiling height and x-ray equipment
construction. This results in a lower quality film from a diagnostic standpoint
because the images of the heart and great vessels are magnified and are not as sharply defined.
PTS: 1
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REF: p. 277
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
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MSC: NCLEX: Physiologic Integrity
28. A patient asks why he had to take a deep breath when the radiology technician took his chest
radiograph. Which statement is the best response?
a. “Deep breaths get the chest wall closer to the machine.”
b. “When the lungs are filled with air, you get a clearer picture.” c.
“Taking a deep breath decreases the error caused by motion.” d. “Holding
your breath makes the heart appear larger.”
ANS: B
A radiograph is taken when the patient has taken a deep breath (inspiration). During exhalation, the
lungs are less full of air, which can make the lung tissue appear “cloudy” as if there is additional lung
water. The heart also appears larger during exhalation. This could lead to an erroneous diagnosis of
heart failure.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 277
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29.
a.
b.
c.
d.
What is the most common complication of a central venous catheter (CVC)?
Air embolus
Infection
Thrombus formation
Pneumothorax
ANS: B
Infection related to the use of central venous catheters (CVCs) is a major problem. The incidence of
infection strongly correlates with the length of time the CVC has been inserted, with longer insertion
times leading to a higher infection rate. The risk of air embolus, although uncommon, is always
present for a patient with a central venous line in place. Air can enter during insertion through a
disconnected or broken catheter by means of an open stopcock, or air can enter along the path of a
removed CVC. Unfortunately, clot formation (thrombus) at
the CVC site is common. Thrombus formation is not uniform; it may involve development of
a fibrin sleeve around the catheter, or the thrombus may be attached directly to the vessel wall.
Pneumothorax has a higher occurrence during placement of a CVC than during removal.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 210
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
30. A physician orders removal of the central venous catheter (CVC) line. The patient has a diagnosis of
heart failure with chronic obstructive pulmonary disease. The nurse would place the patient in what
position for this procedure?
a. Supine in bed
b. Supine in a chair
c. Flat in bed
d. Reverse Trendelenburg position
ANS: A
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Recommended techniques to avoid air embolus during central venous catheter (CVC) removal
include removing the catheter when the patient is supine in bed (not in a chair) and placing the patient
flat or in the reverse Trendelenburg position if the patient’s clinical condition permits this maneuver.
Patients with heart failure, pulmonary disease, and neurologic conditions with raised intracranial
pressure should not be placed flat.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 211
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
31. Mechanical contraction of the heart occurs during which phase of the cardiac cycle?
a.
Phase 0 b.
Phase 2 c. Phase 3
d. Phase 4
ANS: B
During phases 1 and 2, an electrical plateau is created, and during this plateau, mechanical
contraction occurs. Because there is no significant electrical change, no waveform appears on the
electrocardiogram (ECG). During phase 0 (depolarization), the electrical potential changes rapidly
from a baseline of –90 mV to +20 mV and stabilizes at about 0 mV. Because this is a significant
electrical change, it appears as a wave on the ECG as the QRS. During phase 3 (repolarization), the
electrical potential again changes, this time a little more slowly, from 0 mV back to –90 mV. This is
another major electrical event and is reflected on the ECG as a T wave. During phase 4 (resting
period), the chemical balance is restored by the sodium pump, but because positively charged ions are
exchanged on a one-for-one basis, no electrical
activity is generated, and no visible change occurs on the ECG tracing.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 235
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
32. What does the P wave component of the electrocardiographic waveform represent?
a. Atrial contraction
b. Atrial depolarization
c. Sinus node discharge
d. Ventricular contraction
ANS: B
The P wave is an electrical event and represents atrial depolarization. Atrial contraction should
accompany the P wave but does not always. The sinus node discharge is too faint to be recorded on
the surface electrocardiogram. Ventricular contraction usually accompanies the QRS complex.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 239
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
33. Why is the measurement of the QT interval important?
a. It facilitates rhythm identification and is best assessed in Lead II.
b. It helps differentiate myocardial ischemia from infarction.
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c. An increasing QT interval increases the risk of torsades de pointes.
d. A decreasing QT interval increases the risk of torsades de pointes.
ANS: C
A prolonged QT interval is significant because it can predispose the patient to the development of
polymorphic ventricular tachycardia, known also as torsades de pointes. A long QT interval can be
congenital, as a result of genetic inheritance, or it can be acquired from an electrolyte imbalance or
medications.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 240
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
34.
a.
b.
c.
d.
Which lead is best to monitor a patient?
Varies based on the patient’s clinical condition and recent clinical history
Lead aVF
Lead V1
Lead II
ANS: A
The selection of an electrocardiographic monitoring lead is not a decision to be made casually or
according to habit. The monitoring lead should be chosen with consideration of the
patient’s clinical condition and recent clinical history. Lead II is recommended for monitoring of
atrial dysrhythmias. Lead V1 is recommended for monitoring of ventricular dysrhythmias. Leads I
and aVF are selected to detect a sudden change in ventricular axis.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 242
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
35. When performing a 12-lead electrocardiogram (ECG), how many wires are connected to the
patient?
3
5
10
12
a.
b.
c.
d.
ANS: C
The standard 12-lead electrocardiogram provides a picture of electrical activity in the heart using 10
different electrode positions to create 12 unique views of electrical activity occurring within the heart.
Fours wires are applied to the extremities to produce leads I, II, III, aVR, aVL, and aVF. Six wires are
attached to the V1 to V6 chest lead positions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: pp. 236-237
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
36. A patient returns from the cardiac catheterization laboratory after angioplasty and stent placement
(ECG changes had indicated an inferior wall myocardial infarction in progress). Which lead would
best monitor this patient?
a. Varies based on the patient’s clinical condition and recent clinical history
b. Lead V3
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c. Lead V1
d. Lead II
ANS: D
A
The selection of an electrocardiographic monitoring lead is not a decision to be made casually or
according to habit. The monitoring lead should be chosen with consideration of the
patient’s clinical condition and recent clinical history. Lead II is recommended for monitoring of
atrial dysrhythmias and would be appropriate in this case as due to inferior wall injuries. Lead V1 is
recommended for monitoring of ventricular dysrhythmias. Leads I and aVF are selected to detect a
sudden change in ventricular axis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 243
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
37. The patient’s admitting 12-lead ECG shows tall, peaked P waves. What diagnosis could be
responsible for this finding?
Mitral stenosis
Pulmonary edema
Ischemia
Pericarditis
a.
b.
c.
d.
ANS: B
Tall, peaked P waves occur in right atrial hypertrophy and are referred to as P pulmonale because
this condition is often the result of chronic pulmonary disease. Ischemia occurs when the delivery of
oxygen to the tissues is insufficient to meet metabolic demand. Cardiac ischemia in an unstable form
occurs because of a sudden decrease in supply, such as when the artery is blocked by a thrombus or
when coronary artery spasm occurs. If the pulmonary edema is caused by heart failure, sometimes
described as hydrostatic pulmonary edema, the fluid may be in a “bat-wing” distribution, with the
white areas concentrated in the hilar region (origin of the major pulmonary vessels). However, as the
heart failure progresses, the quantity of fluid in the alveolar spaces increases, and the white, fluffy
appearance is seen throughout the lung. Pericarditis is inflammation of the sac around the heart.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 245
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
38. A nurse is obtaining the history of a patient who reveals that he had an myocardial infarction (MI) 5
years ago. When the admission 12-lead electrocardiogram (ECG) is reviewed, Q waves are noted in
leads V3 and V4 only. Which conclusion is most consistent with this situation?
a. The patient may have had a posterior wall MI.
b. The patient must have had a right ventricular MI. c. The
admission 12-lead ECG was done incorrectly. d. The patient
may have had an anterior MI.
ANS: D
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Not every acute myocardial infarction (MI) results in a pathologic Q wave on the 12-lead
electrocardiogram (ECG). When the typical ECG changes are not present, the diagnosis depends
on symptomatic clinical presentation, specific cardiac biomarkers (eg, cTnI, cTnT,
CK-MB), and non-ECG diagnostic tests such as cardiac catheterization. Anterior and posterior wall
MIs have ST changes, not Q wave changes.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 246|Table 13-8
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
39. A new-onset myocardial infarction (MI) can be recognized by what electrocardiogram (ECG)
change?
Q waves
Smaller R waves
Widened QRS
ST segment elevation
a.
b.
c.
d.
ANS: D
Any change from baseline is expressed in millimeters and may indicate myocardial ischemia (one
small box equals 1 mm). ST segment elevation of 1 to 2 mm is associated with acute myocardial
injury, preinfarction, and pericarditis. ST segment depression (decrease from baseline more of 1 to 2
mm) is associated with myocardial ischemia. Widened QRS complexes are indicative of ventricular
depolarization abnormalities such as bundle branch blocks and ventricular dysrhythmias. Q waves and
smaller R waves are indications usually present 24 hours to 1 week after the myocardial infarction is
completely evolved; they represent necrosis.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 246
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
40. To accurately measure the heart rate of a patient in normal sinus rhythm, which technique would
be the most accurate?
The number of R waves in a 6-second strip
The number of large boxes in a 6-second strip
The number of small boxes between QRS complexes divided into 1500
The number of large boxes between consecutive R waves divided into 300
a.
b.
c.
d.
ANS: C
Calculation of heart rate if the rhythm is regular may be done using the following methods. Method
1: number of RR intervals in 6 seconds multiplied by 10 (eg, 8 ´ 10 = 80/min). Method 2: number
of large boxes between QRS complexes divided into 300 (eg, 300 ¸ 4 =
75/min). Method 3: number of small boxes between QRS complexes divided into 1500 (eg,
1500 ¸ 18 = 84/min).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 249
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
41. What is the initial intervention in a patient with sinus tachycardia with the following vital signs:
heart rate, 136 beats/min; blood pressure, 102/60 mm Hg; respiratory rate, 24 breaths/min;
temperature, 99.2° F; SpO2, 94% on oxygen 2 L/min by nasal cannula?
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a.
b.
c.
d.
Administer adenosine IV push.
Identify the cause.
Administer nitroglycerine 0.4 mg sublingual.
Administer lidocaine 75 mg IV push.
ANS: B
Sinus tachycardia can be caused by a wide variety of factors, such as exercise, emotion, pain, fever,
hemorrhage, shock, heart failure, and thyrotoxicosis. Many medications used in critical care can also
cause sinus tachycardia; common culprits are aminophylline, dopamine, hydralazine, atropine, and
catecholamines such as epinephrine. This patient has a stable heart rate and SpO2; therefore, there is
time to identify the cause of the sinus tachycardia. Lidocaine is indicated for ventricular
dysrhythmias. Nitroglycerine is not indicated because the patient is not having chest pain at this time.
Adenosine is usually not indicated unless the heart rate is greater than 150 beats/min.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 251
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
42. A patient presents with atrial flutter with an atrial rate of 280 beats/min and a ventricular rate of 70
beats/min. Which statement best explains this discrepancy in rates?
a. The ventricles are too tired to respond to all the atrial signals.
b. The atrioventricular (AV) node does not conduct all the atrial signals to the
ventricles.
c. Some of the atrial beats are blocked before reaching the AV node.
d. The ventricles are responding to a ventricular ectopic pacemaker.
ANS: B
The atrioventricular (AV) node does not allow conduction of all these impulses to the ventricles.
In this case, the rhythm would be described as atrial flutter with a 4:1 AV block, indicating that
only one of every four atrial signals is conducted to the ventricles.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 254
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
43.
a.
b.
c.
d.
Why is a new-onset of atrial fibrillation serious?
It increases the patient’s risk for a stroke.
It increases the patient’s risk for a deep venous thrombosis.
It may increase cardiac output to dangerous levels.
It indicates the patient is about to have a myocardial infarction.
ANS: A
In atrial fibrillation the atria do not contract normally; they quiver. This increases the chance of the
blood clotting in the atria because of a lack of complete emptying of the atria. These clots can break
free and cause embolic strokes and pulmonary emboli. Atrial fibrillation does not indicate impending
myocardial infarction or an increased risk of deep venous thrombosis. Atrial fibrillation decreases
cardiac output from the loss of atrial kick.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 257
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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44. Which electrocardiographic (ECG) abnormality is most often found in ventricular
dysrhythmias?
Retrograde P waves
Wide QRS complexes
No P waves
An inverted T wave
a.
b.
c.
d.
ANS: B
Ventricular dysrhythmias result from an ectopic focus in any portion of the ventricular myocardium.
The usual conduction pathway through the ventricles is not used, and the wave of depolarization must
spread from cell to cell. As a result, the QRS complex is prolonged and is always greater than 0.12
second. It is the width of the QRS, not the height that is important in the diagnosis of ventricular
ectopy.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 252
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
45. The patient has a heart rate (HR) of 84 beats/min and a stroke volume (SV) of 65 mL.
Calculate the cardiac output (CO).
a. 149 mL
b. 500 mL
c. 4650 mL
d. 5460 mL
ANS: D
Cardiac output (CO) is the product of heart rate (HR) multiplied by stroke volume (SV). SV is the
volume of blood ejected by the heart during each beat (reported in milliliters). 84 ´ 65 =
5460 mL.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 213
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
46. After a myocardial infarction, a patient presents with an increasing frequency of premature
ventricular contractions (PVCs). The patient's heart rate is 110 beats/min, and electrocardiogram
(ECG) indicates a sinus rhythm with up to five unifocal PVCs per minute. The patient is alert and
responsive and denies any chest pain or dyspnea. What action should the nurse take next?
a. Administer lidocaine 100 mg bolus IV push stat.
b. Administer Cardizem 20 mg IV push stat.
c. Notify the physician and monitor the patient closely.
d. Nothing; PVCs are expected in this patient.
ANS: C
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Although premature ventricular contractions (PVCs) are frequently present after myocardial
infarction, they are not always benign. In individuals with underlying heart disease, PVCs or episodes
of self-terminating ventricular tachycardia (VT) are potentially malignant. Nonsustained VT is
defined as three or more consecutive premature ventricular beats at a rate faster than 110 beats/min
lasting less than 30 seconds. The patient does not appear symptomatic from the PVCs at this time;
therefore, lidocaine is not indicated. Cardizem is not prescribed for ventricular ectopy.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 243|pp. 259-260
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
47. A patient becomes unresponsive. The patient’s heart rate is 32 beats/min in an idioventricular rhythm;
blood pressure is 60/32 mm Hg; SpO2 is 90%; and respiratory rate is 14 breaths/min. Which
intervention would the nurse do first?
a. Notify the physician and hang normal saline wide open.
b. Notify the physician and obtain the defibrillator.
c. Notify the physician and obtain a temporary pacemaker.
d. Notify the physician and obtain a 12-lead ECG.
ANS: C
If the sinus node and the atrioventricular (AV) junction fail, the ventricles depolarize at their own
intrinsic rate of 20 to 40 times per minute. This is called an idioventricular rhythm and is naturally
protective mechanism. Rather than trying to abolish the ventricular beats, the aim of treatment is to
increase the effective heart rate (HR) and reestablish dominance of a higher pacing site such as the
sinus node or the AV junction. Usually, a temporary pacemaker is used to increase the HR until the
underlying problems that caused failure of the other pacing sites can be resolved.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 262
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
48.
a.
b.
c.
d.
What effect does ventricular tachycardia have on cardiac output?
Increases cardiac output due to an increase in ventricular filling time
Decreases cardiac output due to a decrease in stroke volume
Increases cardiac output due to an increase in preload
Decreases cardiac output due to a decrease in afterload
ANS: B
Tachycardia is detrimental to anyone with ischemic heart disease because it decreases the time for
ventricular filling, decreases stroke volume, and compromises cardiac output. Tachycardia increases
heart work and myocardial oxygen demand while decreasing oxygen supply by decreasing coronary
artery filling time.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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49. The patient is admitted with a diagnosis of cardiogenic shock. The patient’s heart rate (HR) is
135 beats/min with weak peripheral pulses. The patient has bilaterally crackles in the bases of the
lungs. O2 saturation is 90% on 4L/NC. The practitioner orders diuretics and vasodilators. What
response should the nurse expect after starting the medications?
a. Decreased preload and afterload
b. Increased preload and afterload
c. Decreased preload and increased afterload
d. Increased preload and decreased afterload
ANS: A
Vasodilators are used to decrease afterload, and diuretics are used to decrease preload.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 215|p. 217
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
50. Which diagnostic tool can be used to detect structural heart abnormalities?
a. Echocardiogram
b. Electrocardiogram (ECG)
c. Exercise stress test
d. 24-hour Holter monitor
ANS: A
Echocardiography is used to detect structural heart abnormalities such as mitral valve stenosis and
regurgitation, prolapse of mitral valve leaflets, aortic stenosis and insufficiency, hypertrophic
cardiomyopathy, atrial septal defect, thoracic aortic dissection, cardiac tamponade, and pericardial
effusion.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 281
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
51. What is the target range for an international normalized ratio (INR)?
a. 1.0 to 2.0 b. 1.5
to 3.0 c. 1.5 to 2.5 d.
2.0 to 3.0
ANS: D
A target international normalized ratio of 2.5 (range, 2.0 to 3.0) is desirable.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 258
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
52. What type of atrioventricular (AV) block can be described as a gradually lengthening PR
interval until ultimately the final P wave in the group fails to conduct?
a. First-degree AV block
b. Second-degree AV block, type I c.
Second-degree AV block, type II d. Third-
degree AV block
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ANS: B
In Mobitz type I block, the atrioventricular (AV) conduction times progressively lengthen until a P
wave is not conducted. This typically occurs in a pattern of grouped beats and is observed on the
electrocardiogram (ECG) by a gradually lengthening PR interval until ultimately the final P wave in
the group fails to conduct. When all atrial impulses are conducted to the ventricles but the PR interval
is greater than 0.20 second, a condition known as first-degree AV block exists. Mobitz type II block is
always anatomically located below the AV node in the bundle of His in the bundle branches or even
in the Purkinje fibers. This results in an all-or-nothing situation with respect to AV conduction. Sinus
P waves are or are not conducted. When conduction does occur, all PR intervals are the same.
Because of the anatomic location of the block, on the surface, ECG the PR interval is constant and
the QRS complexes are wide. Third-degree, or complete, AV block is a condition in which no atrial
impulses can conduct from the atria to the ventricles. This is also described by the term complete
heart block.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 267
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
53. Which blood test standardizes prothrombin time (PT) results among worldwide clinical
laboratories?
a. aPTT b. ACT
c. HDL d. INR
ANS: D
The international normalized ratio (INR) was developed by the World Health Organization in
1982 to standardize prothrombin time results among clinical laboratories worldwide. High- density
lipoproteins (HDLs) are particles of the total serum cholesterol. Activated coagulation time (ACT) is
also known as the activated clotting time. The ACT is a point of care test that is performed outside of
the laboratory setting in areas such as the cardiac catheterization laboratory, the operating room, or
critical care units. The activated partial thromboplastin
time (aPTT) is used to measure the effectiveness of intravenous or subcutaneous
ultrafractionated heparin therapy.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 274
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
54. On returning from the cardiac catheterization laboratory, the patient asks if he can get up in the
chair. What should the nurse tell the patient?
“You cannot get up because you may pass out.”
“You cannot get up because you may start bleeding.”
“You cannot get up because you may fall.”
“You cannot get up until you urinate.”
a.
b.
c.
d.
ANS: B
After catheterization, the patient remains flat for up to 6 hours (varies by institutional protocol and
catheter size) to allow the femoral arterial puncture site to form a stable clot. Most bleeding occurs
within the first 2 to 3 hours after the procedure.
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PTS: 1
DIF: Cognitive Level: Applying
REF: p. 275
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
55. Which statement made by a patient would indicate the need for further education before an
electrophysiology procedure?
“I need to take all my heart medications the morning of the procedure.”
“The doctor is going to make my heart beat wrong on purpose.”
“I will be awake but relaxed during the procedure.”
“I will be x-rayed during the procedure.”
a.
b.
c.
d.
ANS: A
All antidysrhythmic medications are discontinued several days before the study so that any
ventricular dysrhythmias may be readily induced during the electrophysiology procedure (EPS).
Anticoagulants, especially warfarin, are also stopped before EPS. Premedication is administered
before the study to induce a relaxed state, and during the procedure, the patient is conscious but
receives sedative agents (midazolam) at regular intervals.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 276
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
56. A positive signal-averaged electrocardiogram (ECG) indicates that a patient is at risk for what
problem?
Myocardial infarction
Sudden cardiac death
Coronary artery disease
Stroke
a.
b.
c.
d.
ANS: B
A positive signal-averaged electrocardiogram (ECG)—in combination with other specific indicators—
is a predictor of increased risk for sudden cardiac death. Many patients with a positive signalaveraged ECG (abnormal) display a normal signal-averaged ECG when placed on antidysrhythmic
medications. The signal-averaged ECG is not analyzed in isolation. It is used in conjunction with
other cardiac diagnostic tests, including the electrophysiology study (EPS). It is a helpful adjunct to
the EPS but does not replace it.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 281
OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
57. Zeroing the pressure transducer on hemodynamic monitoring equipment occurs when the
displays reads which number?
a. 0
b. 250
c. 600
d. 760
ANS: A
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The monitor is adjusted so that “0” is displayed, which equals atmospheric pressure. Atmospheric
pressure is not zero; it is 760 mm Hg at sea level. Using zero to represent current atmospheric
pressure provides a convenient baseline for hemodynamic measurement
purposes.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 199
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
58. Which statement expresses the correct order when working with an invasive pressure
monitor?
a. Level the transducer, locate the phlebostatic axis, zero the transducer, and take the
reading.
b. Locate the phlebostatic axis, level the transducer, zero the transducer, and take the
reading.
c. Take the reading, level the transducer, locate the phlebostatic axis, and zero the
transducer.
d. Locate the phlebostatic axis, zero the transducer, level the transducer, and take the
reading.
ANS: B
The correct order is locate the phlebostatic axis, level the transducer, zero the transducer, and take
the reading. The transducer cannot be zeroed before it is leveled. Readings cannot be taken before
the transducer is zeroed, and leveling the transducer cannot occur until the phlebostatic axis has been
identified.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 199
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
59. A patient’s central venous pressure (CVP) reading suddenly increased from 10 to 48 mm Hg.
His lungs are clear except for fine rales at the bases. What should the nurse do next?
Nothing as this reading is still within normal limits.
Place a STAT call into the physician.
Administer ordered prn Lasix.
Check the level of the transducer.
a.
b.
c.
d.
ANS: D
If the transducer falls below the correct level, the reading would be falsely elevated. This rise is
consistent with a transducer having fallen from the correct level on the bed to the floor. Lasix is not
indicated. Central venous pressure (CVP) of 45 mm Hg, if true, is severely elevated. Not enough
information has been provided to call the physician. If the CVP value is true and the patient’s
condition is poor, a call to the physician would be appropriate after assessment.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 200
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
60. Why is the Allen test performed before placement of a radial arterial line placement?
a. To evaluate collateral circulation to the hand
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b. To estimate patency of the radial artery
c. To appraise the neurologic function of the hand
d. To assess the sensitivity of the insertion point
ANS: A
The Allen test involves occluding the radial or ulnar artery after blanching the hand. If the hand turns
pink, then the nonoccluded artery provides enough circulation to the hand. If the hand remains
blanched, then no collateral circulation exists, and that wrist should not be used for arterial line
placement.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 202
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
61.
a.
b.
c.
d.
Which statement regarding the use of cuff blood pressures is true?
Cuff pressures may be unreliable when a patient is in shock.
Cuff pressures are more accurate than arterial line pressures.
Cuff pressures and arterial line pressures should be nearly identical.
Cuff pressures should not be compared to arterial line pressures.
ANS: A
If the arterial line becomes unreliable or dislodged, a cuff pressure can be used as a reserve system. In
the normotensive, normovolemic patient, little difference exists between the arm cuff blood pressure
and the intravascular catheter pressure, and differences of 5 to 10 mm Hg do not generally alter
clinical management. The situation is different if the patient has a low cardiac output (CO) or is in
shock. The concern is that the cuff pressure may be unreliable because of peripheral vasoconstriction,
and an arterial line is generally required. It is usual practice to compare a cuff pressure after the
arterial line is inserted.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 202
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
62. A patient’s arterial line waveform has become damped. What action should the nurse take to correct
the situation?
Check for kinks, blood, and air bubbles in the pressure tubing.
Prepare for a normal saline fluid challenge for hypotension.
Discontinue the arterial line as it has become nonfunctional.
Check the patient’s lung sounds for a change in patient condition.
a.
b.
c.
d.
ANS: A
A damped waveform occurs when communication from the artery to the transducer is interrupted and
produces false values on the monitor and oscilloscope. Damping is caused by a fibrin “sleeve” that
partially occludes the tip of the catheter, by kinks in the catheter or tubing, or by air bubbles in the
system.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 206|Table 13-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
63. Patient education for a patient with a Holter monitor should include which instruction?
a. Keep a diary of activities, symptoms, and any medications that are taken.
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b. Do not drink coffee while the recorder is on.
c. Do not take a bath but a shower is alright.
d. Carry the monitor in a purse or backpack.
ANS: A
The patient should be instructed to keep a diary of activities, symptoms, and any medications that are
taken and to carry the monitor by a shoulder strap or clipped to a belt or pocket. The only activities
that are restricted while wearing a Holter monitor are those that would get the chest electrodes or
monitor wet, eliminating swimming and taking a shower or tub bath. The patient can drink coffee
during the test.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 279
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
64. A 55-year-old patient is scheduled for a stress test. What is the estimation of the patient’s
maximal predicted heart rate?
a. 65 beats/min b. 155
beats/min c. 165
beats/min d. 265
beats/min
ANS: C
The maximal predicted heart rate is estimated using the formula: 220 – Patient’s age: 220 – 55
= 165.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 280
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
65. Which of the following is most indicative of decreased left ventricular preload?
a. Increased pulmonary artery occlusion pressure (PAOP) b.
Decreased pulmonary artery occlusion pressure (PAOP) c.
Increased central venous pressure (CVP)
d. Decreased central venous pressure (CVP)
ANS: B
Pulmonary artery occlusion pressure (PAOP) normally reflect the pressure in the left ventricle at the
end of diastole. Left ventricular end-diastolic pressure is preload, and so an increase in preload will
first increase the PAOP measurements and vice versa. Central venous pressure changes are reflective
of right ventricular preload.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 213|Table 13-1
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
What is the effect of preload on cardiac output?
As preload increases, cardiac output increases.
As preload increases, cardiac output decreases.
As preload increases, cardiac output increases until it overstretches the ventricle and
cardiac output decreases.
d. Increased preload has no effect on cardiac output.
66.
a.
b.
c.
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ANS: C
According to the Frank-Starling law of the heart, if preload increases stroke volume, then cardiac
output may increase. If, however, preload causes excessive left ventricular stretch, it can actually
decrease cardiac output and may result in congestive heart failure.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 214
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
67. Which condition can cause an artificial increase in the pulmonary artery occlusion pressure
(PAOP)?
Aortic regurgitation
Aortic stenosis
Mitral stenosis
Mitral regurgitation
a.
b.
c.
d.
ANS: D
If mitral regurgitation is present, the mean pulmonary artery occlusion pressure reading is artificially
elevated because of abnormal backflow of blood from the left ventricle to the left atrium during
systole.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 215
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
68. The patient’s admitting 12-lead ECG shows wide, M-shaped P waves. What diagnosis could be
responsible for this finding?
Mitral stenosis
Chronic pulmonary disease
Hypotension
Pericarditis
a.
b.
c.
d.
ANS: A
Wide, M-shaped P waves are seen in left atrial hypertrophy and are called P mitrale because left atrial
hypertrophy is often caused by mitral stenosis.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 245
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
69. Identify the rhythm.
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a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: B
The electrocardiographic tracing in atrial fibrillation is notable for an uneven atrial baseline that lacks
clearly defined P waves and instead shows rapid oscillations or fibrillatory wavelets that vary in size,
shape, and frequency. Junctional escape rhythm has a rate of 40 to 60 beats/min and regular rhythm
but P waves maybe present or absent, inverted in lead II, PR interval less than 0.12 second, and QRS
complex is 0.06 to 0.10 seconds. With premature ventricular contractions, the QRS can manifest in
an unlimited number of shapes or patterns. If all of the ventricular ectopic beats look the same in a
particular lead, they are called unifocal, which means that they probably all result from the same
irritable focus. Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100
times or more per minute, usually maintained by a re-entry mechanism within the ventricular tissue.
The complexes are wide, and the rhythm may be slightly irregular, often accelerating as the
tachycardia continues.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 256
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
70. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: A
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Under normal conditions, the junction never has a chance to escape and depolarize the heart because
it is overridden by the sinus node. However, if the sinus node fails, the junctional impulses can
depolarize completely and pace the heart. In this strip, the ventricular rate is 38. P waves are absent,
and the QRS has a normal width.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 260
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
71. Identify the rhythm.
a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: C
When all of the ventricular ectopic beats look the same in a particular lead, they are called unifocal,
which is what is shown in this strip. This means that they probably all result from the same irritable
focus.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 260
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
72. Identify the rhythm.
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a.
b.
c.
d.
Junctional escape rhythm
Atrial fibrillation
Unifocal premature ventricular contractions
Ventricular tachycardia
ANS: D
Ventricular tachycardia is caused by a ventricular pacing site firing at a rate of 100 times or more per
minute, usually maintained by a re-entry mechanism within the ventricular tissue. The complexes are
wide, and the rhythm may be slightly irregular, often accelerating as the tachycardia continues. In
most cases, the sinus node is not affected, and it continues to depolarize the atria on schedule. P waves
can sometimes be seen on the electrocardiographic tracing. They are not related to the QRS and may
even appear to conduct a normal impulse to the ventricles if their timing is just right.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 263
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
73. Identify the rhythm.
a.
b.
c.
d.
Ventricular tachycardia
Ventricular fibrillation
Supraventricular tachycardia
Torsades de pointes
ANS: B
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On an electrocardiogram, ventricular fibrillation appears as a continuous, undulating pattern without
clear P, QRS, or T waves.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 264
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
74. Which noninvasive imaging technique is useful in diagnosing complications of a myocardial
infarction (MI)?
12-lead ECG
CT
MRI
Echocardiography
a.
b.
c.
d.
ANS: C
Magnetic resonance imaging is useful in diagnosing complications of myocardial infarction, such as
pericarditis or pericardial effusion, valvular dysfunction, ventricular septal rupture, aneurysm, and
intracardiac thrombus. Computed tomography is used to calculate the coronary artery calcium score.
Echocardiography uses ultrasound reflected best at interfaces between tissues that have different
densities. In the heart, these are the blood, cardiac valves, myocardium, and pericardium. Because all
these structures differ in density, their borders can be seen on the echocardiogram. The standard 12lead electrocardiogram provides a picture of electrical activity in the heart using 10 different
electrode positions to create 12 unique views of electrical activity occurring within the heart.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 284
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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Chapter 14: Cardiovascular Disorders
Urden: Critical Care Nursing, 9th
EditionEdition
MULTIPLE CHOICE
1.
a.
b.
c.
d.
Which statement about coronary artery disease (CAD) is accurate?
There is a low correlation between modifiable risk factors and CAD.
The onset of CAD occurs in middle age women sooner than men of the same age.
There is an association between development of specific risk factors and CAD.
The lower the C-reactive protein level the higher the risk for a coronary event.
ANS: C
Research and epidemiologic data collected during the past 50 years have demonstrated a strong
association between specific risk factors and the development of coronary artery disease (CAD).
In general, CAD symptoms are seen in persons age 45 years and older. Primary cardiovascular
risk factors are different in men and women, with women having higher rates of diabetes and
hypertension compared with men. C-reactive protein (CRP) is associated with an increased risk
for development of other cardiovascular risk factors
including diabetes, hypertension, and weight gain. The higher the value, the greater the risk of a
coronary event, especially if all other potential causes of systemic inflammation such as infection
can be ruled out.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 290
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. Which value, when elevated, places the patient at lowest risk for coronary artery disease
(CAD)?
Very-low-density lipoproteins (VLDLs)
Triglycerides
Low-density lipoproteins (LDLs)
High-density lipoproteins (HDLs)
a.
b.
c.
d.
ANS: D
All of the reasons are not completely understood, but one recognized physiologic effect is the
ability of high-density lipoprotein (HDL) to promote the efflux of cholesterol from cells. This
process may minimize the accumulation of foam cells in the artery wall and thus decrease the risk
of developing atherosclerosis. High HDL levels confer both antiinflammatory and antioxidant
benefits on the arterial wall. In contrast, a low HDL level is an independent risk factor for the
development of CAD and other atherosclerotic conditions.
PTS: 1
DIF: Cognitive Level: Remembering
REF: pp. 290-291|Table 14-1
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. The nurse is caring for a patient with these vital signs: blood pressure 220/110, pulse 108,
respiratory rate 24, temperature 103° F, and oxygen saturation of 94% on oxygen 2L nasal cannula.
The patient is responsive and denies chest pain. The physician has ordered a work-up for coronary
artery disease (CAD). These findings are suggestive of which diagnosis?
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a.
b.
c.
d.
Silent ischemia
Prehypertension
Stage 1 hypertension
Stage 2 hypertension
ANS: D
Stage 2 hypertension is defined as a systolic blood pressure of 160 mm Hg or above and a diastolic
blood pressure of 100 mm Hg or above.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 348|Table 14-2
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. Which statement regarding the difference between stable and unstable angina is accurate?
a. Stable angina responds predictably well to nitrates.
b. Stable angina is not precipitated by activity.
c. Stable angina has a low correlation to coronary artery disease (CAD).
d. Stable angina is a result of coronary artery spasm.
ANS: A
Stable angina is predictable and caused by similar precipitating factors each time; typically, it is
exercise induced. Pain control is usually achieved by rest and by sublingual nitroglycerin within 5
minutes. Stable angina is the result of fixed lesions (blockages) of more than 75% of the coronary
artery lumen and thus has a high correlation to coronary artery disease (CAD), not coronary spasm.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
5. The nursing management plan for a patient with angina would include which intervention?
a. Immediate administration of antiplatelet therapy
b. Teaching the patient how to perform the Valsalva maneuver
c. Assessment and documentation of chest pain episodes
d. Administration of prophylactic lidocaine for ventricular ectopy
ANS: C
Nursing interventions focus on early identification of myocardial ischemia, control of chest pain,
recognition of complications, maintenance of a calm environment, and patient and family education. It
is important to document the characteristics of the pain and the patient’s heart rate and rhythm, blood
pressure, respirations, temperature, skin color, peripheral pulses, urine output, mentation, and overall
tissue perfusion. It is essential to teach avoidance of the Valsalva maneuver, which is defined as forced
expiration against a closed glottis.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Planning
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. Why do women have higher mortality rates from acute myocardial infarction (MI) than men?
a. Women wait longer to seek medical care.
b. Women have more risk factors for coronary artery disease than men.
c. Women have a higher risk of coronary spasm than men.
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d. Women have smaller hearts than men.
ANS: A
Many reasons contribute to higher mortality rates from acute myocardial infarction (MI) in women,
and these include waiting longer to seek medical care, having smaller coronary arteries, being older
when symptoms occur, and experiencing very different symptoms from those of men of the same age.
Women do not have a higher risk of coronary spasm than men.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 293
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. What dysrhythmia is most frequently associated with sudden cardiac death?
a. Premature ventricular contractions
b. Ventricular tachycardia
c. Third degree heart block
d. Asystole
ANS: B
When the onset of symptoms is rapid, the most likely mechanism of death is ventricular
tachycardia, which degenerates into ventricular fibrillation.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 306|p. 315
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. Assessment of a patient with pericarditis may reveal which signs and symptoms?
a. Ventricular gallop and substernal chest pain
b. Narrowed pulse pressure and shortness of breath
c. Pericardial friction rub and pain
d. Pericardial tamponade and widened pulse pressure
ANS: C
Pain is the most common symptom of pericarditis, and a pericardial friction rub is the most common
initial sign. A friction rub is best auscultated with a stethoscope at the sternal border and is described as
a grating, scraping, or leathery scratching. Pericarditis frequently produces a pericardial effusion.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 311
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. What are the clinical manifestations of right-sided heart failure?
a. Elevated central venous pressure and sacral edema
b. Pulmonary congestion and jugular venous distention
c. Hypertension and chest pain
d. Liver tenderness and pulmonary edema
ANS: A
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The common manifestations of right ventricular failure are the following: jugular venous
distention, elevated central venous pressure, weakness, peripheral or sacral edema,
hepatomegaly (enlarged liver), jaundice, and liver tenderness. Gastrointestinal symptoms include
poor appetite, anorexia, nausea, and an uncomfortable feeling of fullness.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 320
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
10. Which intervention is an essential aspect of the patient teaching plan for the patient with
chronic heart failure?
Instructing the patient to call the practitioner prior to dental surgery
Stressing the importance of compliance with diuretic therapy
Instructing the patient to take nitroglycerin if chest pain occurs
Teaching the patient how to take an apical pulse
a.
b.
c.
d.
ANS: B
Primary topics of education include (1) the importance of a daily weight, (2) fluid restrictions, and (3)
written information about the multiple medications used to control the symptoms of heart failure.
Reduction or cessation of diuretics usually results in sodium and water retention, which may
precipitate heart failure.
PTS: 1
DIF: Cognitive Level: Creating
REF: p. 326
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
11. In the acute phase after ST segment elevation myocardial infarction (STEMI), fibrinolytic therapy is
used in combination with heparin to recanalize the coronary artery. What dosage is the initial heparin
bolus?
a. 60 units/kg maximum 5000 units
b. 30 units/kg maximum 3000 units
c. 25 units/kg maximum of 2500 units
d. 12 units/kg maximum of 1000 units
ANS: A
In the acute phase after ST segment elevation myocardial infarction, heparin is administered in
combination with fibrinolytic therapy to recanalize (open) the coronary artery. For patients who will
receive fibrinolytic therapy, an initial heparin bolus of 60 units/kg (maximum, 5000 units) is given
intravenously followed by a continuous heparin drip at 12 units/kg/hr (maximum 1000 units/hr) to
maintain an activated partial thromboplastin time between 50 and
70 seconds (1.5 to 2.0 times control).
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 313
OBJ: Nursing Process Step: N/A
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
12. The nurse is caring for a patient with left-sided heart failure. The nurse suspects the patient is
developing pulmonary edema. Which finding would confirm the nurse’s suspicions?
a. Pulmonary crackles
b. Peripheral edema
c. Pink, frothy sputum
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d. Elevated central venous pressure
ANS: C
Patients experiencing heart failure and pulmonary edema are extremely breathless and anxious and
have a sensation of suffocation. They expectorate pink, frothy sputum and feel as if they are
drowning. They may sit bolt upright, gasp for breath, or thrash about. The respiratory rate
is elevated, and accessory muscles of ventilation are used, with nasal flaring and bulging neck
muscles. Respirations are characterized by loud inspiratory and expiratory gurgling sounds.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 324
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. A patient is admitted with hypertrophic cardiomyopathy. The nurse would expect the medical
management of this patient to include which intervention?
a. Administration of beta-blockers
b. Administration of positive inotropes c. Plans
for intensive exercise regimen d. Plans for an
aortic valve replacement
ANS: A
Pharmacologic management includes beta-blockers to decrease left ventricular workload,
medications to control and prevent atrial and ventricular dysrhythmias, anticoagulation if atrial
fibrillation or left ventricular thrombi are present, and, finally, drugs to manage heart failure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 327
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. The nurse is developing a patient education plan for a patient with valvular heart disease.
Which instruction would be included as part of that plan?
Increase fluid intake to increase cardiac output.
Take sodium replacement tablets to replace sodium lost with diuretics.
Increase daily activity until shortness of breath occurs.
Take prophylactic antibiotics before undergoing any invasive procedure.
a.
b.
c.
d.
ANS: D
Education for the patient with acute or chronic heart failure secondary to valvular dysfunction
includes (1) information related to diet, (2) fluid restrictions, (3) the actions and side effects of heart
failure medications, (4) the need for prophylactic antibiotics before undergoing any invasive
procedures such as dental work, and (5) when to call the health care provider to
report a negative change in cardiac symptoms.
PTS: 1
DIF: Cognitive Level: Creating
REF: p. 342
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
15. A patient has been admitted in hypertensive crisis. Which medication would the nurse expect the
practitioner to order for this patient?
a. Digitalis
b. Vasopressin
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c. Verapamil
d. Sodium nitroprusside
ANS: D
Sodium nitroprusside is frequently the first drug used to lower blood pressure in hypertensive
emergency. Sodium nitroprusside is useful because of its half-life of seconds. It is not suitable for
long-term use because of development of a metabolite that causes cyanide-like toxicity. Short-acting
beta-blockers that are effective are labetalol and esmolol. Beta-blockers are especially effective if
aortic dissection is present. Digoxin is frequently prescribed for atrial fibrillation.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 352-353
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. Which description best describes the pain associated with aortic dissection?
a. Substernal pressure
b. Tearing in the chest, abdomen, or back c.
Numbness and tingling in the left arm d.
Stabbing in the epigastric area
ANS: B
The classic clinical presentation is the sudden onset of intense, severe, tearing pain, which may be
localized initially in the chest, abdomen, or back. As the aortic tear (dissection) extends, pain radiates
to the back or distally toward the lower extremities. Many patients have hypertension upon initial
presentation, and the focus is on control of blood pressure and early operation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 343
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. Which clinical manifestation is usually the first symptom of peripheral arterial disease (PAD)?
a. Cramping when walking
b. Thrombophlebitis
c. Pulmonary embolism
d. Cordlike veins
ANS: A
Arterial occlusion obstructs blood flow to the distal extremity. The lack of blood flow produces
ischemic muscle pain known as intermittent claudication. This cramping, aching
pain while walking is often the first symptom of peripheral arterial occlusive disease. The pain is
relieved by rest and may remain stable in occurrence and intensity for many years.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 346
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
18. The nurse developing a patient education plan for the patient with endocarditis. What
information would be included in the plan?
a. Endocarditis is a viral infection that is easily treated with antibiotics.
b. The risk of this diagnosis is occlusion of the coronary arteries.
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c. A long course of antibiotics is needed to treat this disorder.
d. Complications are rare after antibiotics have been started.
ANS: C
Treatment requires prolonged IV therapy with adequate doses of antimicrobial agents tailored to the
specific infective endocarditis microbe and patient circumstances. Antibiotic treatment
is prolonged, administered in high doses intravenously, and may involve combination therapy. Best
outcomes are achieved if therapy is initiated before hemodynamic compromise.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 355
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Health Promotion and Maintenance
19. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram
(ECG) is done to validate the area of infarction. Which finding on the ECG is most conclusive for
infarction?
a. Inverted T waves
b. Tall, peaked T waves
c. ST segment depression
d. Pathologic Q waves
ANS: D
The changes in repolarization are seen by the presence of new Q waves. These new, pathologic Q
waves are deeper and wider than tiny Q waves found on the normal 12-lead ECG.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 301
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
20. A patient is admitted with an acute inferior myocardial infarction (MI). A 12-lead electrocardiogram
(ECG) is done to validate the area of infarction. Which leads on the ECG would correlate with an
inferior wall MI?
a. II, III, aVF
b. V5 to V6, I, aVL
c. V2 to V4
d. V1 to V2
ANS: A
Inferior infarctions are manifested by electrocardiographic (ECG) changes in leads II, III, and aVF.
Lateral wall infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Anterior wall
infarctions are manifested by ECG changes in leads V2 to V4. Posterior wall infarctions are
manifested by ECG changes in leads V1 to V2.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 307
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
21. A patient is admitted with an acute myocardial infarction (MI). What common complication should
the nurse anticipate in this patient?
a. Pulmonary edema
b. Cardiogenic shock
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c. Dysrhythmias
d. Deep vein thrombosis
ANS: C
Many patients experience complications occurring either early or late in the postinfarction course.
These complications may result from electrical dysfunction or from a cardiac contractility problem.
Cardiac monitoring for early detection of ventricular dysrhythmias is ongoing. Pumping
complications can cause heart failure, pulmonary edema, and cardiogenic shock. The presence of a
new murmur in a patient with an acute myocardial infarction warrants special attention because it
may indicate rupture of the papillary muscle. The
murmur can be indicative of severe damage and impending complications such as heart failure and
pulmonary edema.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 304
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Which classification of dysrhythmia is most common with an inferior wall infarction in the first
hour after ST segment elevation myocardial infarction (STEMI)?
Sinus tachycardia b.
Multifocal PVCs c. Atrial
fibrillation d.
Sinus
bradycardia
a.
ANS: D
Sinus bradycardia (heart rate less than 60 beats/min) occurs in 30% to 40% of patients who sustain
an acute myocardial infarction (MI). It is more prevalent with an inferior wall infarction in the first
hour after ST segment elevation MI. Sinus tachycardia (heart rate more than 100 beats/min) most
often occurs with an anterior wall MI. Premature atrial contractions (PACs) occur frequently in
patients who sustain an acute MI. Atrial fibrillation is also common and may occur spontaneously or
may be preceded by PACs. Premature ventricular contractions (PVCs) are seen in almost all patients
within the first few hours after an MI.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 304
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. Which laboratory value indicates a heightened risk for the development of coronary artery
disease (CAD)?
Total cholesterol level of 170 mg/dL
HDL cholesterol level of 30 mg/dL
Triglyceride level of 120 mg/dL
LDL cholesterol level >190 mg/dL
a.
b.
c.
d.
ANS: D
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Low-density lipoprotein (LDL) cholesterol is usually described as the “bad cholesterol” because
high levels are associated with an increased risk of acute coronary syndrome (ACS), stroke, and
peripheral arterial disease (PAD). High LDL levels initiate the atherosclerotic process by infiltrating
the vessel wall and binding to the matrix of cells beneath the endothelium. Total cholesterol levels
below 200 are considered normal. High-density lipoprotein (HDL) cholesterol levels below 40 are at
low risk of coronary artery disease. Triglyceride levels below 150 are considered normal.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 291
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
24. A patient with coronary artery disease (CAD) is admitted with chest pain. The patient is suddenly
awakened with severe chest pain. Three nitroglycerin sublingual tablets are administered 5 minutes
apart without relief. A 12-lead electrocardiograph (ECG) reveals nonspecific ST segment elevation.
The nurse suspects the patient may have which disorder? a. Silent ischemia
b. Stable angina
c. Unstable angina
d. Prinzmetal angina
ANS: C
Unstable angina usually is more intense than stable angina, may awaken the person from sleep, or
may necessitate more than nitrates for pain relief. A change in the level or frequency of symptoms
requires immediate medical evaluation. Severe angina that persists for more than
5 minutes, worsens in intensity, and is not relieved by one nitroglycerin tablet is a medical
emergency. Stable angina is predictable and caused by similar precipitating factors each time;
typically, it is exercise induced. Patients become used to the pattern of this type of angina and may
describe it as “my usual chest pain.” Pain control should be achieved within 5 minutes of rest and by
taking sublingual nitroglycerin. Silent ischemia describes a situation in which objective evidence of
ischemia is observed on an electrocardiographic monitor but the person does not complain of anginal
symptoms. Variant unstable angina, or Prinzmetal angina, is caused by a dynamic obstruction from
intense vasoconstriction of a coronary artery. Spasm can occur with or without atherosclerotic
lesions. Variant angina commonly occurs when the individual is at rest, and it is often cyclic,
occurring at the same time every day.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 298
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
25. A patient has been newly diagnosed with stable angina. He tells the nurse he knows a lot
about his diagnosis already because his father had the same diagnosis 15 years ago. The nurse asks
him to state what he already knows about angina. Which response indicates the need for additional
education?
a. He should stop smoking.
b. He can no longer drink colas or coffee.
c. He can no longer get a strong back massage.
d. He should take stool softeners to prevent straining.
ANS: C
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Longer term education of the patient and the family can begin. Points to cover include (1) risk factor
modification, (2) signs and symptoms of angina, (3) when to call the physician, (4) medications, and
(5) dealing with emotions and stress. It is essential to teach avoidance of the Valsalva maneuver,
which is defined as forced expiration against a closed glottis. This can be explained to the patient as
“bearing down” during defecation or breath holding when repositioning in bed. Relaxation therapy
and techniques including back rubs are encouraged when appropriate.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 301
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. A patient presents with severe substernal chest pain. The patient exclaims, “This is the most severe
pain I have ever felt!” The patient reports that the pain came on suddenly about 2 hours ago and that
three sublingual nitroglycerin tablets have not relieved the pain. The 12-lead electrocardiogram
(ECG) reveals only the following abnormalities: T-wave inversion in leads I, aVL, V4, and V5;
pathologic Q waves in leads II, III, and aVF; ST segment elevation in leads V1, V2, V3, and V4.
Which statement is accurate about this patient?
a. This patient has an old lateral wall infarction.
b. This patient is having an inferior wall infarction.
c. This patient is having an acute anterior wall infarction.
d. This patient is having a posterior wall infarction.
ANS: C
Acute anterior wall infarctions are manifested by electrocardiographic (ECG) changes in leads V2 to
V4. Inferior infarctions are manifested by ECG changes in leads II, III, and aVF. Lateral wall
infarctions are manifested by ECG changes in leads V5 to V6, I, and aVL. Posterior wall infarctions
are manifested by ECG changes in leads V1 to V2.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: p. 303
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
27. A patient was admitted 3 days ago with an acute myocardial infarction (MI). The patient complains
of fatigue, not sleeping the past two nights, and change in appetite. Based on these findings the nurse
suspects the patient may be experiencing which problem?
a. Angina
b. Anxiety
c. Depression
d. Endocarditis
ANS: C
Depression is a phenomenon that occurs across a wide spectrum of human experience. Key
symptoms of depression mentioned frequently by cardiac patients are fatigue, change in appetite,
and sleep disturbance.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 314
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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28. Patient is admitted with heart failure. The patient has developed dyspnea with wheezing, a
nonproductive cough, and pulmonary crackles that progress to the gurgling sounds of pulmonary
edema. The nurse suspects the patient may be developing with problem?
a. Dyspnea
b. Orthopnea
c. Paroxysmal nocturnal dyspnea
d. Cardiac asthma
ANS: D
Dyspnea with wheezing, a nonproductive cough, and pulmonary crackles that progress to the
gurgling sounds of pulmonary edema are symptoms of cardiac asthma. With dyspnea, the patient
feels shortness of breath from pulmonary vascular congestion and decreased lung compliance. In
orthopnea, the patient has difficulty breathing when lying flat because of an increase in venous
return that occurs in the supine position. Paroxysmal nocturnal dyspnea is a severe form of
orthopnea in which the patient awakens from sleep gasping for air.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 324
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29. A patient is admitted for palliative care for end-stage heart failure. What is the nurse’s primary goal
when caring for this patient?
To reverse heart failure with the use of diuretics
To increase activity tolerance
To manage symptoms and relieve pain
To increase cardiac output related to alteration of contractility
a.
b.
c.
d.
ANS: C
The primary aim of palliative care is symptom management and the relief of suffering.
Fundamental to all symptom management strategies for heart failure is the optimization of
medications, according to current guidelines.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 325
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
30. A patient is admitted with a fever of unknown origin. The patient is complaining of fatigue, malaise,
joint pain, and shivering. The patient’s vital signs include temperature, 103° F; heart rate, 90
beats/min; respiratory rate, 22 breaths/min; blood pressure, 132/78; and oxygen saturation, 94% on
2L nasal cannula. The patient has developed a cardiac murmur. The nurse suspects that the patient
has developed which problem?
a. Coronary artery disease
b. Heart failure
c. Endocarditis
d. Pulmonary embolus
ANS: C
Initial symptoms include fever, sometimes accompanied by rigor (shivering), fatigue, and malaise,
with up to 50% of patients complaining of myalgias and joint pain. Blood cultures are drawn
during periods of elevated temperature.
PTS: 1
DIF:
Cognitive Level: Remembering
REF: p. 336
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OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
TOP: Cardiovascular
31. At what size is an aortic aneurysm evaluated for surgical repair or stent placement?
a. 2 cm b. 4
cm c. 5 cm
d. >5 cm
ANS: D
An aneurysm smaller than 4 cm in diameter can be managed on an outpatient basis with frequent
blood pressure monitoring and ultrasound testing to document any changes in the size of the
aneurysm. Management includes weight loss, smoking cessation, and control of hypertension as
appropriate. An aortic aneurysm larger than 5 cm in diameter requires evaluation for surgical
repair or placement of an aortic stent to eliminate the risk of rupture.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 343
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. Which physiologic effects can be associated with physical exercise? (Select all that apply.)
a.
Decreased LDL cholesterol b.
Increased HDL cholesterol c.
Decreased triglycerides
d. Increased insulin resistance
e. Decreased incidence of depression
ANS: A, B, C, E
Many research trials have demonstrated the positive effects of physical activity on the other major
cardiac risk factors. Exercise alters the lipid profile by decreasing low-density lipoprotein (LDL)
cholesterol and triglyceride levels and increasing high-density lipoprotein (HDL) cholesterol levels.
Exercise reduces insulin resistance at the cellular level, lowering the risk for developing type 2
diabetes, especially if combined with a weight loss program.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 292
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders
MSC: NCLEX: Physiologic Integrity
2. Which clinical manifestations are indicative of left ventricular failure? (Select all that apply.)
a. Cool, pale extremities
b. Jugular venous distention
c. Liver tenderness
d. Weak peripheral pulses
e. Rales
ANS: A, D, E
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Patients presenting with left ventricular failure have one of the following: (1) decreased exercise
tolerance, (2) fluid retention, or (3) discovery during examination of noncardiac problems. Clinical
manifestations of left ventricular failure include decreased peripheral perfusion with weak or
diminished pulses; cool, pale extremities; and, in later stages, peripheral cyanosis.
PTS: 1
DIF: Cognitive Level: Analyzing
REF: pp. 318-319
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Disorders
MSC: NCLEX: Physiologic Integrity
3. Which mechanisms responsible for a myocardial infarction (MI)? (Select all that apply.)
a. Coronary artery thrombosis
b. Plaque rupture
c. Coronary artery spasm near the ruptured plaque
d. Preinfarction angina
e. Hyperlipidemia
ANS: A, B, C
The three mechanisms that block the coronary artery and are responsible for the acute reduction in
oxygen delivery to the myocardium are (1) plaque rupture, (2) new coronary artery thrombosis, and (3)
coronary artery spasm close to the ruptured plaque.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 301
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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Chapter 15: Cardiovascular Therapeutic Management
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE CHOICE
1. The possibility of microshock when handling a temporary pacemaker can be minimized by
which intervention?
a. Decreasing the milliamperes
b. Wearing gloves
c. Positioning the patient on the left side
d. Wearing rubber-soled shoes
ANS: B
The possibility of “microshock” can be minimized by wearing gloves when handling the pacing
wires and by proper insulation of terminal pins of pacing wires when they are not in
use. The latter can be accomplished either by using caps provided by the manufacturer or by
improvising with a plastic syringe or section of disposable rubber glove. The wires are to be taped
securely to the patient’s chest to prevent accidental electrode displacement.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 366|Box 15-6
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Safe and Effective Care Environment
2. Which hemodynamic alteration is the most common cause of a decrease in cardiac output in the
postoperative cardiovascular patient?
a. Reduced preload
NURSINGTB.COM
b. Increased afterload
c. Increased contractility
d. Bradycardia
ANS: A
In most patients, reduced preload is the cause of low postoperative cardiac output. To enhance
preload, volume may be administered in the form of crystalloid, colloid, or packed red blood cells.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 386
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
3. A patient has an implantable cardioverter defibrillator (ICD) for chronic ventricular
tachydysrhythmias. What action should the nurse take when the patient’s rhythm deteriorates to
ventricular fibrillation?
a. Apply an external defibrillator to the patient.
b. Call a code and start cardiopulmonary resuscitation (CPR) on the patient.
c. Wait for the ICD to defibrillate the patient.
d. Turn the ICD off and administer epinephrine.
ANS: C
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If the dysrhythmia deteriorates into ventricular fibrillation, the implantable cardioverter defibrillator
is programmed to defibrillate at a higher energy. If the dysrhythmia terminates spontaneously, the
device will not discharge.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 368
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
4. How does a percutaneous transluminal coronary angioplasty (PTCA) improve blood flow?
a. The balloon stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.
b. Medication is delivered through the catheter that dissolves the plague and enhances vessel
patency.
c. The balloon removes blood clots from the vessel improving patency of the vessel.
d. The balloon compresses the plaque against the vessel wall enlarging the vessel lumen.
ANS: A
Percutaneous transluminal coronary angioplasty involves the use of a balloon-tipped catheter that,
when advanced through an atherosclerotic lesion (atheroma), can be inflated intermittently for the
purpose of dilating the stenotic area and improving blood flow through it. The high balloon-inflation
pressure stretches the vessel wall, fractures the plaque, and enlarges the vessel lumen.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 374-375
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
NURSINGTB.COM
5. What is the rationale for administrating a fibrinolytic agent to a patient experiencing acute
ST-elevation myocardial infarction (STEMI)?
a. Dilation of the blocked coronary artery
b. Anticoagulation to prevent formation of new emboli
c. Dissolution of atherosclerotic plaque at the site of blockage
d. Restoration of blood flow via lysis of the thrombus
ANS: D
The administration of a fibrinolytic agent results in the lysis of the acute thrombus, thus recanalizing,
or opening, the obstructed coronary artery and restoring blood flow to the affected tissue. After
perfusion is restored, adjunctive measures are taken to prevent further clot formation and reocclusion.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 370
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
6. A nurse is providing care to a patient on fibrinolytic therapy. Which of the following statements
from the patient warrants further assessment and intervention by the nurse? a. “My back is killing
me!”
b. “There is blood on my toothbrush!”
c. “Look at the bruises on my arms!”
d. “My arm is bleeding where my IV is!”
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ANS: A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding
and oozing around venipuncture sites are common and not causes for concern.
However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious
bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation
factors, or both are administered.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 373|Box 15-12
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
7. Which finding is a reliable indicator of reperfusion after fibrinolytic therapy?
a. Dysrhythmias
b. Q waves
c. Elevated ST segments
d. Immediate rapid decrease in cardiac biomarkers
ANS: A
Initially, when there is reperfusion, ischemic chest pain ceases abruptly as blood flow is restored.
Another reliable indicator of reperfusion is the appearance of various “reperfusion” dysrhythmias.
Premature ventricular contractions, bradycardias, heart block, ventricular tachycardia, and (rarely)
ventricular fibrillation may occur.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 373
OBJ: Nursing Process Step: Evaluation TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
8. What is the most common coN
mU
pR
licS
atI
ioN
nG
oT
f fB
ib.
riC
noOlyMtic therapy?
a. Reperfusion chest pain
b. Lethargy
c. Bleeding
d. Heart blocks
ANS: C
The most common complication related to thrombolysis is bleeding.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 373
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
9. Which mechanism is responsible for the augmentation of coronary arterial blood flow and increased
myocardial oxygen supply seen with the intraaortic balloon pump?
a. The vacuum created in the aorta as a result of balloon deflation
b. Diastolic inflation with retrograde perfusion
c. Forward flow to the peripheral circulation
d. Inflation during systole to augment blood pressure
ANS: B
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The blood volume in the aorta below the level of the balloon is propelled forward toward the
peripheral vascular system, which may enhance renal perfusion. Subsequently, the deflation of the
balloon just before the opening of the aortic valve creates a potential space or vacuum
in the aorta, toward which blood flows unimpeded during ventricular ejection. This decreased
resistance to left ventricular ejection, or decreased afterload, facilitates ventricular emptying and
reduces myocardial oxygen demands.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 391
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
10. What parameter must be assessed frequently in the patient with an intraaortic balloon in place?
a. Skin turgor in the affected extremity
b. Peripheral pulses distal to the insertion site
c. Blood pressures in both arms and legs
d. Oxygen saturation
ANS: B
One complication of intraaortic balloon support is lower extremity ischemia resulting from occlusion
of the femoral artery by the catheter itself or by emboli caused by thrombus formation on the balloon.
Although ischemic complications have decreased with sheathless insertion techniques and the
introduction of smaller balloon catheters, evaluation of peripheral circulation remains an important
nursing assessment. The presence and quality of peripheral pulses distal to the catheter insertion site
are assessed frequently along with color,
temperature, and capillary refill of the involved extremity. Signs of diminished perfusion must be
reported immediately.
NURSINGTB.COM
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 392
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
11. Which of the following statements regarding beta-blockers is correct?
a. They increase heart rate and are contraindicated in tachydysrhythmias.
b. They result in bronchospasm and should not be used in patients with chronic
obstructive pulmonary disease (COPD).
c. They increase cardiac output and help with left ventricular failure.
d. They are helpful in increasing atrioventricular node conduction and are used in heart
blocks.
ANS: B
Knowledge of the effects of adrenergic-receptor stimulation allows for anticipation of not only the
therapeutic responses brought about by beta-blockade but also the potential adverse effects of these
agents. For example, bronchospasm can be precipitated by noncardioselective beta-blockers in a
patient with chronic obstructive pulmonary disease secondary to blocking the effects of beta2
receptors in the lungs.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 399
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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12. Adenosine is an antidysrhythmic agent that is given primarily what reason?
a. To convert supraventricular tachycardias
b. To suppress premature ventricular contractions (PVCs)
c. To treat second and third degree AV blocks
d. To coarsen ventricular fibrillation so that defibrillation is effective
ANS: A
Adenosine occurs endogenously in the body as a building block of adenosine triphosphate (ATP).
Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV) node,
causing transient AV block. It is used clinically to convert supraventricular tachycardias and to
facilitate the differential diagnosis of rapid dysrhythmias.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 400|Table 15-16
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
13. Which dosage of dopamine results in stimulation of beta1 receptors and increased myocardial
contractility?
a. 1 mcg/kg/min
b. 5 mcg/kg/min
c. 15 mcg/kg/min
d. 20 mcg/kg/min
ANS: B
At low dosages of 1 to 2 mcg/kg/min, dopamine stimulates dopaminergic receptors, causing renal and
mesenteric vasodilation. Moderate dosages result in stimulation of beta1 receptors to increase
myocardial contractility and improve cardiac output. At dosages greater than 10
mg/kg/min, dopamine predom
NiUnaRnStlyIsNtiGmTulBat.esCaOlpMha receptors, resulting in vasoconstriction that
often negates both the beta-adrenergic and dopaminergic effects.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 402|Table 15-18
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
14. A patient is admitted with left-sided heart failure and a blood pressure of 220/118 mm Hg.
Which drug will be most effective in decreasing the blood pressure and reducing afterload?
a. Dopamine
b. Verapamil
c. Propranolol
d. Sodium nitroprusside
ANS: D
Sodium nitroprusside (Nipride) is a potent, rapidly acting venous and arterial vasodilator, particularly
suitable for rapid reduction of blood pressure in hypertensive emergencies and perioperatively. It also
is effective for afterload reduction in the setting of severe heart failure. The drug is administered by
continuous intravenous infusion, with the dosage titrated to maintain the desired blood pressure and
systemic vascular resistance.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 403|Table 15-19
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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15.
a.
b.
c.
d.
Through what mechanism does enalapril decrease blood pressure?
Direct arterial vasodilation
Block the conversion of angiotensin I to angiotensin II
Increase fluid excretion at the loop of Henle
Peripheral vasoconstriction and central vasodilation.
ANS: B
Enalapril is an angiotensin-converting enzyme (ACE) inhibitors that produces vasodilation by
blocking the conversion of angiotensin I to angiotensin II. Because angiotensin is a potent
vasoconstrictor, limiting its production decreases peripheral vascular resistance. In contrast to the
direct vasodilators and nifedipine, ACE inhibitors do not cause reflex tachycardia or induce sodium
and water retention.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 404
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
16. Noninvasive emergency pacing is best achieved via the use of which type of temporary pacing?
a. Transvenous (endocardial)
b. Epicardial
c. Transthoracic
d. Transcutaneous
ANS: D
Transcutaneous cardiac pacing involves the use of two large skin electrodes, one placed anteriorly and
the other posteriorly on the chest, connected to an external pulse generator. It is
a rapid, noninvasive proceduN
reUthRaS
t nIuN
rsG
esTcB
an.pCeO
rfoMrm in the emergency setting and is
recommended for the treatment of symptomatic bradycardia.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 361|Box 15-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
17. A transvenous pacemaker is inserted through the right subclavian vein and threaded into the right
ventricle. The pacemaker is placed on demand at a rate of 70. What is the three letter code for this
pacing mode?
a. VVI b.
AOO c. DDD d.
VAT
ANS: A
The original code is based on three categories, each represented by a letter. The first letter refers
to the cardiac chamber that is paced. The second letter designates which chamber is sensed, and
the third letter indicates the pacemaker’s response to the sensed event. A VVI pacemaker paces
the ventricle when the pacemaker fails to sense an intrinsic ventricular depolarization.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 362|Table 15-2
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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18. A patient is connected to an external temporary pulse generator. What does the sensitivity control
regulate?
a. The time interval between the atrial and ventricular pacing stimuli
b. The amount of electrical current and is measured in milliamperes
c. The ability of the pacemaker to detect the heart's intrinsic electrical activity
d. The number of impulses that can be delivered to the heart per minute
ANS: C
The sensitivity control regulates the ability of the pacemaker to detect the heart’s intrinsic electrical
activity. Sensitivity is measured in millivolts (mV) and determines the size of the intracardiac signal
that the generator will recognize.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 363
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
19. When analyzing the electocardiogram (ECG) strip of the patient with a pacemaker, the nurse notices
there is a spike before each QRS complex. What is this phenomenon indicative of?
a. 60-cycle electrical interference; check equipment
b. Pacing artifact; the pacemaker is sensing and capturing
c. Electrical artifact; the pacemaker is not sensing
d. Patient movement; check electrodes
ANS: B
The pacing artifact is the spike that is seen on the electrocardiographic tracing as the pacing stimulus
is delivered to the heart. A P wave is visible after the pacing artifact if the atrium is being paced.
Similarly, a QRN
S coR
mpI
lex fG
olloBw.
sC
a veM
ntricular
U
S Npacing
T artifact.
O With
dual-chamber pacing, a pacing artifact precedes both the P wave and the QRS complex.
PTS: 1
DIF: Cognitive Level: Applying
Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
REF: p. 363|Figure 15-4B OBJ:
20. A patient is undergoing ventricular pacing via a transvenous pacing lead. The nurse notes a pacing
artifact, but it is not followed by a QRS on the electrocardiogram (ECG) monitoring. Which nursing
intervention may correct this situation?
a. Position the patient on the left side
b. Decrease the milliamperes as ordered
c. Increase the rate as ordered
d. Monitor the patient in a different lead
ANS: A
The patient is experiencing “loss of capture,” which most often can be attributed either to
displacement of the pacing electrode or to an increase in threshold as a result of drugs, metabolic
disorders, electrolyte imbalances, or fibrosis or myocardial ischemia at the site of electrode
placement. In many cases, increasing the output milliamperes (mA) may elicit capture. For
transvenous leads, repositioning the patient to the left side may improve lead contact and restore
capture.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 365
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
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MSC: NCLEX: Physiologic Integrity
21. A patient suddenly develops a wide QRS complex tachycardia. The patient’s heart rate is 220
beats/min and regular; blood pressure is 96/40 mm Hg; and respiratory rate is 22 breaths/min, and the
patient is awake without complaint except for palpitations. Which of the following interventions
would be best to try first?
a. Adenosine 6 mg rapid IV push
b. Lidocaine 1 mg/kg IV push
c. Verapamil 5 mg IV push
d. Digoxin 0.5 mg IV push
ANS: A
Adenosine (Adenocard) is an antidysrhythmic agent that remains unclassified under the current
system. Adenosine occurs endogenously in the body as a building block of adenosine triphosphate
(ATP). Given in intravenous boluses, adenosine slows conduction through the atrioventricular (AV)
node, causing transient AV block. It is used clinically to convert supraventricular tachycardias and to
facilitate differential diagnosis of rapid dysrhythmias.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 400|Table 15-16
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
22. Why are vasopressors used cautiously in the treatment of critical care patients?
a. They cause vasoconstriction of the smooth muscles.
b. They cause vasodilation of the smooth muscles.
c. They increase afterload.
d. They decrease preload.
NURSINGTB.COM
ANS: C
Vasopressors are not widely used in the treatment of critically ill cardiac patients because the
dramatic increase in afterload is taxing to a damaged heart. Vasopressin, also known as antidiuretic
hormone, has become popular in the critical care setting for its vasoconstrictive effects. At higher
doses, vasopressin directly stimulates V1 receptors in vascular smooth muscle, resulting in
vasoconstriction of capillaries and small arterioles.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 405
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
23. Which calcium channel blocker is beneficial in the treatment of patients with coronary artery disease
or ischemic stroke?
a. Nifedipine
b.
Nicardipine c.
d.
Clevidipine
Diltiazem
ANS: B
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Nicardipine was the first available intravenous calcium channel blocker and as such could be more
easily titrated to control blood pressure. Because this medication has vasodilatory effects on coronary
and cerebral vessels, it has proven beneficial in treating hypertension in patients with coronary artery
disease or ischemic stroke. Nifedipine is available only in an oral form, but in the past it was
prescribed sublingually during hypertensive emergencies. Clevidipine is
a new, short-acting calcium channel blocker that allows for even more precise titration of blood
pressure in the management of acute hypertension. Diltiazem (Cardizem) is from the benzothiazine
group of calcium channel blockers. These medications dilate coronary arteries but have little effect
on the peripheral vasculature. They are used in the treatment of angina, especially that which has a
vasospastic component, and as antidysrhythmics in the treatment of supraventricular tachycardias.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 404
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
24. A patient is admitted after a femorotibial bypass graft. What nursing action is critical in the
immediate postoperative period?
a. Frequent assessment of the skin
b. Hourly assessment of intake and output
c. Monitoring for ST segment changes
d. Frequent pulse checks to the affected limb
ANS: D
The primary focus of nursing care in the immediate postprocedural period is assessment of the
adequacy of perfusion to the affected limb and identification of complications. Pulse checks are
performed frequently, and the physician is notified of any decrease in the strength of the
NNnRiT
I GOomised
B.C inMthis patient population, nursing
Doppler signal. Because distal U
perfSusio
s compr
measures to prevent skin breakdown are implemented. If the repair was performed above the
renal arteries, kidney function may be impaired as a result of interruption of renal blood flow during
the procedure. Urine output is therefore assessed hourly and supported with fluids and diuretics as
needed. Because patients with peripheral vascular disease are at high risk for cardiac events, ST
segment monitoring is performed to detect episodes of myocardial ischemia throughout the
perioperative period.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 398
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
25. When is a patient a candidate for a surgical repair of an abdominal aortic aneurysm (AAA)?
a. Size is 1 cm
b. Patient experiencing symptoms
c. Aneurysm size unchanged over several years
d. Size less than 4 cm
ANS: B
An abdominal aortic aneurysm (AAA) is usually repaired when the aneurysm is 5 cm or larger,
creating symptoms, or rapidly expanding. This is done to prevent the high mortality rate
associated with abdominal rupture.
PTS: 1
DIF:
Cognitive Level: Understanding
REF: p. 396
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OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
26. The patient is 72 hours postoperative for a coronary artery bypass graft (CABG). The patient’s
vital signs include temperature 103° F, heart rate 112, respiratory rate 22, blood pressure
134/78 mm Hg, and O2 saturation 94% on 3L nasal cannula. The nurse suspects that the
patient has developed what problem?
a. Infection and notifies the physician immediately
b. Infection, which is common postoperatively, and monitors the patient’s condition
c. Cardiac tamponade and notifies the physician immediately
d. Delirium caused by the elevated temperature
ANS: A
Postoperative fever is fairly common after cardiopulmonary bypass. However, persistent
temperature elevation to greater than 101° F (38.3° C) must be investigated. Sternal wound
infections and infective endocarditis are the most devastating infectious complications, but leg
wound infections, pneumonia, and urinary tract infections also can occur. A potentially lethal
complication, cardiac tamponade may occur after surgery if blood accumulates in the mediastinal
space, impairing the heart’s ability to pump. Signs of tamponade include elevated and equalized
filling pressures (eg, central venous pressure, pulmonary artery diastolic pressure, pulmonary artery
occlusion pressure), decreased cardiac output, decreased blood pressure, jugular venous distention,
pulsus paradoxus, muffled heart sounds, sudden cessation of chest tube drainage, and a widened
cardiac silhouette on radiographs. The risk of delirium is increased in cardiac surgery patients,
especially elderly patients, and is associated with increased mortality rates and reduced quality of
life and cognitive function. Nursing staff can play a critical role in the prevention and recognition
of delirium.
PTS: 1
DIF:
N R I G B.C M
CogU
nitivS
e LN
evelT
: ApplyiO
ng
REF: p. 388
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
27. Identify complications with the above rhythm strip.
a.
b.
c.
d.
Undersensing from a pacemaker
Oversensing from a pacemaker
ICD firing caused by VF
Atrial pacing failure to capture
ANS: A
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Undersensing is the inability of the pacemaker to sense spontaneous myocardial depolarizations.
Undersensing results in competition between paced complexes and the heart’s intrinsic rhythm. This
malfunction is manifested on the electrocardiogram by pacing artifacts that occur after or are
unrelated to spontaneous complexes. Oversensing occurs as a result of inappropriate sensing of
extraneous electrical signals that leads to unnecessary triggering or inhibition of stimulus output,
depending on the pacer mode. The source of these electrical signals can range from tall peaked T
waves to external electromagmetic interference in the critical care environment. The implantable
cardioverter defibrillator system consists of leads and a generator and is similar to a pacemaker but
with some key differences. The leads
contain not only electrodes for sensing and pacing but also integrated defibrillator coils capable
of delivering a shock. If the pacing stimulus fires but fails to initiate a myocardial depolarization,
a pacing artifact will be present but will not be followed by the expected P wave.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 365
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
28. What is the preferred initial treatment of an acute myocardial infarction?
a. Fibrinolytic therapy
b. Percutaneous coronary intervention (PCI)
c. Coronary artery bypass surgery (CABG)
d. Implanted Cardioverter defibrillator (ICD)
ANS: B
Percutaneous coronary intervention (PCI) is now preferred as the initial method of treatment for
acute myocardial infarction (MI; primary PCI). PCI includes balloon angioplasty,
RTll Ias aGnOumber
B.CofMadjunctive devices used to
atherectomy, and stent implantU
atioS
n, N
aN
s we
facilitate successful revascularization in coronary vessels.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 374
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
29. What two medications are commonly prescribed at discharge for patients who have had a
coronary artery stent placed?
a. Aspirin and prasugrel
b. Aspirin and abciximab
c. Clopidogrel and eptifibatide
d. Tirofiban and tricagrelor
ANS: A
Because platelet activation is a complex process involving multiple pathways, combination therapy
with two or more agents has proven most effective. The current standard of care for percutaneous
coronary intervention typically includes dual antiplatelet therapy with aspirin and a thienopyridine.
These oral agents are administered before the procedure and continued at discharge. Abciximab,
eptifibatide, and tirofiban are all intravenous antiplatelet agents.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 376|Table 15-5
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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30. Which anticoagulant enhances the activity of antithrombin III and does not require activated partial
thromboplastin time (aPTT) or activated clotting time (ACT) monitoring?
a. Heparin
b.
Enoxaparin c.
d.
Bivalirudin
Argatroban
ANS: B
Enoxaparin (Lovenox) enhances activity of antithrombin III, a more predictable response than
heparin, because enoxaparin is not largely bound to protein. There is no need for activated partial
thromboplastin time (aPTT) or activated clotting time (ACT) monitoring, and there is a lower risk of
heparin-induced thrombocytopenia (HIT) than with unfractionated heparin (UFH). Heparin sodium
enhances activity of antithrombin III, a natural anticoagulant, to prevent clot formation. The
effectiveness of treatment may be monitored by aPTT or ACT. Response is variable because of
binding with plasma proteins effects may be reversed with
protamine sulfate. Bivalirudin (Angiomax) directly inhibits thrombin. It may be administered alone
or in combination with glycoprotein IIb/IIIa inhibitors and produces a dose-dependent increase in
aPTT and ACT. It may be used instead of UFH for patients with HIT. Argatroban (Argatroban)
directly inhibits thrombin. It may be used instead of UFH for patients with HIT. Whereas ACT is
monitored during percutaneous coronary intervention, aPTT is used during prolonged infusion.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 378|Table 15-8
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
Mill test with a diagnosis of coronary artery disease
31. A patient is admitted after a pNoU
siR
tivSeIeN
xeG
rcT
isB
e.
treCaO
dm
(CAD) and stable angina. Radiographic tests show that the patient has blockage in the left main
coronary artery and four other vessels. The nurse anticipates that the patient’s treatment plan will
include what treatment or procedure?
a. Medical therapy
b. PCI
c. TAVR
d. CABG
ANS: D
Early studies demonstrated coronary artery bypass graft (CABG) surgery was more effective than
medical therapy for improving survival in patients with left main or three-vessel coronary artery
disease and at relieving anginal symptoms. Medical therapy is recommended if the ischemia is
prevented by antianginal medications that are well tolerated by the patient.
Surgical revascularization has been shown to be more efficacious than percutaneous coronary
intervention (PCI) in patients with multivessel or left main coronary disease. Transcatheter aortic
valve replacement (TAVR) is a transformational therapy for patients who have severe aortic stenosis
but who are extremely high-risk surgical candidates or who are inoperable by virtue of associated comorbidities.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 382-383
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
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MULTIPLE RESPONSE
1. A patient is diagnosed with third-degree heart failure. The nurse reviews the patient’s medication
list. Which classifications of drugs should be avoided with this patient? (Select all that apply.)
a. Nonsteroidal antiinflammatory drugs (NSAIDs)
b. Antidysrhythmics
c. Angiotensin-converting enzyme (ACE) inhibitors
d. Calcium channel blockers
e. Beta-blockers
ANS: A, B, D
Types of medications that have been found to worsen heart failure should be avoided,
including most antidysrhythmics, calcium channel blockers, and nonsteroidal
antiinflammatory medications. Angiotensin-converting enzyme inhibitors and beta-blockers are
used to treat heart failure.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 405|Table 15-21
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular
MSC: NCLEX: Physiologic Integrity
2. Which patients would be a candidate for fibrinolytic therapy? (Select all that apply.)
a. The patient’s chest pain started 8 hours ago. She has a diagnosis of non-
ST-elevation myocardial infarction (NSTEMI).
b. The patient’s chest pain started 3 hours ago, and her electrocardiogram (ECG)
shows a new left bundle bNranR
ch bIlocG
k.
B.C M
U Sdepartment
N T with
O chest pain of 30 minutes’
c. The patient presents to the emergency
duration. She has a history of cerebrovascular accident 1 month ago.
d. The patient has a history of unstable angina. He has been experiencing chest pain with
sudden onset.
e. The patient’s chest pain started 1 hour ago, and his ECG shows ST elevation.
ANS: B, E
Eligibility criteria for administering fibrinolytics include chest pain of less than 12 hours’
duration and persistent ST elevation. Exclusion criteria include recent surgery, cerebrovascular
accident, and trauma.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 370-371
OBJ: Nursing Process Step: Assessment TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic Integrity
3. Which signs and symptoms would indicate successful reperfusion after administration of a
fibrinolytic agent? (Select all that apply.)
a. Gradual decrease in chest pain
b. Intermittent, multifocal premature ventricular contractions
c. Rapid resolution of ST elevation
d. Rapid rise in creatine kinase MB fraction
ANS: B, C, D
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A reliable indicator of reperfusion is the appearance of various “reperfusion” dysrhythmias such as
premature ventricular contractions, bradycardia, heart block, and ventricular tachycardia. Rapid
resolution of the previously elevated ST segment should occur. The serum concentration of creatine
kinase rises rapidly and markedly, a phenomenon termed washout.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 373
OBJ: Nursing Process Step: Diagnosis
TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic Integrity
4. Nursing interventions after angioplasty would include which of the following? (Select all that apply.)
a. Elevating the head of the bed to 45 degrees
b. Hydration as a renal protection measure
c. Assessing pedal pulses on the involved limb every 15 minutes for the first 2 hours after the
procedure
d. Monitoring the vascular hemostatic device for signs of bleeding
e. Educating the patient on the necessity of staying supine for 1 to 2 hours after the
procedure
ANS: B, C, D
The head of the bed must not be elevated more than 30 degrees, and the patient should be instructed to
keep the affected leg straight. Bed rest is 6 to 8 hours in duration unless a vascular hemostatic device
is used. The nurse observes the patient for bleeding or swelling at the puncture site and frequently
assesses adequacy of circulation to the involved extremity.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 380
OBJ: Nursing Process Step: Intervention TOP: Cardiovascular Therapeutic Management
MSC: NCLEX: Physiologic InN
tegUriR
tySINGTB.COM
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Chapter 16: Pulmonary Anatomy and Physiology
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE CHOICE
1. At what anatomic site does the trachea divide into the right and left mainstem bronchi?
a.
Posterior larynx b.
Cricoid
cartilage
c.
Epiglottis
d. Major carina
ANS: D
The trachea is a hollow tube approximately 11 cm in length and 2.5 cm in diameter. It begins at
the cricoid cartilage and ends at the bifurcation (the major carina) from which the two mainstem
bronchi arise.
PTS: 1
DIF: Cognitive Level: Remembering
REF: pp. 415-416|Figure 16-5
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
2. Which physiologic mechanism is a passive event in a spontaneously breathing patient?
a.
Coughing b.
Inhalation
c.
Exhalation
d.
Yawning
ANS: C
Inhalation involves the contraction of the diaphragm, an active event, as do yawning and
coughing. Exhalation in the healthy lung is a passive event requiring very little energy.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 414
3. What substance do Alveolar type II cells secrete?
a. Trypsin b.
Chyme
c. Amylase d.
Surfactant
ANS: D
The most important function of the type II cells is their ability to produce, store, and secrete
pulmonary surfactant. Trypsin and amylase are proteins used for digestion. Chyme is a semifluid
mass of partly digested food that is expelled by the stomach into the duodenum.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 418
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4. Which pulmonary condition is related to a lack of surfactant?
a. Pulmonary embolus
b. Pulmonary hypertension c.
Pulmonary atelectasis
d. Pulmonary edema
ANS: C
Surfactant is responsible for preventing the alveoli from completely collapsing on exhalation.
Lack of this lipoprotein allows the alveoli to collapse, producing atelectasis. Lack of surfactant is
not responsible for the other conditions.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 418
5. What is the main function of the conducting airways?
a. Gas exchange
b. Cool the inhaled air
c. Remove moisture from inhaled air
d. Prevent the entry of foreign material
ANS: D
The conducting airways consist of the upper airways, the trachea, and the bronchial tree. Their major
functions are to warm and humidify the inhaled air, prevent the entrance of foreign matter into the
gas exchange areas, and serve as a passageway for air entering and leaving the gas exchange regions
of the lungs.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 414-415
6. A patient has sustained a stroke and is no longer able to control his epiglottis. Why should the nurse
be concerned about the patient?
a. The patient is at increased risk of aspiration.
b. The patient will need surgery to close his epiglottis. c. The
patient will need a tracheostomy to breathe.
d. The patient is at risk for a pneumothorax.
ANS: A
The epiglottis is responsible for closing over the trachea and preventing entry of swallowed material
into the lungs. An inability to control the epiglottis increases the risk of aspiration and may warrant
placement of a feeding tube. The patient will still be able to breathe. Closure of the epiglottis over the
trachea will occlude the airway.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 415
7. Patients who have aspiration pneumonitis often present with right lower lobe involvement more than
left lower lobe involvement. Why does this occur?
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a. The left mainstem bronchus angles down more than the right. b. More
people are right-side dominant.
c. The right mainstem bronchus angles down more than the left. d. The
right mainstem bronchus is narrower than the left.
ANS: C
The right bronchus is wider than the left and angles at 20 to 30 degrees from the midline. Because of
this angulation and the forces of gravity, the most common site of aspiration of foreign objects is
through the right mainstem bronchus into the lower lobe of the right lung.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 415-416
8. Which artery(s) have the lowest oxygen saturation?
a. Aorta
b. Subclavian c.
Carotid
d. Pulmonary
ANS: D
The pulmonary artery delivers blood from the right ventricle to the lungs, where they receive
oxygen from the alveoli. The aorta, subclavian artery, and carotid artery are all supplied from
the left ventricle, where the oxygen concentration is highest.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
9. Which range would be considered normal for pulmonary artery systolic pressures?
a. 15 to 30 mm Hg b. 4 to
12 mm Hg c. 25 to 35 mm
Hg d. 1 to 11 mm Hg
ANS: A
Pulmonary artery systolic pressure ranges from 15 to 30 mm Hg, pulmonary artery diastolic pressure
ranges from 4 to 12 mm Hg, and pulmonary artery mean pressure ranges from 9 to
18 mm Hg. Pulmonary hypertensions is defined as pulmonary artery systolic pressure of greater
than 35 mm Hg.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
10. The oxygen saturation of a healthy individual rarely reaches 100% on room air. This can best be
explained by what concept?
a. Physiologic shunting
b. Alveolar capillary diffusion c.
Collateral air passages
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d. Anatomic dead space
ANS: A
The mixing of venous blood from the bronchial circulation with the oxygenated blood in the left
atrium decreases the saturation of left atrial blood to a range between 96% and 99%.
This is referred to as physiologic shunting. For this reason, while a person is breathing room air, the
oxygen saturation of arterial blood is less than 100%.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
11. Which pulmonary alteration increases the work of breathing in the patient with emphysema?
a. Decreased lung recoil
b. Decreased chest wall compliance c.
Increased lung compliance
d. Increased airway resistance
ANS: A
Emphysema results in destruction and enlargement of the alveoli, leading to decreased lung recoil
and increased work of breathing. Emphysema results in decreased lung compliance not increased
compliance. Emphysema does not affect chest wall compliance or airway resistance.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 420-422|Box 16-2
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
12. What anatomic regions are considered physiologic dead space?
a. Respiratory bronchiole and unperfused alveoli b.
Trachea and perfused alveoli
c. Trachea and unperfused alveoli d.
Trachea and mainstem bronchi
ANS: C
Respiratory bronchioles participate in gas exchange. The areas in the lungs that are ventilated but in
which no gas exchange occurs are known as dead space regions (trachea and mainstem bronchi).
These unperfused alveoli are known as alveolar dead space. Anatomic dead space plus alveolar
dead space is called physiologic dead space.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
13. If a patient sustained an injury to the apneustic center in the lower pons area, in which area should
the nurse most expect the patient to exhibit problems?
a. Respiratory rate
b. Triggering exhalation c.
Respiratory rhythm
d. Depth of respiration
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ANS: D
The apneustic center in the lower pons is thought to work with the pneumotaxic center to regulate the
depth of inspiration. The pneumotaxic center in the pons is responsible for limiting inhalation and
triggering exhalation. This response also facilitates control of the rate and pattern of respiration. The
ventral respiratory group, located in the medulla, is responsible for inspiration and expiration during
periods of increased ventilation.
PTS: 1
DIF: Cognitive Level: Remembering
REF: pp. 423-44|Figure 16-18
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
14. Normally, the central chemoreceptors responsible for triggering ventilation changes respond to which
of the following?
a. Increased PaCO2 b.
Increased HCO3¯ c.
Decreased PaO2 d. Increased
PaO2
ANS: A
Ventilation increases when the hydrogen ion concentration increases and decreases when the
hydrogen ion concentration decreases. An increase in the partial pressure of carbon dioxide (PaCO2)
causes the movement of carbon dioxide across the blood–brain barrier into the cerebrospinal fluid,
stimulating the movement of hydrogen ions into the brain’s extracellular fluid. Peripheral
chemoreceptors respond to changes in PaO2 levels.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 424
15. Which V/Q ratio would most suggest intrapulmonary shunting?
a. 0.8 b. 2.2 c.
0.4
d. V/Q ratios are not related to shunting.
ANS: C
A V/Q ratio of 4:5 or 0.8 is considered normal. A V/Q less than 0.8 is considered shunt
producing, and a V/Q greater than 0.8 is considered dead space producing.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 426-427
16. A shift to the left of the oxyhemoglobin dissociation curve would cause which physiologic
alteration?
a. Better tissue perfusion b.
Lower SpO2
c. Decreased hemoglobin affinity for O2 d.
Impaired tissue oxygen delivery
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ANS: D
When the curve is shifted to the left, there is a higher arterial saturation for any given PaO2 because
hemoglobin has an increased affinity for oxygen. Although the saturation is higher, oxygen delivery
to the tissues is impaired because hemoglobin does not unload as easily.
PTS: 1
DIF: Cognitive Level: Remembering
REF: pp. 428-429|Figure 16-23
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
17. A patient in diabetic ketoacidosis would exhibit what alteration to the pulmonary system?
a. Breathe faster to increase pH b.
Breathe slower to increase pH c. Breathe
faster to decrease pH d. Breathe slower to
decrease pH
ANS: C
Breathing faster increases the expiration of CO2, which results in less acid in the
bloodstream and a decreased pH.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 428|Figure 16-23
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
18. What are the primary functions of the pulmonary system?
a. Gas exchange and the movement of air in and out of the lungs b. Gas
exchange and the transfer of oxygen to the tissues
c. The movement of blood in and out of the lungs and the removal of waste products d. Gas
exchange and the prevention of infections
ANS: A
The primary functions of the pulmonary system are ventilation and respiration. Ventilation is the
movement of air in and out of the lungs. Respiration is the process of gas exchange, that is, the
movement of oxygen from the atmosphere into the bloodstream and the movement of carbon dioxide
from the bloodstream into the atmosphere.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 411
19. Which part of the pulmonary anatomy does most of the work of breathing?
a. Pleura
b. Intercostal muscles c.
Diaphragm
d. Sternocleidomastoid
ANS: C
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The main muscle of inhalation is the diaphragm. It is connected to the sternum, ribs, and vertebrae.
During normal, quiet breathing, the diaphragm does approximately 80% of the work of breathing.
The most important of these are the external intercostal muscles, which elevate the ribs and expand
the chest cage outward. The scalene, anterior serratus, and sternocleidomastoid muscles also
participate to elevate the first two ribs and sternum.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 413
20. Which statement best describes the left bronchus?
a. The left bronchus has a slight angle of 20 to 30 degrees from the midline. b. The
two mainstem bronchi are structurally and functionally similar.
c. The left bronchus is slightly narrower.
d. The bronchi are the end units of the bronchial tree.
ANS: C
The two mainstem bronchi are structurally different. The right bronchus is wider and angles at 20 to
30 degrees from the midline. The right mainstem bronchus is the most common site of aspiration of
foreign objects. The left bronchus is slightly narrower than the right, and because of its position above
the heart, the left bronchus angles directly toward the left lung at approximately 45 to 55 degrees from
the midline.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 415-416|Figure 16-5
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
21. What is the most important function of type I alveolar epithelial cells?
a. They comprise 90% of total alveolar surface in the lungs for gas exchange. b. The
ability to produce, store, and secrete pulmonary surfactant.
c. The ability to trap foreign particles for auto digestion.
d. The maintenance, repair, and restoration of the mucociliary escalator.
ANS: A
Type I alveolar epithelial cells comprise approximately 90% of the total alveolar surface within the
lungs. The most important function of the type II cells is their ability to produce, store, and secrete
pulmonary surfactant.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 417
22. Which statement describes the relationship between the pulmonary circulation and the
pulmonary vascular bed?
a. The pulmonary circulation is a high-pressure system with normal pressures averaging
100/60 to 120/70 mm Hg.
b. Because of the low pulmonary arterial pressures, the right ventricular wall thickness
needs to be only one-third that of the left ventricle.
c. Pulmonary hypertension is defined as increased pulmonary artery systolic pressure above 20
mm Hg.
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d. The most common cause of pulmonary hypertension is right-sided heart failure.
ANS: B
Because of low pulmonary artery pressures, right ventricular wall thickness needs to be only
approximately one-third of left ventricular wall thickness. Pulmonary hypertension is defined as
increased pressure (pulmonary artery systolic greater than 35 mm Hg and pulmonary artery mean less
than 25 mm Hg at rest or less than 30 mm Hg with exertion) within the pulmonary arterial system.
Pulmonary hypertension increases the afterload of the right ventricle and, when chronic, can result in
right ventricular hypertrophy (cor
pulmonale) and failure.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 419
23. Oxygen saturation of left atrial blood is normally between 96% and 99%. What is the
explanation for less than 100% saturation?
a. As blood passes to the alveolar–capillary membrane, a predicted percentage of
hemoglobin will not bind with oxygen.
b. During normal respiration, the majority of alveoli are not expanded.
c. Venous blood from the bronchial circulation is returned to the left atrium.
d. A small amount of blood leaks from the right atrium to the left atrium with each
ventricular contraction.
ANS: C
Venous blood from the bronchial circulation returns directly into the left atrium. The mixing of
venous blood decreases the saturation of left atrial blood to a range between 96% and
99%.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
24. What is the movement of air into and out of the lungs termed?
a.
Ventilation b.
Respiration c. Diffusion
d. Perfusion
ANS: A
Ventilation is the movement of air into and out of the lungs and is distinct from respiration, which
refers to gas exchange, not movement by air. Respiration is the process of gas exchange by means of
movement of oxygen from the atmosphere into the bloodstream and movement of carbon dioxide
from the bloodstream into the atmosphere. Diffusion moves molecules from an area of high
concentration to an area of low concentration. The distribution of perfusion through the lungs is
related to gravity and intra-alveolar pressures.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
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25. How much of the basal oxygen consumption is required by the pulmonary system during normal
quiet breathing?
a. 10% to 20% b. 5%
to 10% c. 3% to 5%
d. 1% to 2%
ANS: D
During normal quiet ventilation, only 1% to 2% of basal oxygen consumption is required by the
pulmonary system.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 420
26. What is the portion of total ventilation that participates in gas exchange termed?
a. Alveolar dead space b.
Anatomic dead space
c. Physiologic dead space d.
Alveolar ventilation
ANS: D
The portion of total ventilation that participates in gas exchange is known as alveolar ventilation.
The areas in the lungs that are ventilated but in which no gas exchange occurs are known as dead
space regions. The conducting airways are referred to as anatomic dead space because they are
ventilated but not perfused and therefore not able to participate in gas exchange. These unperfused
alveoli are known as alveolar dead space. Anatomic dead space plus alveolar dead space is called
physiologic dead space.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
27. Which physiologic alteration will stimulate the central chemoreceptors?
a. Decreased PaO2 b.
Increased PaO2 c.
Decreased SaO2
d. Increased PaCO2
ANS: D
The central chemoreceptors respond to changes in the hydrogen ion concentration of that fluid.
Ventilation is increased when the hydrogen ion concentration increases, as evidenced by a rise in the
plasma arterial PaCO2.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 424
28. Which factor will increase diffusion of gases across the alveolar capillary membrane?
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a. A decrease in the surface area of the membrane b. An
increase in the thickness of the membrane
c. An increase in the driving pressure of the gas
d. A decrease in the solubility coefficient of the gas
ANS: C
Several factors affect the rate of diffusion, including increasing the driving pressure of the gas. A
decrease in surface area of the membrane, an increase in the thickness of the membrane, and a
decrease in the solubility coefficient of the gas decrease diffusion of gases across the membrane.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 425
29. Atelectasis can cause a shunt-producing ventilation-perfusion mismatch. Which
pathophysiologic mechanism explains how this occurs?
a. An alveolus that is receiving perfusion exceeding ventilation b. An
alveolus that is receiving ventilation exceeding perfusion c. An alveolus
that is receiving ventilation but not perfusion
d. An alveolus that is not receiving perfusion or ventilation
ANS: A
A shunt-producing ventilation-perfusion mismatch is one in which perfusion exceeds ventilation.
Whereas situations in which ventilation exceeds perfusion V/Q greater than 0.8 are considered to be
dead space producing, situations in which perfusion exceeds ventilation V/Q less than 0.8 are
considered to be shunt producing.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 426-427|Figure 16-21
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
30. Which factor will result in a shift of the oxyhemoglobin dissociation curve to the left?
a. Increased PaCO2 b.
Increased pH
c. Increased temperature d.
Increased 2,3-DPG
ANS: B
Factors shifting the curve to the left are increased pH, decreased PaCO2, decreased
temperature, and decreased 2,3-DPG.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 428-429|Figure 16-23
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
31. Which statement about methemoglobin is true?
a. Methemoglobin does not carry oxygen.
b. Methemoglobin occurs when carbon monoxide combines with hemoglobin. c.
Carbon dioxide is carried on methemoglobin.
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d. Hemoglobin S is responsible for methemoglobin.
ANS: A
Methemoglobin occurs when the iron atoms within the hemoglobin molecule are oxidized from the
ferrous state to the ferric state. Methemoglobin does not carry oxygen. The most common
abnormality involving hemoglobin is a decrease in amount. This can be an acute or a chronic situation
(anemia). Abnormal hemoglobin structure also can pose problems, such as hemoglobin S, which is
responsible for sickle cell anemia. Hemoglobin carries approximately 97% of the total amount of
oxygen held within the bloodstream.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 429
32. A patient is admitted with community-associated pneumonia. Respirations are 32 breaths/min.
Temperature is 102° F (38.6° C). Based on the readings the nurse would expect the oxyhemoglobin
dissociation curve to shift. What other factors would cause the curve to shift in the same direction?
a. Decreased 2,3-DPG
b. Increased pH
c. Increased CO2 d.
Increased O2
ANS: C
The oxyhemoglobin dissociation curve will shift to the right as a result of the patient’s temperature.
Other factors that cause the curve to shift to the right are decreased pH, increased CO2, and
increased 2,3-DPG. Increased O2 will not shift the curve either right or left.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 428-429|Figure 16-23
OBJ: Nursing Process Step: N/A TOP:
Pulmonary MSC: NCLEX: Physiologic Integrity
33. A patient is admitted with an acute exacerbation of asthma. Respirations are 28 breaths/min.
Blood gases reveal an uncompensated respiratory acidosis. The patient’s work effort for
breathing is increased due to which pathophysiologic mechanism?
a. Increased lung compliance b.
Decreased lung recoil
c. Increased chest wall compliance d.
Increased airway resistance
ANS: D
Pulmonary diseases that decrease lung compliance (eg, atelectasis, pulmonary edema), decrease
chest wall compliance (eg, kyphoscoliosis), increase airway resistance (eg, bronchitis, asthma), or
decrease lung recoil (eg, emphysema) can increase the work of breathing so much that one-third
or more of the total body energy is used for ventilation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: N/A
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 421
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34. Based on the oxyhemoglobin dissociation curve, respiratory acidosis will have which effect?
a. A shifting of the curve to the left b.
Increased oxygen saturation
c. Enhanced oxygen delivery at the tissue level d.
Hypothermia
ANS: C
When the curve is shifted to the right, as occurs in acidosis, although the saturation is lower than
expected, a right shift enhances oxygen delivery at the tissue level because hemoglobin unloads more
readily.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 428-429|Figure 16-23
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
35. The lobes are divided into 18 segments. How many are on the right lung?
a. 3
b. 8
c. 10
d. 15
ANS: C
The lobes are divided into 18 segments, each of which has its own bronchus branching immediately
off a lobar bronchus. Ten segments are located in the right lung and eight in the left lung.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 411
36. Which pleura adheres to the lungs?
a. Parietal b.
Visceral
c. Intrapleural d.
Surfactant
ANS: B
The visceral pleura adheres to the lungs, extending onto the hilar bronchi and into the major fissures.
The parietal pleura lines the inner surface of the chest wall and mediastinum. The pleural space has a
pressure within it called the intrapleural pressure. Surfactant is responsible for preventing the alveoli
from completely collapsing on exhalation.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 411
37. Which nerve stimulates movement of the diaphragm?
a. Musculocutaneous nerve b.
Phrenic nerve
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c. Median nerve d.
Axillary nerve
ANS: B
The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with
secondary contributions by the third and fifth cervical nerves. The other nerves control use and
feeling of the arms.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 413-414
38. Trauma to which vertebrae will cause ventilation dysfunction?
a. C3 to C5 b. C5
to T3 c. T4 to T6 d.
T7 to T10
ANS: A
The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with
secondary contributions by the third and fifth cervical nerves. For this reason and because the
diaphragm does most of the work of inhalation, trauma involving levels C3 to C5 causes
ventilation dysfunction.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 414
MULTIPLE RESPONSE
1. Muscles of exhalation include which of the following? (Select all that apply.)
a. Abdominal b.
Diaphragm
c.
External intercostals d.
Internal
intercostals
e.
Scalene
ANS: A, D
Exhalation occurs when the diaphragm relaxes and moves back up toward the lungs. The intrinsic
elastic recoil of the lungs assists with exhalation. Because exhalation is a passive act, there are no
true muscles of exhalation other than the internal intercostal muscles, which assist the inward
movement of the ribs.
PTS: 1
DIF: Cognitive Level: Remembering
REF: p. 414
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
2. The lymphatic system plays which of the following important roles? (Select all that apply.)
a. Ridding lung tissue of excess CO2
b. Connecting the thebesian veins to the coronary circulation
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c. Removing fluid from the lungs d.
Producing immune responses
e. Removing cell debris from the lungs
ANS: C, D, E
The lymphatic system in the lungs serves two purposes. As part of the immune system, it is
responsible for removing foreign particles and cell debris from the lungs and for producing both
antibody and cell-mediated immune responses. It also is responsible for removing fluid from the lungs
and for keeping the alveoli clear.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 420
OBJ: Nursing Process Step: N/A
TOP: Pulmonary Anatomy and Physiology
MSC: NCLEX: Physiologic Integrity
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Chapter 17: Pulmonary Clinical Assessment
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE CHOICE
1. The nurse performs inspection of the oral cavity as part of a focused pulmonary assessment to
check for evidence of what condition?
a. Hypoxia b.
Dyspnea
c. Dehydration d.
Malnutrition
ANS: A
Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral
areas. Although dehydration and nutritional status can both be partially assessed by oral cavity
inspection, this information is not as vital as determining hypoxia. Dyspnea means difficulty
breathing.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
2. Which lung sounds would be most likely heard in a patient experiencing an asthma attack?
a. Coarse rales
b. Pleural friction rub c.
Fine crackles
d. Expiratory wheezes
ANS: D
Wheezes are high-pitched, squeaking, whistling sounds produced by airflow through narrowed
small airways. They are heard mainly on expiration but may also be heard throughout the
ventilatory cycle. Depending on their severity, wheezes can be further classified as mild,
moderate, or severe. Rales are crackling sounds produced by fluid in the small airways or alveoli
or by the snapping open of collapsed airways during inspiration. A pleural friction rub is a dry,
coarse sound produced by irritated pleural surfaces rubbing together and is caused by
inflammation of the pleura.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 436|pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
3. Which statement describes the major difference between tachypnea and hyperventilation?
a. Tachypnea has increased rate; hyperventilation has decreased rate. b.
Tachypnea has decreased rate; hyperventilation has increased rate.
c. Tachypnea has increased depth; hyperventilation has decreased depth. d.
Tachypnea has decreased depth; hyperventilation has increased depth.
ANS: D
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Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation.
Hyperventilation is manifested by an increase in both the rate and depth of ventilation.
PTS: 1
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OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433
4. A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse
documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal
deviation to the right. In addition, the patient’s tongue is blue-gray. Based on this assessment data,
what additional assessment findings would the nurse expect to find?
a. Kussmaul breathing pattern
b. Absent breath sounds in the right lower lung fields c.
Absent breath sounds in the left lung fields
d. Diminished breath sounds in the right upper lung fields
ANS: C
The clinical picture described is most consistent with left pneumothorax. This would cause the
trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this
severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The
right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 438|Table 17-2
5. While palpating a patient’s lungs the nurse notes fremitus over the patient’s trachea but not the lung
periphery. What do these findings indicate?
a. Bilateral pleural effusion b.
Bronchial obstruction
c. A normal finding
d. Apical pneumothorax
ANS: C
Fremitus is described as normal, decreased, or increased. With normal fremitus, vibrations can be felt
over the trachea but are barely palpable over the periphery. With decreased fremitus, there is
interference with the transmission of vibrations. Examples of disorders that decrease fremitus include
pleural effusion, pneumothorax, bronchial obstruction, pleural thickening, and emphysema.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 434
6. Which chest wall deformity is characterized by an increase in anteroposterior (AP) diameter with
displacement of the sternum forward and the ribs outward?
a. Funnel chest b.
Pigeon breast c. Barrel
chest
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d. Harrison’s groove
ANS: C
Normal ratio of anteroposterior diameter to lateral diameter ranges from 1:2 to 5:7. A barrel chest is
characterized by displacement of the sternum forward and the ribs outward and is suggestive of
chronic obstructive pulmonary disease. Funnel chest, pectus excavatum, creates a pit-shaped
depression. Pigeon chest, pectus carinatum, causes an increase in anteroposterior diameter. Both are
related to restrictive pulmonary disease. Harrison’s groove, a rib deformity, is a result of rickets.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
7. A patient is admitted in respiratory distress secondary to pneumonia. The nurse knows that obtaining
a history is very important. What is the appropriate intervention at this time for obtaining this data?
a. Collect an overview of past medical history, present history, and current health status.
b. Do not obtain any history at this time.
c. Curtail the history to just a few questions about the patient’s chief complaint and
precipitating events.
d. Complete the history and then provide measures to assist the patient to breathe easier.
ANS: C
The initial presentation of the patient determines the rapidity and direction for the interview. For a
patient in acute distress, the history should be curtailed to just a few questions about the patient’s chief
complaint and the precipitating events.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
8. While conducting a physical assessment on a patient with chronic obstructive pulmonary disease
(COPD), the nurse notes that the patient’s breathing is rapid and shallow. What is this type of
breathing pattern called?
a. Hyperventilation b.
Tachypnea
c. Obstructive breathing d.
Bradypnea
ANS: B
Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation.
Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive
breathing is characterized by progressively shallower breathing until the patient actively and
forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in
an adult.
PTS:
1
DIF:
Cognitive Level: Applying
REF: p. 433
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OBJ: Nursing Process Step: Assessment
MSC: NCLEX: Physiologic Integrity
TOP: Pulmonary
9. Which condition is an example of a disorder with increased tactile fremitus?
a. Emphysema
b. Pleural effusion c.
Pneumothorax d. Pneumonia
ANS: D
Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and
pulmonary fibrosis. Emphysema, pleural effusion, and pneumothorax are disorders that decrease
fremitus.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 434
10. What is the sequence for auscultation of the anterior chest?
a. Right side, top to bottom, then left side, top to bottom b. Left
side, top to bottom, then right side, top to bottom c. Side to side,
bottom to top
d. Side to side, top to bottom
ANS: D
Auscultation should be done in a systematic sequence: side to side, top to bottom,
posteriorly, laterally, and anteriorly.
PTS: 1
DIF: Cognitive Level: Remembering
8
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436|Figure 17-
11. A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to
the left side, and asymmetric chest movement. These findings are indicative of which disorder?
a. Tension pneumothorax b.
Pneumonia
c. Pulmonary fibrosis d.
Atelectasis
ANS: A
Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and
asymmetric chest movement are indicative of tension pneumothorax.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 433|p. 439|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
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12. When auscultating a patient’s lungs, the nurse notes breath sounds that sound like popping in the
small airways. What should the nurse document in the patient’s record?
a. Sonorous wheezes b.
Crackles
c. Sibilant wheezes
d. Pleural friction rub
ANS: B
Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small
airways or alveoli.
PTS: 1
DIF: Cognitive Level: Applying
8
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436|Figure 17-
13. In what condition are bronchophony, egophony, and whispering pectoriloquy increased?
a. Pneumonia with consolidation b.
Pneumothorax
c. Asthma
d. Bronchiectasis
ANS: A
Voice sounds are increased in pneumonia with consolidation because there is increased vibration
through material. Bronchophony and whispering pectoriloquy are heard as clear transmission of
sounds on auscultation; egophony is heard as an “a” sound when the patient is saying “e.”
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 436|pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
14. A patient is admitted with acute lung failure secondary to chronic obstructive pulmonary disease
(COPD). Upon inspection of the patient, the nurse observes that the patient’s fingers appear
discolored. What does this finding indicate the presence of?
a. Clubbing
b. Central cyanosis
c. Peripheral cyanosis d.
Chronic tuberculosis
ANS: C
Discoloration of the fingers is an indication of peripheral cyanosis. Central cyanosis occurs when the
unsaturated hemoglobin of arterial blood exceeds 5 g/dL and is considered a life- threatening
situation. Clubbing refers to an abnormality of the fingers caused by chronically low blood levels of
oxygen often related to a heart or lung disease.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 431
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15. A patient is admitted with acute lung failure secondary to emphysema. Percussion of the lung
fields will predictably exhibit which tone?
a. Resonance
b. Hyperresonance c.
Tympany
d. Dullness
ANS: B
The percussion tone of hyperresonance is heard with emphysema related to overinflation of the lung.
Resonance can be found in normal lungs or with the diagnosis of bronchitis. Tympany occurs with
the diagnosis of large pneumothorax and emphysematous blebs. Dullness occurs with the diagnosis
of atelectasis, pleural effusion, pulmonary edema, pneumonia, and a lung mass.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 436|Table 17-1
16. A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the
nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during
inspiration and expiration. This finding is indicative of what condition?
a. Emphysema b.
Atelectasis
c. Pulmonary fibrosis d.
Pleural effusion
ANS: D
A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized
by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy
and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 438|Table 17-2
17. A patient is admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). The
nurses notes that the patient has difficulty getting breath out. Which phrase best describes the
patient’s breathing pattern?
a. Deep sighing breaths without pauses b.
Rapid, shallow breaths
c. Normal breathing pattern interspersed with forced expirations d.
Irregular breathing pattern with both deep and shallow breaths
ANS: C
Difficulty getting breath out is indicative of air trapping. Air trapping is described as a normal
breathing pattern interspersed with forced expirations. As the patient breathes, air becomes trapped
in the lungs, and ventilations become progressively shallower until the patient actively and
forcefully exhales.
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PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 433
18. A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his
injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is
suspected and is further validated when assessment of the trachea reveals what finding?
a. A shift to the right b. A
shift to the left
c. No deviation
d. Subcutaneous emphysema
ANS: A
With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the
trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related
to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the
mediastinum and general neck area.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 433-434
19. The nurse is caring for a patient with respiratory failure. The nurse notes the patient’s diaphragmatic
excursing is 8 cm. What coexisting conditions could account for this finding? a. Asthma and
emphysema
b. Hepatomegaly and ascites
c. Atelectasis and pleural effusion d.
Pneumonia and pneumothorax
ANS: C
Normal diaphragmatic excursion is 3 to 5 cm and is part of the percussion component of the physical
examination. Diaphragmatic excursion is increased in pleural effusion, and disorders that elevate the
diaphragm, such as atelectasis or paralysis. Diaphragmatic excursion is decreased in disorders such
as ascites, pregnancy, hepatomegaly, and emphysema.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 435
20. When assessing a patient, the use of touch to judge the character of the body surface and
underlying organs is known as what technique?
a. Inspection b.
Palpation
c. Percussion
d. Auscultation
ANS: B
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Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of
the body surface or underlying structures. Inspection is the process of looking intently at the patient.
Percussion is the process of creating sound waves on the surface of the body to determine abnormal
density of any underlying areas. Auscultation is
the process of concentrated listening with a stethoscope to determine characteristics of body
functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
21. When assessing a patient, the use of observation is referred to as what technique?
a. Inspection b.
Palpation
c. Percussion
d. Auscultation
ANS: A
Inspection is the process of looking intently at the patient. Palpation is the process of touching the
patient to judge the size, shape, texture, and temperature of the body surface or underlying structures.
Percussion is the process of creating sound waves on the surface of the body to determine abnormal
density of any underlying areas. Auscultation is the process of concentrated listening with a
stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
22. What assessment technique uses the creation of sound waves across the body surface to
determine abnormal densities?
a. Inspection b.
Palpation
c. Percussion
d. Auscultation
ANS: C
Percussion is the process of creating sound waves on the surface of the body to determine abnormal
density of any underlying areas. Palpation is the process of touching the patient to judge the size,
shape, texture, and temperature of the body surface or underlying structures. Inspection is the process
of looking intently at the patient. Auscultation is the process of concentrated listening with a
stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
23. What assessment technique involves having the patient breathe in and out slowly with an open
mouth?
a. Inspection b.
Palpation
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c. Percussion
d. Auscultation
ANS: D
Percussion is the process of creating sound waves on the surface of the body to determine abnormal
density of any underlying areas. Palpation is the process of touching the patient to judge the size,
shape, texture, and temperature of the body surface or underlying structures. Inspection is the process
of looking intently at the patient. Auscultation is the process of concentrated listening with a
stethoscope to determine characteristics of body functions.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
24. The nurse is observing a new graduate listen to a patient’s lungs. Which action by the new graduate
indicates a need to review auscultation skills?
a. The nurse starts at the apices and moves to the bases. b. The
nurse compares breath sounds from side to side. c. The nurse
listens during inspiration.
d. The nurse listens posteriorly, laterally, and anteriorly.
ANS: C
Breath sounds are assessed during both inspiration and expiration. Auscultation is done in a
systematic sequence: side-to-side, top-to-bottom, posteriorly, laterally, and anteriorly
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 436-437|Figure 17-8
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
25. The nurse is performing a pulmonary assessment on a patient with pulmonary fibrosis.
Which finding is unexpected?
a. Diminished thoracic expansion
b. Tracheal deviation to the most affected side c.
Hyperresonant percussion tones
d. Decreased breath sounds
ANS: C
Assessment findings associated with pulmonary fibrosis include diminished thoracic expansion,
tracheal deviation to the most affected side, decreased or absent breath sounds, and resonance or
dullness on percussion. Hyperresonance is not an expected finding in pulmonary fibrosis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
26. The nurse is performing a pulmonary assessment on a patient with acute bronchitis. Which finding
is unexpected?
a. Rasping productive cough b.
Decreased tactile fremitus
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c. Resonant percussion tones d.
Crackles and wheezes
ANS: B
Assessment findings associated with acute bronchitis include rasping productive cough,
resonance on percussion, crackles and wheezes, and normal to increased tactile fremitus.
Decreased tactile fremitus is not associated with acute bronchitis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
27. The nurse is performing a pulmonary assessment on a patient with a pleural effusion. Which
finding is unexpected?
a. Increased diaphragmatic excursion b.
Decreased tactile fremitus
c. Dull percussion tones d.
Pleural friction rub
ANS: A
Assessment findings associated with pleural effusion include dullness on percussion,
decreased tactile fremitus, pleural friction rub, and decreased diaphragmatic excursion.
Increased diaphragmatic excursion is not associated with acute bronchitis.
PTS: 1
DIF: Cognitive Level: Applying
REF: pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1. How does the patient history assist the nurse in developing the management plan? (Select all
that apply.)
a. Provides direction for the rest of the assessment b.
Exposes key clinical manifestations
c. Aids in developing the plan of care
d. The degree of the patient’s distress determines the extent of the interview e.
Determines length of stay in the hospital setting
ANS: A, B, C, D
The initial presentation of the patient determines the rapidity and direction of the interview. For a
patient in acute distress, the history should be curtailed to just a few questions about the patient’s
chief complaint and precipitating events.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 431
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
2. Deviation of the trachea occurs in which conditions? (Select all that apply.)
a. Pneumothorax
b. Pulmonary fibrosis
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c. Chronic obstructive pulmonary disease d.
Emphysema
e. Pleural effusion
ANS: A, B, E
Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia,
pulmonary fibrosis, and pleural effusion.
PTS: 1
DIF: Cognitive Level: Applying
REF: p. 433
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Clinical Assessment
MSC: NCLEX: Physiologic Integrity
3. Which conditions will commonly reveal breath sounds with inspiration greater than expiration on
assessment? (Select all that apply.)
a. Normal lung
b. Bronchiectasis c.
Emphysema
d. Acute bronchitis
e. Diffuse pulmonary fibrosis
ANS: A, B, D
The normal lung, bronchiectasis, and acute bronchitis will commonly present with an inspiration
greater than expiration ratio. Acute bronchitis can also have inspiration that equals expiration ratio as
also seen with emphysema, diffuse pulmonary fibrosis, and consolidating pneumonia. Noting that
many conditions present with the same findings affirms the need for further assessment and
evaluation.
PTS: 1
DIF: Cognitive Level: Understanding
REF: pp. 439-443|Table 17-3
OBJ: Nursing Process Step: Assessment
TOP: Pulmonary MSC: NCLEX: Physiologic Integrity
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Chapter 18: Pulmonary Diagnostic Procedures
Urden: Critical Care Nursing, 9th EditionEdition
MULTIPLE CHOICE
1. The patient’s arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2,
52 mm Hg; and
, 24 mEq/L. What is the interpretation of the patient’s ABG? a.
Uncompensated metabolic alkalosis
b. Uncompensated respiratory acidosis c.
Compensated respiratory acidosis
d. Compensated respiratory alkalosis
ANS: B
The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated
respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and
of
22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2
greater than 45 mm Hg, and
greater than 26 mEq/L. Compensated respiratory alkalosis
values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and
below 22 mEq/L.
Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to
45 mm Hg, and
above 26 mEq/L.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447|Table 18-1
2. On admission, a patient presents with a respiratory rate of 24 breaths/min, pursed-lip
breathing, heart rate of 96 beats/min in sinus tachycardia, and a blood pressure of 110/68 mm
Hg. The patient’s arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.38;
PaCO2, 52 mm Hg; and
, 34 mEq/L. What diagnoses would be most consistent with the
above arterial blood gas values?
a.
Acute pulmonary embolism b.
Acute myocardial infarction c.
Congestive heart failure
d. Chronic obstructive pulmonary disease
ANS: D
The fact that the
level has increased enough to compensate for the increased pCO2 level
indicates that this is not an acute condition because the kidneys can take several days to adjust.
The other choices would present with a lower
level. The values indicate respiratory
acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential
causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and
congestive heart failure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
REF: p. 447|Table 19-2
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MSC: NCLEX: Physiologic Integrity
3. On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min
in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient’s arterial blood gas (ABG)
values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and
action should the nurse anticipate for this patient?
a. Initiate oxygen therapy.
b. Prepare for emergency intubation.
c. Administer 1 ampule of sodium bicarbonate. d.
Initiate capnography.
, 26 mEq/L. What
ANS: A
The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient’s arterial
blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated
because this patient has a normal bicarbonate level. Capnography would not be indicated at this time
as the patient’s CO2 is normal. A repeat ABG may be ordered to assess the patient’s ongoing
respiratory status.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 446-447
4. The patient’s arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44
mm Hg; and
, 16 mEq/L. What is the interpretation of the patient’s ABG? a. Uncompensated
respiratory acidosis
b. Uncompensated metabolic acidosis c.
Compensated metabolic acidosis
d. Compensated respiratory acidosis
ANS: B
The pH is below normal range (7.35 to7.45), so this is uncompensated acidosis. The PaCO2 normal
and the
is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated
metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and
below 22
mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm
Hg, and
of 22 to 26 mEq/L. Compensated
metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and
below 22
mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm
Hg, and
above 26 mEq/L.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447|Table 18-1
5. In a patient who is hemodynamically stable, which procedure can be used to estimate the
PaCO2 levels?
a. PaO2/FiO2 ratio
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b. A-a gradient
c. Residual volume (RV)
d. End-tidal CO2
ANS: D
Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal
CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of
normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the
end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater
than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20
mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is
the least reliable clinically, but it is used often in clinical decision making. Residual volume is the
amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450|p. 453
6. A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg;
PaCO2, 35 mm Hg; and
, 11 mEq/L. What is the interpretation of the patient’s ABG?
a. Uncompensated respiratory acidosis b.
Uncompensated metabolic acidosis c.
Uncompensated metabolic alkalosis
d. Uncompensated respiratory alkalosis
ANS: B
The pH indicates acidosis, and the
is markedly decreased, indicating a metabolic disorder.
Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and
below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2
above 45 mm Hg, and
of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include
a pH above 7.45, PaCO2 below 35 mm Hg, and
of 22 to 26 mEq/L. Uncompensated metabolic
alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
above 26 mEq/L.
REF: p. 447|Table 18-1
7. A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35
mm Hg; and
, 11 mEq/L. What symptom would be most consistent with the ABG values?
a. Diarrhea
b. Shortness of breath c.
Central cyanosis
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d. Peripheral cyanosis
ANS: A
Diarrhea is one mechanism by which the body can lose large amounts of
. The other choices
are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447|Table 18-2
8. A bronchoscopy is indicated for a patient with what condition?
a. Pulmonary edema
b. Ineffective clearance of secretions c.
Upper gastrointestinal bleed
d. Instillation of surfactant
ANS: B
Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by
suctioning and sent for culture to help adjust antibiotic therapy.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 448
9. A patient presents moderately short of breath and dyspneic. A chest radiographic
examination reveals a large right pleural effusion with significant atelectasis. The
practitioner would be most likely to prescribe which procedure?
a. Thoracentesis b.
Bronchoscopy
c. Ventilation-perfusion (V/Q) scan d.
Repeat chest radiograph
ANS: A
Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from
the pleural space. It is used most often as a diagnostic measure; it may also be performed
therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would
necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest
radiograph is not indicated.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 449
10. A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses
the patient’s rapid shallow breathing index (RSBI). Which result best suggests that the patient is
ready for a spontaneous breathing trial?
a. RSBI = 150 b. RSBI
= 125 c. RSBI = 110 d.
RSBI = 90
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ANS: D
The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is
considered predictive of weaning success. If the patient is receiving sedation, the medication is
discontinued at least 1 hour before the RSBI is measured. If the patient meets criteria for weaning
readiness and has an RSBI of less than 105, a spontaneous breathing
trial can be performed.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Evaluation TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 451|Table 18-5
11. Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the
following?
a. Pulmonary emboli
b. Acute myocardial infarction c.
Emphysema
d. Acute respiratory distress syndrome
ANS: A
This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes
are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and
pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and
hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 451
12. A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath,
and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest
radiography and reading are obtained. Which finding best supports the nurse’s suspicions?
a.
Blackness in the left lower lung area b.
Whiteness in the left lower lung area c. Blunted
costophrenic angles
d. Elevated left hemidiaphragm
ANS: A
With a pneumothorax, the pleural edges become evident as one looks through and between the
images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the
lung markings have pulled away from the chest wall. In addition, the collapsed lung will be
manifested as an area of increased density separated by an area of radiolucency (blackness).
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 452
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13. A patient with chronic obstructive pulmonary disease (COPD) requires intubation. After the
practitioner intubates the patient, the nurse auscultates for breath sounds. Breath sounds are
questionable in this patient. Which action would best assist in determining endotracheal tube
placement in this patient?
a. Stat chest radiographic examination b. Endtidal CO2 monitor
c. Ventilation-perfusion (V/Q) scan
d. Pulmonary artery catheter insertion
ANS: B
Although a stat chest radiography examination would be helpful, it has a long turnaround time, and
the patient’s respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate
response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are
not for endotracheal tube placement.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 453
14. A patient’s pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the
nurse should perform?
a. Prepare to intubate.
b. Assess the patient’s condition.
c. Turn off the alarm and reapply the oximeter sensor. d.
Increase O2 level to 4L/NC.
ANS: B
The first nursing action would be to assess the patient to see if there is a change in his or her
condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter
sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated
levels of abnormal hemoglobin falsely elevate the SpO2. The ability
of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room
air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a
reliable method of detecting hypercapnia and should not be used for this purpose.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 454
15. Which patient would be considered hypoxemic?
a. A 70-year-old man with a PaO2 of 72
b. A 50-year-old woman with a PaO2 of 65 c. An
84-year-old man with a PaO2 of 96
d. A 68-year-old woman with a PaO2 of 80
ANS: B
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Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining
PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age
above 60 years of age, for example, 70 years old = 80 mm Hg – 10 mm
Hg = 70 mm Hg; 84 years old = 80 mm Hg – 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg
– 8 mm Hg = 72 mm Hg.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 445
16. Which blood gas parameter is the acid–base component that reflects kidney function?
a. pH
b. PaO2
c. PaCO2
d. HCO3¯
ANS: D
The bicarbonate (
) is the acid–base component that reflects kidney function. The bicarbonate is
reduced or increased in the plasma by renal mechanisms. The normal range is
22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial
pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of
carbon dioxide dissolved in arterial blood plasma.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: pp. 445-446
17. Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis?
b.
a.
pH, 7.29; PaCO2, 57 mm Hg;
, 22 mEq/L
pH,
c.
7.36; PaCO2, 33 mm Hg;
, 18 mEq/L
pH, 7.22;
d.
PaCO2, 42 mm Hg;
, 18 mEq/L
pH, 7.52; PaCO2,
38 mm Hg;
, 29 mEq/L
ANS: C
A pH of 7.22 is below normal, reflecting acidosis. The metabolic component (
) is low, indicating
that the acidosis is metabolic in origin. Uncompensated metabolic acidosis values include a pH below
7.35, PaCO2 of 35 to 45 mm Hg, and
PTS:
REF:
OBJ:
MSC:
below 22 mEq/L.
1
DIF: Cognitive Level: Understanding
p. 446|Box 18-2 | p. 447|Table 18-1
Nursing Process Step: Diagnosis
TOP: Pulmonary
NCLEX: Physiologic Integrity
18. Which ABG values reflect compensation?
a.
pH, 7.26; PaCO2, 55 mm Hg;
, 24 mEq/L
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b.
c.
, 18 mEq/L
pH,
d.
7.48; PaCO2, 30 mm Hg;
, 22 mEq/L
pH, 7.38;
PaCO2, 58 mm Hg;
, 30 mEq/L
pH, 7.30; PaCO2, 32 mm Hg;
ANS: D
The pH is within normal limits, and both the PaCO2 and the
values are abnormal.
Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and
above 26 mEq/L.
PTS:
REF:
OBJ:
MSC:
1
DIF: Cognitive Level: Understanding
p. 446|Box 18-3 | p. 448|Table 18-1
Nursing Process Step: Assessment TOP: Pulmonary
NCLEX: Physiologic Integrity
19. Determination of oxygenation status by oxygen saturation alone is inadequate. What other value
must be known?
a. pH
b. PaCO2
c.
d. Hemoglobin (Hgb)
ANS: D
Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that
97% of the available hemoglobin is bound with oxygen. The word available is essential to
evaluating the SaO2 level because the hemoglobin level is not always within normal limits and
oxygen can bind only with what is available.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 446
20. A patient is intubated, and sputum for culture and sensitivity is ordered. Which of the
following is important for obtaining the best specimen?
a. After the specimen is in the container, dilute thick secretions with sterile water.
b. Apply suction when the catheter is advanced to obtain secretions from within the
endotracheal tube.
c. Do not apply suction while the catheter is being withdrawn because this can
contaminate the sample with sputum left in the endotracheal tube.
d. Do not clear the endotracheal tube of all local secretions before obtaining the
specimen.
ANS: C
To prevent contamination of secretions in the upper portion of the endotracheal tube, do not apply
suction while the catheter is being withdrawn. Clear the endotracheal or tracheostomy tube for all
local secretions, avoiding deep airway penetration. This will prevent contamination with upper airway
flora. Do not dilute thick secretions with sterile water. This will compromise the specimen.
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PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 449|Box 18-4
21. What medication may be included in the preprocedural medications for a diagnostic
bronchoscopy?
a. Aspirin for anticoagulation
b. Vecuronium to inhibit breathing
c. Codeine to decrease the cough reflex
d. Cimetidine to decrease hydrochloric acid secretion
ANS: C
Preprocedural medications for a diagnostic bronchoscopy may include atropine and intramuscular
codeine. Whereas atropine lessens the vasovagal response and reduces the secretions, codeine
decreases the cough reflex. When a bronchoscopy is performed therapeutically to remove secretions,
decreased cough and gag reflexes are present, which may impair secretion clearance.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Intervention TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 449
22. Severe coughing and shortness of breath during a thoracentesis are indicative of what
complication?
a. Re-expansion pulmonary edema b.
Pleural infection
c. Pneumothorax d.
Hemothorax
ANS: A
Re-expansion pulmonary edema can occur when a large amount of effusion fluid (~1000 to
1500 mL) is removed from the pleural space. Removal of the fluid increases the negative intrapleural
pressure, which can lead to edema when the lung does not re-expand to fill the space. The patient
experiences severe coughing and shortness of breath. The onset of these symptoms is an indication to
discontinue the thoracentesis.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450
23. A static lung compliance of 40 mL/cm H2O is indicative of which disorder?
a. Pneumonia
b. Bronchospasm
c. Pulmonary emboli
d. Upper airway obstruction
ANS: A
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Static compliance is measured under no-flow conditions so that resistance forces are removed. Static
compliance decreases with any decrease in lung compliance, such as occurs with pneumothorax,
atelectasis, pneumonia, pulmonary edema, and chest wall restrictions. A normal value is 57 to 85
mL/cm of H2O.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 450
24. A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What
diagnostic test most conclusive to determine this diagnosis?
a. ABG
b. Bronchoscopy
c. Pulmonary function test d. V/Q
scan
ANS: D
A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial
blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the
bronchi, and pulmonary function tests are used to measure lung volume.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 451
25. What chest radiography finding is consistent with a left pneumothorax?
a. Flattening of the diaphragm
b. Shifting of the mediastinum to the right c.
Presence of a gastric air bubble
d. Increased radiolucency of the left lung field
ANS: B
Shifting of the mediastinal structures away from the area of involvement is a sign of a
pneumothorax.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 452
26. What does an intrapulmonary shunting value of 35% indicate?
a. Normal gas exchange of venous blood
b. An abnormal finding indicative of a shunt-producing disorder c. A
serious and potentially life-threatening condition
d. Metabolic alkalosis
ANS: C
A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A
shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary
intervention.
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PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447
27. A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas
(ABG) values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3¯,
27 mEq/L. What is the correct interpretation of the patient’s ABG values?
a. Compensated respiratory acidosis b.
Compensated metabolic alkalosis
c. Uncompensated respiratory alkalosis d.
Uncompensated metabolic acidosis
ANS: A
The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to
7.39, PaCO2 above 45 mm Hg, and
above 26 mEq/L. Uncompensated respiratory alkalosis
values include a pH below 7.35, PaCO2 above 45 mm Hg, and
of 22 to 26 mEq/L.
Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above
45 mm Hg, and
above 26 mEq/L. Uncompensated metabolic acidosis values include a pH
above 7.35, PaCO2 of 35 to 45 mm Hg, and
below 22 mEq/L.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Pulmonary
MSC: NCLEX: Physiologic Integrity
REF: p. 447|Table 18-1
28. Place the steps for analyzing arterial blood gases in the proper order.
1. Assess
level for metabolic abnormalities
2. Assess PaO2 for hypoxemia
3. Examine PaCO2 for acidosis or alkalosis
4. Re-examine pH to determine level of compensation
5. Examine pH for acidemia or alkalemia
a. 5, 1, 2, 4, 3
b. 2, 5, 3, 1, 4
c. 1, 2, 4, 3, 5
d. 1, 3, 4, 5, 2
ANS: B
A methodic approach when assessing arterial blood gases allows the nurse to detect subtle
changes. A methodic approach includes look at the PaO2 level, look at the pH level, look at the
PaCO2 level, look at the
, and look again at the pH level.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 446|Box 18-1
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
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1. What risk factors need to be considered when preparing a patient for a thoracentesis? (Select all that
apply.)
a. Coagulation defects
b. Unstable hemodynamics c.
Pleural effusion
d. Uncooperative patient e.
Empyema
ANS: A, B, D
No absolute contraindications to thoracentesis exist, although some risks may contraindicate the
procedure in all but emergency situations. These risk factors include unstable hemodynamics,
coagulation defects, mechanical ventilation, the presence of an intraaortic balloon pump, and patients
who are uncooperative. It is used most often as a diagnostic measure; it may also be performed
therapeutically for the drainage of a pleural effusion or empyema.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 449
OBJ: Nursing Process Step: Assessment TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
2. Nursing management of a patient undergoing a diagnostic procedure entails what nursing actions?
(Select all that apply.)
a. Positioning the patient for the procedure
b. Monitoring the patient’s responses to the procedure c.
Monitoring vital signs
d. Teaching the patient about the procedure
e. Medicating the patient before and after procedure
ANS: A, B, C, D, E
Preparing the patient includes teaching the patient about the procedure, answering any questions, and
positioning the patient for the procedure. Monitoring the patient’s responses to the procedure includes
observing the patient for signs of pain and anxiety and monitoring vital signs, breath sounds, and
oxygen saturation. Assessing the patient after the procedure includes observing for complications of
the procedure and medicating the patient for any postprocedural discomfort.
PTS: 1
DIF: Cognitive Level: Understanding
REF: p. 453
OBJ: Nursing Process Step: Intervention TOP: Pulmonary Diagnostic Procedures
MSC: NCLEX: Physiologic Integrity
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Chapter 19: Kidney Clinical Assessment and Diagnostic Procedures
Test Bank
MULTIPLE
CHOICE
1. Which of the following assessment findings would indicate fluid volume excess?
a. Venous filling of the hand veins greater than 5 seconds
b. Distended neck veins in the supine position
c. Presence of orthostatic hypotension
d. Third heart sound
ANS: D
Auscultation of the heart requires not only assessing rate and rhythm but also listening for
extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which
is best heard with the bell of the stethoscope.
2. Loss of albumin from the vascular space may result in
a. peripheral edema.
b. extra heart
sounds. c.
hypertension.
d. hyponatremia.
ANS: A
Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift,
creating peripheral edema. A decreased albumin level can occur as a result of proteincalorie malnutrition, which occurs in many critically ill patients in whom available stores of
albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts
from the vascular space to the interstitial space.
3. Which of the following auscultatory parameters may exist in the presence of hypovolemia?
a. Hypertension
b. Third or fourth heart sound
c. Orthostatic hypotension
d. Vascular bruit
ANS: C
A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of
10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or
from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs
because a sufficient preload is not immediately available when the patient changes position.
The heart rate increases in an attempt to maintain cardiac output and circulation.
4. Percussion of kidneys is usually done to
a. assess the size and shape of the kidneys.
b. detect pain in the renal area.
c. elicit a fluid wave.
d. evaluate fluid status.
ANS: B
Percussion is performed to detect pain in the area of a kidney or to determine
excess accumulation of air, fluid, or solids around the kidneys. Percussion of the
kidneys also provides information about kidney location, size, and possible
problems.
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5. Differentiating ascites from distortion caused by solid bowel contents in the
distended abdomen is accomplished by
assessing for bowel sounds in four quadrants.
palpation of the liver margin.
measuring abdominal girth.
the presence of a fluid wave.
a.
b.
c.
d.
ANS: D
Differentiating ascites from distortion by solid bowel contents is accomplished by
producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to
the abdominal midline while one hand is placed on the right or left flank. Tapping the
opposite flank produces a wave in the accumulated fluid that can be felt under the hands.
6. The most important assessment parameters for evaluating the patient's fluid status is
to measure
daily weights.
urine and serum osmolality.
intake and output.
hemoglobin and hematocrit levels.
a.
b.
c.
d.
ANS: A
One of the most important assessments of kidney and fluid status is the patient’s weight. In
the critical care unit, weight is monitored for each patient every day and is an important
vital
signs measurement.
7. Which of the following parameters is indicative of volume overload?
a. Central venous pressure of 4 mm Hg
b. Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg
c. Cardiac index of 2.5 L/min/m2
d. Mean arterial pressure of 40 mm Hg
ANS: B
The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required
to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents
the volume of blood available for ejection. It is also known as left ventricular preload and
is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess,
PAOP rises. In fluid volume deficit, PAOP is low.
8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release
of
a.
b.
c.
d.
ketones.
glucagon.
antidiuretic hormone.
potassium.
ANS: C
When the serum osmolality level increases, antidiuretic hormone is released from the
posterior pituitary gland and stimulates increased water resorption in the kidney tubules.
This expands the vascular space, returns the serum osmolality level back to normal, and
results in more concentrated urine and an elevated urine osmolality level.
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9. Which of the following urine values reflects a decreased ability of the kidneys to
concentrate urine?
pH of 5.0
Specific gravity of 1.000
No casts
Urine sodium of 140 mEq/24 hr
a.
b.
c.
d.
ANS: B
Specific gravity measures the density or weight of urine compared with that of distilled
water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific
gravity of distilled water is 1.000. Because urine is composed of many solutes and
substances suspended in water, the specific gravity should always be higher than that of
water.
10. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. The nurse suspects the main cause of ascites is
a. hypervolemia.
b. dehydration.
c. volume overload.
d. liver damage.
ANS: C
Individuals with kidney failure may have ascites caused by volume overload, which forces
fluid into the abdomen because of increased capillary hydrostatic pressures. However,
ascites may or may not represent fluid volume excess. Severe ascites in persons with
compromised liver function may result from decreased plasma proteins. The ascites occurs
because the increased vascular pressure associated with liver dysfunction forces fluid and
plasma proteins from the vascular space into the interstitial space and abdominal cavity.
Although the individual may exhibit marked edema, the intravascular space is volume
depleted, and the patient is hypovolemic.
11. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. Which of the following diagnostic tests would give the best information about the
internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and bladder?
a.
Kidney–ureter–bladder
(KUB) b.
Intravenous
pyelography (IVP) c.
Renal
ultrasonography (ECHO) d.
Renal angiography
ANS: B
Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces,
pelvis, ureters, and bladder. Kidney–ureter–bladder flat-plate radiography of the abdomen
determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is
useful for evaluating the presence of calculi and masses and is usually followed by
additional tests.
In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary
tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies
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fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for
evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial
blood perfusing the kidneys. It allows for visualization of renal blood flow and may also
visualize stenosis, cysts, clots, trauma, and infarctions.
12. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. The patient weight upon admission was 176 lb. The patient’s weight the next day is
184 lb. What is the approximate amount of fluid retained with this weight gain?
a. 800
mL b.
2200 mL
c. 3600
mL d.
8000 mL
ANS: C
One liter of fluid equals 1 kg, which is 2.2 pounds; 8 pounds equals 3.6 kg, which is 3.6
liters;
3.6 liters is equal to 3600 mL.
13. When calculating the anion gap, the predominant cation is
a. sodium.
b. potassium.
c. chloride.
d. bicarbonate.
ANS: A
The anion gap is a calculation of the difference between the measurable extracellular
plasma cations (sodium and potassium) and the measurable anions (chloride and
bicarbonate). In plasma, sodium is the predominant cation, and chloride is the
predominant anion.
14. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. The patient urinalysis has a specific gravity of 1.040. What could be the potential
cause for this value?
a. Volume overload
b. Volume deficit
c. Acidosis
d. Urine ketones
ANS: B
Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values
include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI).
Possible causes for decreased values include volume overload and interrenal AKI.
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15. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. The nurse is assessing the peripheral edema. The nurse presses two fingers over
the tibial area, and it takes 1 minute before the indention disappears. The nurse would chart
the following result:
a.
+1 pitting
edema. b.
+2
pitting edema. c.
+3 pitting edema.
d.
+4 pitting
edema.
ANS:
C
The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15
sec);
+3 = 6-mm depth (lasting up to 60 sec); and +4 = 8-mm depth (lasting longer than 60
sec).
16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that
the patient has developed
a.
glycosuria.
b.
proteinuria.
c.
myoglobin.
d. uremia.
ANS:
D
A history of recent onset of nausea and vomiting or appetite loss caused by taste changes
(uremia often causes a metallic taste) may provide clues to the rapid onset of kidney
problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of
protein in the urine. Myoglobin is the presence of red blood cells in the urine.
17. A patient has been on complete bed rest for 3 days. The health care provider has ordered
for the patient to sit at the bedside for meals. The patient complains of feeling dizzy and
faint while sitting at the bedside. The nurse anticipates that the patient is experiencing
a.
orthostatic
b.
hypertension.
orthostatic hypotension. c.
hypervolemia.
d.
electrolyte
imbalance.
ANS:
B
Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness.
Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect
of medications that affect blood volume or blood pressure.
MULTIPLE RESPONSE
1. Which of the following may be present in the patient with significant fluid volume
overload?
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(Select all that
apply.)
a.
S3 or S4 may
develop.
b.
Distention of the hand veins will disappear if the hand is
elevated.
c. When testing the quality of skin turgor, the skin will not return to the
normal position for several seconds.
d.
Tachycardia with hypotension may be
present.
e.
Dependent edema may be
present.
ANS: A, E
A gallop and dependent edema are indicative of fluid excess; the other signs are indicative
of fluid volume deficit.
2. A patient is admitted to the critical care unit in congestive heart failure secondary to renal
insufficiency. The patient reports that over the past few weeks, his urine output has
decreased, and he has developed peripheral edema and ascites. A diagnosis of renal failure
is made. The nurse would expect to see elevated values in the following laboratory results:
(Select all that apply).
a. BUN.
b. creatinine.
c. glucose.
d. hemoglobin and hematocrit.
e. protein.
ANS: A, B, D
With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease
in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the
BUN can be correlated with the clinical manifestations of uremia; as the BUN rises,
symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are
affected by fewer factors than BUN. As a result, the serum creatinine level is a more
sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most
often in persons with kidney failure resulting from impaired excretion. Decreased
hematocrit value can indicate
fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also
can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals
with acute kidney failure, anemia may occur early in the disease.
Chapter 20: Kidney Disorders and Therapeutic Management
Test Bank
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MULTIPLE
CHOICE
1. An elderly patient is in a motor vehicle accident and sustains a significant internal
hemorrhage. Which category of renal failure is the patient at the greatest risk of
developing? a. Intrinsic
b. Postrenal
c. Prerenal
d. Acute tubular necrosis
ANS: C
Any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial
blood reaches the renal artery that supplies the kidney may be anatomically described as
prerenal acute kidney injury (AKI). When arterial hypoperfusion caused by low cardiac
output, hemorrhage, vasodilation, thrombosis, or other cause reduces the blood flow to the
kidney, glomerular filtration decreases, and consequently urine output decreases. Any
condition that produces an ischemic or toxic insult directly at parenchymal nephron tissue
places the patient at risk for development of intrarenal AKI. Any obstruction that hinders
the flow of urine from beyond the kidney through the remainder of the urinary tract may
lead to postrenal AKI. When the internal filtering structures are pathologically affected, the
condition was previously known as acute tubular necrosis.
2. Which of the following laboratory values is the most help in evaluating a patient for
acute renal failure?
a. Serum sodium
b.
Serum
c.
creatinine
Serum potassium d.
Urine potassium
ANS: B
Serum creatinine is the most reliable predictor of kidney function. In the acutely ill patient,
small changes in the serum creatinine level and urine output may signal important declines
in the glomerular filtration rate and kidney function.
3. Which of the following IV solutions is recommended for treatment of prerenal
failure?
a.
b.
c.
d.
Dextrose in water
Normal saline
Albumin
Lactated Ringer solution
ANS: B
Prerenal failure is caused by decreased perfusion and flow to the kidney. It is often
associated with trauma, hemorrhage, hypotension, and major fluid losses. If contrast dye is
used, aggressive fluid resuscitation with normal saline (NaCl) is recommended.
4. One therapeutic measure for treating hyperkalemia is the administration of dextrose
and regular insulin. How do these agents lower potassium?
a. They force potassium out of the cells and into the serum, lowering it on a cellular
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leve
l.
b. They promote higher excretion of potassium in the urine.
c. They bind with resin in the bowel and are eliminated in the feces.
d. They force potassium out of the serum and into the cells, thus causing potassium
to lower.
ANS: D
Acute hyperkalemia can be treated temporarily by intravenous administration of insulin
and glucose. An infusion of 50 mL of 50% dextrose accompanied by 10 units of regular
insulin forces potassium out of the serum and into the cells.
5. Which of the following IV solutions is contraindicated for patients with kidney or
liver disease or in lactic acidosis?
D5W
0.9% NaCl
Lactated Ringer solution
0.45% NaCl
a.
b.
c.
d.
ANS: C
Lactated Ringer solution is contraindicated for patients with kidney or liver diseases or
in lactic acidosis.
6. To assess whether or not an arteriovenous fistula is functioning, what must be done and
why?
a. Palpate the quality of the pulse distal to the site to determine whether a thrill is
present; auscultate with a stethoscope to appreciate a bruit to assess the quality
of the blood flow.
b. Palpate the quality of the pulse proximal to the site to determine whether a thrill
is present; auscultate with a stethoscope to appreciate a bruit to assess the
quality of the blood flow.
c. Palpate gently over the site of the fistula to determine whether a thrill is present;
listen with a stethoscope over this site to appreciate a bruit to assess the quality
of the blood flow.
d. Palpate over the site of the fistula to determine whether a thrill is present;
check whether the extremity is pink and warm.
ANS: C
The critical care nurse frequently assesses the quality of blood flow through the fistula. A
patent fistula has a thrill when palpated gently with the fingers and a bruit when auscultated
with a stethoscope. The extremity should be pink and warm to the touch. No blood pressure
measurements, intravenous infusions, or laboratory phlebotomy is performed on the arm
with the fistula.
7. To remove fluid during hemodialysis, a positive hydrostatic pressure is applied to the
blood and a negative hydrostatic pressure is applied to the dialysate bath. This process is
known as a. ultrafiltration.
b. hemodialysis.
c. reverse osmosis.
d. colloid extraction.
ANS: A
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To remove fluid, a positive hydrostatic pressure is applied to the blood, and a negative
hydrostatic pressure is applied to the dialysate bath. The two forces together, called
transmembrane pressure, pull and squeeze the excess fluid from the blood. The
difference between the two values (expressed in millimeters of mercury [mm Hg])
represents the transmembrane pressure and results in fluid extraction, known as
ultrafiltration, from the vascular space.
8. Which electrolytes pose the most potential hazard if not within normal limits for a person
with renal failure?
Phosphorous and calcium
Potassium and calcium
Magnesium and sodium
Phosphorous and magnesium
a.
b.
c.
d.
ANS: B
Although most electrolytes, such as potassium, become increasingly elevated in patients
with acute renal failure, calcium levels are reduced. In each case, these conditions produce
life- threatening cardiac dysrhythmias.
9. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection
developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic.
After 3 days of administration, oliguria occurred, and subsequent laboratory values
indicated elevated BUN and creatinine levels. The patient is transferred to the critical care
unit with acute kidney injury (previously known as acute tubular necrosis). Which dialysis
method would be most appropriate for the patient’s condition?
a. Peritoneal dialysis
b. Hemodialysis
c. Continuous renal replacement therapy
d. Continuous venovenous hemodialysis (CVVH)
ANS: B
As a treatment, hemodialysis literally separates and removes from the blood the excess
electrolytes, fluids, and toxins by use of a hemodialyzer. Although hemodialysis is efficient
in removing solutes, it does not remove all metabolites. Furthermore, electrolytes, toxins,
and fluids increase between treatments, necessitating hemodialysis on a regular basis.
10. A patient has been hospitalized for a subtotal gastrectomy. After the procedure, an infection
developed that eventually had to be treated with gentamicin, an aminoglycoside antibiotic.
After 3 days of administration, oliguria occurred, and subsequent laboratory values
indicated elevated BUN and creatinine levels. The patient is transferred to the critical care
unit with acute kidney injury (previously known as acute tubular necrosis). The fluid that is
removed each hour is not called urine; it is known as
a. convection.
b. diffusion.
c. replacement fluid.
d. ultrafiltrate.
ANS: D
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The fluid that is removed each hour is not called urine; it is known as ultrafiltrate.
Typically, some of the ultrafiltrate is replaced through the continuous renal replacement
therapy circuit by a sterile replacement fluid. Diffusion is the movement of solutes along a
concentration gradient from a high concentration to a low concentration across a
semipermeable membrane. Convection occurs when a pressure gradient is set up so that the
water is pushed or pumped across the dialysis filter and carries the solutes from the
bloodstream with it.
11. The most common site for short-term vascular access for immediate hemodialysis is
the
a.
b.
c.
d.
subclavian artery.
subclavian vein.
femoral artery.
radial vein.
ANS: B
Subclavian and femoral veins are catheterized when short-term access is required or when a
graft or fistula vascular access is nonfunctional in a patient requiring immediate
hemodialysis. Subclavian and femoral catheters are routinely inserted at the bedside. Most
temporary catheters are venous lines only. Blood flows out toward the dialyzer and flows
back to the patient through the same catheterized vein. A dual-lumen venous catheter is
most commonly used.
12. A patient has acute kidney injury (previously known as acute tubular necrosis). The following
blood work was noted: complete blood count shows a white blood cell count of 11,000 mm3,
a hemoglobin of 8 g/dL, and a hematocrit of 30%. His chemistry panel shows serum
potassium,
4.5 mg/dL; serum sodium, 135 mg/dL; serum calcium, 8.5 mg/dL; BUN, 20 mg/dL; and
creatinine, 1.5 mg/dL. What laboratory value(s) need(s) to be treated most immediately
and why?
a. Administration of 5% dextrose in water and insulin because the patient
is hyperkalemic and needs this level reduced
b. Administration of Epogen to treat anemia
c. Administration of a broad-spectrum antibiotic to treat the elevated blood cell count
d. Administration of a calcium supplement for low calcium
ANS: B
A patient showing signs of anemia per his hematocrit and hemoglobin must be
treated. Epogen is used because it helps stimulate erythrocyte production by the
bone marrow.
13. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an
amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less
than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop
prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter,
which was placed into her right femoral access, and started on vasopressors with a fair
response (BP, 80/50 mm Hg;
HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis,
the patient was begun on CVVH. Which of the statements best describes CVVH?
a. Complete renal replacement therapy requiring large volumes of ultrafiltrate
and filter replacement
b. Complete renal replacement therapy that allows removal of solutes and
modification of the volume and composition of extracellular fluid to occur
evenly over time
c. Involves the introduction of sterile dialyzing fluid through an implanted catheter
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into the abdominal cavity, which relies on osmosis, diffusion, and active
transport to help remove waste from the body
d. Complete renal replacement therapy that allows an exchange of fluid, solutes,
and solvents across a semipermeable membrane at 100 to 300 mL/hr
ANS: B
Continuous venovenous hemodialysis is indicated when the patient’s clinical condition
warrants removal of significant volumes of fluid and solutes. Fluid is removed by
ultrafiltration in volumes of 5 to 20 mL/min or up to 7 to 30 L/24 hr. Removal of solutes
such as urea, creatinine, and other small non–protein-bound toxins is accomplished by
convection. The replacement fluid rate of flow through the continuous renal replacement
therapy circuit can be altered to achieve desired fluid and solute removal without causing
hemodynamic instability.
14. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an
amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less
than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop
prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter,
which was placed into her right femoral access, and started on vasopressors with a fair
response (BP, 80/50 mm Hg;
HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis,
the patient was begun on CVVH. Identify three complications of CVVH therapy.
a. Fat emboli, increased ultrafiltration, and hypertension
b. Hyperthermia, overhydration, and power surge
c. Air embolism, decreased inflow pressure, and electrolyte imbalance
d. Blood loss, decreased outflow resistance, and acid–base imbalance
ANS: C
Air embolism, decreased inflow pressure, electrolyte imbalances, blood leaks, access
failure, and clotted hemofilter are just a few complications that can occur with continuous
venovenous hemodialysis.
15. The patient is a gravida 6, para 1. She is admitted after a cesarean section after an
amniotic embolus. Her heart rate (HR) is more than 150 beats/min with a systolic BP less
than 80 mm Hg. Her temperature is 38°C, and her condition has caused her to develop
prerenal azotemia. The patient was fluid resuscitated through a double-lumen catheter,
which was placed into her right femoral access, and started on vasopressors with a fair
response (BP, 80/50 mm Hg;
HR, 122 beats/min). Because of her diagnosis and a concern regarding fulminating sepsis,
the patient was begun on CVVH. Why would this therapy be chosen for this patient?
a. Hyperdynamic patients can better tolerate abrupt fluid and solute changes.
b. It is the treatment of choice for patients with diminished renal perfusion who
are unresponsive to diuretics.
c. It is indicated for patients who require large-volume removal for severe uremia
or critical acid–base imbalances.
d. It is indicated for hemodynamically unstable patients, who are often intolerant
of the abrupt fluid and solute changes that can occur with hemodialysis.
ANS: D
Continuous venovenous hemodialysis is indicated for patients who require large-volume
removal for severe uremia or critical acid–base imbalances or for those who are resistant
to diuretics.
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16. What is a continuous venovenous hemodialysis filter permeable to?
a. Electrolytes
b. Red blood cells
c. Protein
d. Lipids
ANS: A
A continuous venovenous hemodialysis filter is permeable to solutes such as urea,
creatinine, uric acid, sodium, potassium, ionized calcium, and drugs not bound by proteins.
17. A patient has sepsis and is placed on broad-spectrum antibiotics. Her temperature is 37.8°C.
Her BUN level is elevated. She continues on vasopressor therapy. What other steps should
be taken to protect the patient from inadequate organ perfusion?
a. Increase net ultrafiltrate of fluid.
b. Discontinue vasopressor support.
c. Assess the patient for blood loss and hypotension.
d. Notify the physician of access pressures.
ANS: C
The patient should be assessed for blood loss or response to blood products and
medications. The nurse should use ordered vasopressor support and decrease the net
ultrafiltrate to zero.
18. To control azotemia, the recommended nutritional intake of protein is
a. .5 to 1.0 g/kg/day.
b. 1.2 to 1.5
g/kg/day. c. 1.7 to
2.5 g/kg/day. d. 2.5
to 3.5 g/kg/day.
ANS: B
The recommended energy intake is between 20 and 30 kcal/kg/day, with 1.2 to 1.5
grams/kg of protein per day to control azotemia (increased blood urea nitrogen level).
19. Which of the following diuretics maybe combined to work on different parts of the nephron?
a. Loop and thiazide diuretics
b. Loop and osmotic diuretics
c. Osmotic and carbonic anhydrase inhibitor diuretics
d. Thiazide and osmotic diuretics
ANS: A
A thiazide diuretic such as chlorothiazide (Diuril) or metolazone (Zaroxolyn) may be
administered and followed by a loop diuretic to take advantage of the fact that these
medications work on different parts of the nephron. Sometimes a thiazide diuretic is added
to a loop diuretic to compensate for the development of loop diuretic resistance.
20. What is the dose for low-dose dopamine?
a. 1 to 2
mcg/kg/min b. 1 to
2 mg/kg/min c. 2 to
3 mcg/kg/min d. 2
to 3 mg/kg/min
ANS: C
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Low-dose dopamine (2–3 mcg/kg/min), previously known as renal-dose dopamine, is
frequently infused to stimulate blood flow to the kidney. Dopamine is effective in
increasing urine output in the short term, but tolerance of the dopamine renal receptor to
the medication
is theorized to develop in the critically ill patients who are most at risk for acute kidney
injury.
21. Laboratory results come back on a newly admitted patient. They are as follows: serum
BUN,
64 mg/dL; serum creatinine, 2.4 mg/dL; urine osmolality, 210 mOsm/kg; specific gravity,
1.002; and urine sodium, 96 mEq/L. The urine output has been 120 mL since
admission 2 hours ago. These values are most consistent with which of the following
diagnoses?
a. Prerenal failure
b. Postrenal failure
c. Oliguric renal failure
d. Acute kidney injury (AKI)
ANS: D
Urinary sodium less than 10 mEq/L (low) suggests a prerenal condition. Urinary sodium
greater than 40 mEq/L (in the presence of an elevated serum creatinine and the absence
of a high salt load) suggests intrarenal damage has occurred. The urine output does not
seem to suggest oliguria. The other options do not fit the data as presented.
22. A patient with renal failure reports all of the following during the medical history. Which
is most likely to have precipitated the patient’s renal failure?
Recent computed tomography of the brain with and without contrast
A recent bout of congestive heart failure after an acute myocardial infarction
Twice-daily prescription of Lasix 40 mg by mouth
A recent bout of benign prostatic hypertrophy and transurethral resection of
the prostate
a.
b.
c.
d.
ANS: A
Intravenous contrast media can be nephrotoxic, especially with the patient’s preexisting cardiac disease. The other choices, although possible causes, are less likely
than the intravenous contrast media.
23. An alert and oriented patient presents with a pulmonary artery wedge pressure of 4 mm
Hg and a cardiac index of 0.8. The BUN is 44 mg/dL, creatinine is 3.2 mg/dL, and BP is
88/36 mm Hg. Urine output is 15 mL/hr. Lungs are clear to auscultation with no peripheral
edema noted. Which of the following treatments would the physician most likely order?
a. Lasix 40 mg intravenous push
b. 0.9% normal saline at 125 mL/hr
c. Dopamine 15
/kg/min
d. Transfuse 1 U of packed red blood cells
ANS: B
The patient’s hemodynamic parameters are most consistent with hypovolemia. The renal
failure would then most probably be prerenal from inadequate blood flow. The treatment of
choice for hypovolemia is fluid resuscitation. Important criteria when calculating fluid
volume replacement include baseline metabolism, environmental temperature, and
humidity. The rate of replacement depends on cardiopulmonary reserve, adequacy of kidney
function, urine output, fluid balance, ongoing loss, and type of fluid replaced.
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24. A patient in acute renal failure presents with a potassium level of 6.9 mg/dL. He has had no
urine output in the past 4 hours despite urinary catheter insertion and Lasix 40 mg
intravenous push. Vital signs are as follows: HR, 76 beats/min; respiratory rate, 18
breaths/min; and BP,
145/96 mm Hg. He is given 100 mL of 50% dextrose in water and 20 U of regular
insulin intravenous push. A repeat potassium level 2 hours later shows a potassium
level of 4.5 mg/dL. What order would now be expected?
a. Sodium Kayexalate 15 g PO
b. Nothing; this represents a normal potassium level
c. Lasix 40 mg IVP
d. 0.9% normal saline at 125 mL/hr
ANS: A
This patient appears to be in acute anuric renal failure. The potassium was not eliminated
from the body; it was simply shifted intracellularly. Soon the potassium will return to the
bloodstream, and the Kayexalate will help permanently remove it from the body. Lasix is
not expected to work in the presence of anuria. The patient’s vital signs do not support
hypovolemia. In the presence of anuria, a large fluid infusion can precipitate congestive
heart failure.
25. A patient with chronic renal failure receives hemodialysis treatments 3 days a week.
Every 2 weeks, the patient requires a transfusion of 1 or 2 U of packed red blood cells.
What is the probable reason for this patient’s frequent transfusion needs?
a. Too much blood phlebotomized for tests
b. Increased destruction of red blood cells because of the increased toxin levels
c. Lack of production of erythropoietin to stimulate red blood cell formation
d. Fluid retention causing hemodilution
ANS: C
In chronic renal failure, the kidneys do not produce sufficient amounts of erythropoietin
in response to normal stimuli such as anemia or hypotension. The other choices are not
reasons for frequent blood transfusions in this patient.
26. Which of the following medications is considered a loop diuretic?
a. Acetazolamide (Diamox)
b. Furosemide (Lasix)
c. Mannitol
d. Metolazone (Zaroxolyn)
ANS: B
Loop diuretics include furosemide (Lasix), bumetanide (Bumex), and torsemide
(Torsemide). Furosemide is the most frequently used diuretic in critical care patients. It
may be administered orally, as an intravenous (IV) bolus, or as a continuous IV infusion.
Diamox is a carbonic anhydrase inhibitor diuretic. Mannitol is an osmotic diuretic, and
Zaroxolyn is a thiazide diuretic.
MULTIPLE
RESPONSE
1. Which of the following conditions is associated between kidney failure and
respiratory failure? (Select all that apply.)
a. ARDS
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b.
c.
d.
e.
Lower GFR
Increased urine output
Decreased urine output
Decreased blood flow to the kidneys
ANS: A, B, D, E
Mechanical ventilation for respiratory failure can alter kidney function. Positive-pressure
ventilation reduces blood flow to the kidney, lowers the glomerular filtration rate, and
decreases urine output. Kidney failure increases inflammation, causes the lung vasculature
to become more permeable, and contributes to the development of acute respiratory distress
syndrome.
2. To prevent catheter-associated UTI (CAUTI), the nurse should (Select all that apply.)
a. insert urinary catheters using aseptic techniques.
b. change the urinary catheter daily.
c. review the need for the urinary catheter daily and remove promptly.
d. flush the urinary catheter q8 hours to maintain patency.
e. avoid unnecessary use of indwelling urinary catheters.
ANS: A, C, E
The key components of CAUTI prevention are to avoid unnecessary use of urinary
catheters, insert urinary catheters using aseptic technique, adopt evidence-based standards
for maintenance of urinary catheters, review the need for the urinary catheter daily, and
remove the catheter promptly.
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Chapter 21: Gastrointestinal Clinical Assessment and Diagnostic Procedures
Test Bank
MULTIPLE
CHOICE
1. When assessing the gastrointestinal system, the order of assessment progresses in which of
the following?
Inspection, palpation, percussion,
auscultation b.
Palpation, percussion,
inspection, auscultation c.
Inspection,
d.
auscultation,
percussion,
palpation
Palpation, inspection, auscultation, percussion
a.
ANS: C
To prevent stimulation of gastrointestinal activity, the order for the assessment should
be inspection, auscultation, percussion, and palpation.
2. When assessing the abdomen, how long must the nurse listen to the abdomen to be able
to accurately chart that bowel sounds are absent?
a. 30 seconds in each quadrant
b. 1
minute c.
3 minutes
d. 5
minutes
ANS: D
Normal bowel sounds include high-pitched, gurgling sounds that occur approximately
every 5 to 15 seconds or at a rate of 5 to 34 times per minute. Abnormal findings include
the absence of bowel sounds throughout a 5-minute period, extremely soft and widely
separated sounds, and increased sounds with a high-pitched, loud rushing sound (peristaltic
rush).
3. Which assessment technique is most useful in detecting abdominal pathologic
conditions?
a.
b.
c.
d.
Percussion
Palpation
Inspection
Auscultation
ANS: B
Palpation is the assessment technique that is most useful in detecting abdominal
pathologic conditions. Both light and deep palpation of each organ and quadrant should
be completed. Deep palpation is most helpful in detecting abdominal masses. Areas in
which the patient complains of tenderness should be palpated last.
4. Which of the following findings is considered an abnormal gastrointestinal
assessment finding?
Visible peristaltic waves
Hyper-resonance of the intestine
High-pitched gurgling sounds in the small intestine
Dull sounds over the liver and spleen
a.
b.
c.
d.
ANS: A
Visible pulsations or peristaltic waves are considered an abnormal assessment finding.
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5. Which of the following serum laboratory values is increased in acute pancreatitis?
a. Bilirubin
b. Amylase
c. Lactate dehydrogenase
d. Ammonia
ANS: B
Serum amylase will rise with acute pancreatitis. The other values are affected
by hepatocellular disease.
6. The best diagnostic test for the determination of upper gastrointestinal bleeding is
a. endoscopic retrograde cholangiopancreatography (ERCP).
b. colonoscopy.
c. endoscopy.
d. angiography.
ANS: C
Endoscopy is the procedure of choice for the diagnosis of upper gastrointestinal (GI)
bleeding. Colonoscopy permits viewing of the lower GI tract from the rectum to the distal
ileum, and it
is used to evaluate sources of lower GI bleeding. Angiography is used as a diagnostic and
a therapeutic procedure. Diagnostically, it is used to evaluate the status of the GI
circulation. Endoscopic retrograde cholangiopancreatography (ERCP) enables viewing of
the biliary and pancreatic ducts, and it is used in the evaluation of pancreatitis.
7. Upon auscultation, the nurse hears borborygmi. This is a change in the patient’s condition.
The nurse suspects the patient maybe experiencing
a. a complete ileus.
b.
early intestinal
obstruction. c. abnormality
of blood flow. d. peritonitis.
ANS: B
Hyperactive bowel sounds (borborygmi) that are loud and prolonged are caused by
hunger, gastroenteritis, or early intestinal obstruction. Decreased (hypoactive) bowel
sounds are symptoms of possible peritonitis or ileus. Bruits are caused by abnormality of
blood flow.
8. Nursing management of the patient undergoing an angiogram includes
a. keeping the patient flat for 24 hours.
b. inserting a nasogastric tube before the procedure.
c. administering tap water enemas until clear.
d. checking the patient's pulse distal to the injection site every 15 minutes.
ANS: D
Postprocedural assessment involves monitoring vital signs, observing the injection site for
bleeding, and assessing neurovascular integrity distal to the injection site every 15 minutes
for the first 1 to 2 hours. Depending on how the puncture site is stabilized after the
procedure, the patient may have to remain flat in bed for a specified length of time.
9. Which of the following diagnostic procedures is used to identify gallstones and
hepatic abscesses?
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a.
b.
c.
d.
Ultrasonography
Abdominal radiography
Angiography
Liver scan
ANS: A
Abdominal ultrasonography is useful in evaluating the status of the gallbladder and biliary
system, the liver, the spleen, and the pancreas. It plays a key role in the diagnosis of many
acute abdominal conditions, such as acute cholecystitis and biliary obstructions, because it
is sensitive in detecting obstructive lesions, as well as ascites. Ultrasonography is used to
identify gallstones and hepatic abscesses, candidiasis, and hematomas.
10. A 78-year-old patient was admitted to the critical care unit with cirrhosis of the liver.
In cirrhosis of the liver, which of the following laboratory values is expected to drop?
Albumin
Total bilirubin
Alkaline phosphatase
Aspartate aminotransferase
a.
b.
c.
d.
ANS: A
In a patient with cirrhosis, total bilirubin, alkaline phosphatase, aspartate aminotransferase,
and alanine aminotransferase values all show elevation, but albumin values drop as a result
of the catabolism.
11. Signs and symptoms of which condition include nausea, localized right lower quadrant
guarding and tenderness after 12 to 24 hours, fever, and an elevated white blood cell
count? a. Appendicitis
b. Hepatitis
c. Cecal volvulus
d. Perforated duodenal ulcer
ANS: A
Signs and symptoms of appendicitis include anorexia, nausea, and vomiting; early vague
epigastric, periumbilical, or generalized pain after 12 to 24 hours; RLQ at McBurney
point; localized RLQ guarding and tenderness after 12 to 24 hours; a white blood cell
count of
10,000/mm or left shift; and low-grade fever. Signs are highly variable.
12. A health care provider has ordered an MRI (magnetic resonance imaging) of the liver.
The nurse’s first action is to
prepare the patient psychologically and physically for the procedure.
monitor the patient’s response to the procedure.
assess the patient after the procedure.
inform the patient’s family of the results.
a.
b.
c.
d.
ANS: A
The nursing management of a patient undergoing a diagnostic procedure involves a variety
of interventions. Nursing actions include preparing the patient psychologically and
physically for the procedure, monitoring the patient’s responses to the procedure, and
assessing the patient after the procedure. Preparing the patient includes teaching the patient
about the procedure, answering any questions, and transporting and positioning the patient
for the procedure.
13. Steatorrhea is determined by which laboratory study?
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a.
b.
c.
d.
Gastric acid stimulation
Urea breath test
Culture and sensitivity
Stool studies
ANS: D
Steatorrhea (an increase of fat in the stool) results from malabsorption or pancreatic
insufficiency and is determined with stool studies. The result of the urea breath test is
positive if the patient has a Helicobacter pylori infection. Gastric acid stimulation is used
for the detection of duodenal ulcers, gastric atrophy, and gastric carcinoma.
14. Which radiographic test would be used to identify pseudocysts of the pancreas?
a. Plain film radiography
b. Abdominal ultrasonography
c. CT of abdomen
d. MRI of the abdomen
ANS: C
CT (Computed tomography) detects mass lesions more than 2 cm in diameter and allows
visualization and evaluation of many different aspects of gastrointestinal (GI) disease. It
is particularly useful in identifying pancreatic pseudocysts, abdominal abscesses, biliary
obstructions, and a variety of GI neoplastic lesions.
15. The patient has just returned from a liver biopsy. The patient should be positioned on the
a. left side for 2 hours.
b. right side for 2 hours.
c. left side for 6 to 8 hours.
d. right side for 6 to 8 hours.
ANS: B
After the procedure, the patient is positioned on the right side for 2 hours and kept
on complete bed rest for the next 6 to 8 hours.
MULTIPLE
RESPONSE
1. Identify anatomic structures that are found in the right upper quadrant. (Select all that
apply.)
a. Duodenum
b. Portion of the transverse colon
c. Liver
d. Stomach
e. Cecum
ANS: A, B, C
The right upper quadrant includes the liver and gallbladder, pylorus, duodenum, head
of pancreas, right adrenal gland, portion of the right kidney, hepatic flexure of colon,
and a portion of the ascending and transverse colon. The stomach is located in the left
upper quadrant and the cecum is located in the right lower quadrant.
2. Identify anatomic structures that are found in the right lower quadrant. (Select all that
apply.)
a. Sigmoid colon
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b.
c.
d.
e.
Portion of the ascending colon
Portion of the descending colon
Distended bladder
Enlarged uterus
ANS: B, D, E
The right lower quadrant includes the lower pole of the right kidney, cecum and appendix,
portion of the ascending colon, bladder (if distended), ovary and salpinx, uterus (if
enlarged), right spermatic cord, and right ureter. The sigmoid colon and portion of the
descending colon are found in the left lower quadrant.
3. Identify anatomic structures that are found in the left upper quadrant. (Select all that apply.)
a. Stomach
b. Spleen
c. Portion of the transverse and descending colon
d. Head of the pancreas
e. Body of the pancreas
ANS: A, B, C, E
The left upper quadrant includes the left lobe of the liver, spleen, stomach, body of the
pancreas, left adrenal gland, portion of the left kidney, splenic flexure of the colon, and
portions of the transverse and descending colon. The head of the pancreas is found in the
right upper quadrant.
4. Identify anatomic structures that are found in the left lower quadrant. (Select all that apply.)
a. Distended uterus
b. Cecum and appendix
c. Left ureter
d. Portion of the descending colon
e. Sigmoid colon
ANS: A, C, D, E
The left lower quadrant includes the lower pole of the left kidney, sigmoid colon, portion
of the descending colon, bladder (if distended), ovary and salpinx, uterus (if distended),
left spermatic cord, and left ureter. The cecum and appendix is found in the right lower
quadrant.
5. Potential complications of an endoscopy include (Select all that apply.)
a. perforation of the GI tract.
b.
hemorrhage. c.
oversedation.
d.
constipation. e.
aspiration.
ANS: A, B, C, E
Fiberoptic endoscopy may present risks for the patient. Although rare, potential
complications include perforation of the gastrointestinal (GI) tract, hemorrhage, aspiration,
vasovagal stimulation, and oversedation. Signs of perforation include abdominal pain and
distention, GI bleeding, and fever.
6. Inspection of the GI system should include the (Select all that apply.)
a. mouth.
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b.
c.
d.
e.
esophagus.
skin.
bladder.
abdomen.
ANS: A, C, E
Although assessment of the gastrointestinal system classically begins with inspection of the
abdomen, the patient’s oral cavity also must be inspected to determine any unusual findings.
Abnormal findings of the mouth include temporomandibular joint tenderness, inflammation
of gums, missing teeth, dental caries, ill-fitting dentures, and mouth odor. The skin should
be observed for pigmentation, lesions, striae, scars, petechiae, signs of dehydration, and
venous pattern.
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Chapter 22: Gastrointestinal Disorders and Therapeutic Management
Test Bank
MULTIPLE
CHOICE
1. Which of the following disorders is the leading cause of upper GI hemorrhage?
a. Stress ulcers
b. Peptic ulcers
c. Nonspecific erosive gastritis
d. Esophageal varices
ANS: B
Peptic ulcer disease (gastric and duodenal ulcers), resulting from the breakdown of
the gastromucosal lining, is the leading cause of upper GI hemorrhage, accounting
for approximately 21% of cases.
2. Esophagogastric varices are the result of
a. portal hypertension resulting in diversion of blood from a high-pressure area
to a low-pressure area.
b. superficial mucosal erosions as a result of increased stress levels.
c. proulcer forces breaking down the mucosal resistance.
d. inflammation and ulceration secondary to nonsteroidal anti-inflammatory drug use.
ANS: A
Esophagogastric varices are engorged and distended blood vessels of the esophagus and
proximal stomach that develop as a result of portal hypertension secondary to hepatic
cirrhosis, a chronic disease of the liver that results in damage to the liver sinusoids.
Without adequate sinusoid function, resistance to portal blood flow is increased, and
pressures within the liver are elevated. This leads to a rise in portal venous pressure
(portal hypertension),
causing collateral circulation to divert portal blood from areas of high pressure within the
liver to adjacent areas of low pressure outside the liver, such as into the veins of the
esophagus, spleen, intestines, and stomach.
3. The patient at risk for GI hemorrhage should be monitored for which of the following
signs and symptoms?
Metabolic acidosis and hypovolemia
Decreasing hemoglobin and hematocrit
Hyperkalemia and hypernatremia
Hematemesis and melena
a.
b.
c.
d.
ANS: D
The initial clinical presentation of the patient with acute gastrointestinal (GI) hemorrhage
is that of a patient in hypovolemic shock; the clinical presentation depends on the amount
of blood lost. Hematemesis (bright red or brown, coffee grounds emesis), hematochezia
(bright red stools), and melena (black, tarry, or dark red stools) are the hallmarks of GI
hemorrhage.
4. A nursing priority for a patient with GI hemorrhage is
a. positioning the patient in a high-Fowler position.
b. airway protection.
c. irrigating the nasogastric tube with iced saline.
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d. maintaining venous access so that fluids and blood can be administered.
ANS: D
Priorities in the medical management of a patient with gastrointestinal hemorrhage
include airway protection, fluid resuscitation to achieve hemodynamic stability,
correction of co- morbid conditions (e.g., coagulopathy), therapeutic procedures to
control or stop bleeding, and diagnostic procedures to determine the exact cause of the
bleeding.
5. The physician orders gastric lavage to control GI bleeding. The nurse has inserted a large-
bore
NG tube. What temperature and irrigating fluid would be used to obtain the best results?
a. Warm NS or water
b. Iced NS or water
c. Room temperature NS or water
d. Iced NS only
ANS: C
Historically, iced saline was favored as a lavage irrigant. Research has shown, however,
that low-temperature fluids shift the oxyhemoglobin dissociation curve to the left,
decrease oxygen delivery to vital organs, and prolong bleeding time and prothrombin time.
Iced saline also may further aggravate bleeding; therefore, room temperature water or
saline is the preferred irrigant for use in gastric lavage.
6. A patient with a 10-year history of alcoholism was admitted to the critical care unit with
the diagnosis of acute pancreatitis. The physiologic alteration that occurs in acute
pancreatitis is a. uncontrolled hypoglycemia caused by an increased release of insulin.
b. loss of storage capacity for senescent red blood cells.
c. premature activation of inactive digestive enzymes, resulting in autodigestion.
d. release of glycogen into the serum, resulting in hyperglycemia.
ANS: C
In acute pancreatitis, the normally inactive digestive enzymes become prematurely
activated within the pancreas itself, creating the central pathophysiologic mechanism of
acute pancreatitis, namely autodigestion.
7. A patient with a 10-year history of alcoholism was admitted to the critical care unit with
the diagnosis of acute pancreatitis. Based on the diagnosis, the patient
is at risk for hypovolemic shock from plasma volume depletion.
requires observation for hypoglycemia and hypercalcemia.
should be started on enteral feedings after the nasogastric tube is placed.
is placed on a fluid restriction to avoid the fluid sequestration.
a.
b.
c.
d.
ANS: A
Because pancreatitis if often associated with massive fluid shifts, intravenous crystalloids
and colloids are administered immediately to prevent hypovolemic shock and maintain
hemodynamic stability. Electrolytes are monitored closely, and abnormalities such as
hypocalcemia, hypokalemia, and hypomagnesemia are corrected. If hyperglycemia
develops, exogenous insulin may be required.
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8. A patient with a 10-year history of alcoholism was admitted to the critical care unit with
the diagnosis of acute pancreatitis. The patient is complaining of a pain in left upper
quadrant. Using a 1- to 10-point pain scale, the patient states the current level is at an 8.
To properly manage the patient’s pain, the priority of nursing interventions is to
a. administer antiemetics around the clock.
b. administer analgesics around the clock.
c. educate the patient and family on lifestyle changes.
d. teach relaxation techniques.
ANS: B
Pain management is a major priority in acute pancreatitis. Administration of around-theclock analgesics to achieve pain relief is essential. Morphine, fentanyl, and hydromorphone
are the commonly used narcotics for pain control. Relaxation techniques and the knee–chest
position can also assist in pain control.
9. A patient with a 10-year history of alcoholism was admitted to the critical care unit with the
diagnosis of acute pancreatitis. The patient is preparing for discharge. Nursing intervention
should include
a. diabetes management.
b. alcohol cessation program.
c. frequency of hemoccult testing.
d. frequency of PT and PTT testing.
ANS: B
As the patient moves toward discharge, teaching should focus on the interventions
necessary for preventing the recurrence of the precipitating disorder. If an alcohol abuser,
the patient should be encouraged to stop drinking and be referred to an alcohol cessation
program.
10. Verification of feeding tube placement
a.
b.
c.
d.
includes
auscultation for position.
aspiration of stomach contents.
x-ray study for confirmation.
gastric pH measurement.
ANS: C
The traditional practice of confirming placement by auscultating air inserted through the
tube over the epigastrium is not reliable and is not recommended. Aspiration of stomach
contents and gastric pH measurement are also not recommended. If there is any doubt as to
the tube’s position, a repeat radiograph should be obtained.
11. Which of the following medications is/are given to help control ammonia levels in a
patient with acute liver failure (ALF)?
Insulin
Vitamin K
Lactulose
Benzodiazepines
a.
b.
c.
d.
ANS: C
Lactulose, a synthetic Ketoanalogue of lactose split into lactic acid and acetic acid in the
intestine, is given orally through a nasogastric tube or as a retention enema. The result is the
creation of an acidic environment that results in ammonia being drawn out of the portal
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circulation. Lactulose has a laxative effect that promotes expulsion. Vitamin K is used to
help control bleeding. Insulin would be given to control hyperglycemia. Use of
benzodiazepines and other sedatives is discouraged in a patient with ALF because pertinent
neurologic changes may be masked, and hepatic encephalopathy may be exacerbated.
12. Esophagectomy is usually performed for
a. cancer of the proximal esophagus and gastroesophageal junction.
b. cancer of the distal esophagus and gastroesophageal junction.
c. cancer of the pancreatic head.
d. varices of the distal esophagus and gastroesophageal junction.
ANS: B
Esophagectomy is usually performed for cancer of the distal esophagus and
gastroesophageal junction.
13. Roux-en-Y gastric bypass is
a. a restrictive type of bariatric surgery.
b. a malabsorptive type of bariatric surgery.
c. a combination of restrictive and malabsorption types of bariatric surgery.
d. standard operation for pancreatic cancer.
ANS: C
Bariatric procedures are divided into three broad types: (1) restrictive, (2) malabsorptive,
and (3) combined restrictive and malabsorptive. The roux-en-Y gastric bypass combines
both strategies by creating a small gastric pouch and anastomosing the jejunum to the
pouch. Food then bypasses the lower stomach and duodenum, resulting in decreased
absorption of digestive materials. The standard operation for pancreatic cancer is a
pancreaticoduodenectomy, also called the Whipple procedure.
14. Signs and symptoms of an anastomotic leak include
a. pneumonia.
b. subcutaneous emphysema.
c. bleeding.
d. atelectasis.
ANS: B
The clinical signs and symptoms of a leak can be subtle and often go unrecognized. They
include tachycardia, tachypnea, fever, abdominal pain, anxiety, and restlessness. In a
patient who had an esophagectomy, a leak of the esophageal anastomosis may manifest as
subcutaneous emphysema in the chest and neck. Upper gastrointestinal (GI) bleeding is
an uncommon but life-threatening complication of GI surgery. Early bleeding usually
occurs at the site of the anastomosis and can usually be treated through endoscopic
intervention. The risk for pulmonary complications is substantial after GI surgery, and
adverse respiratory events such as atelectasis and pneumonia are twice as likely to occur
in the patient who is obese.
15. Which of the following nursing interventions after GI surgery would have the highest
priority of care?
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a.
b.
c.
d.
Oxygenation
Pain management
Circulation
Preventing infection
ANS: A
Nursing interventions in the postoperative period are focused first on promoting
ventilation, adequate oxygenation, and preventing complications such as atelectasis and
pneumonia. Adequate analgesia is necessary to promote the mobility of the patient and
decrease pulmonary complications. Early ambulation is encouraged to reduce the risk of
pulmonary embolus. Infection prevention with hand hygiene and antibiotics is important
as well.
16. Which classification of medication is used to reduce volume and concentration of
gastric secretions?
a. Antacids
b. Histamine2 (H2) antagonists
c. Gastric mucosal agents
d. Gastric proton pump inhibitors
ANS: B
Histamine2 (H2) antagonists are used to reduce volume and concentration of gastric
secretions. Antacids are used to buffer stomach acid and raise gastric ph. Gastric mucosal
agents forms an ulcer-adherent complex with proteinaceous exudate. It covers the ulcer and
protects against acid, pepsin, and bile salts. Gastric proton pump inhibitors inactivate acid
or hydrogen acid pump, blocking secretion of hydrochloric acid by gastric parietal cells.
17. A patient has a Salem sump to lower intermittent suction. Nursing interventions
a.
b.
c.
d.
include
prevention of esophageal erosion and stricture.
prevention of dry mouth.
prevention of ulceration of the nares.
irrigating the tube every 4 hours or as ordered by the health care provider.
ANS: D
Interventions include irrigating the tube every 4 hours with normal saline, ensuring the
blue air vent of the Salem sump is patent and maintained above the level of the patient’s
stomach, and providing frequent mouth and nares care. Nursing management focuses on
preventing complications common to this therapy, for example, ulceration and necrosis of
the nares, esophageal reflux, esophagitis, esophageal erosion and stricture, gastric erosion,
and dry mouth and parotitis from mouth breathing.
MULTIPLE
RESPONSE
1. Which of the following is a potential cause for acute liver failure? (Select all that
apply.)
a. Ischemia
b. Hepatitis A, B, C, D, E, non-A, non-B, non-C
c. Acetaminophen toxicity
d.
Wilson
e.
disease
Reye
f.
syndrome
Diabetes
ANS: A, B, C, D, E
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Diabetes is not a primary cause of acute liver failure but is associated with pancreatitis.
2. A patient is admitted with the diagnosis of acute pancreatitis. The nurse expects which of
the following laboratory test results to be elevated? (Select all that apply.)
a. Calcium
b.
Serum
c.
amylase
Serum glucose
d. Potassium
e. WBC
f. Serum triglycerides
ANS: B, C, E, F
Calcium and potassium decrease with acute pancreatitis.
3. Which of the following are clinical manifestations of pancreatitis? (Select all that apply.)
a. Epigastric and abdominal pain
b. Nausea and vomiting
c. Diaphoresis
d. Jaundice
e. Hyperactive bowel sounds
f. Fever
ANS: A, B, D, F
Clinical manifestations of acute pancreatitis include pain, vomiting, nausea, fever,
abdominal distention, abdominal guarding, abdominal tympany, hypoactive or absent bowel
sounds, severe disease, peritoneal signs, ascites, jaundice, palpable abdominal mass, GreyTurner sign, Cullen sign, and signs of hypovolemic shock. There may be peritonitis
involved with pancreatitis and percussion will reveal a tympanic abdomen; bowel sounds
will be decreased
or absent.
4. Which of the following interventions would you expect in the management of hepatic
failure?
(Select all that apply.)
a. Benzodiazepines for agitation
b. Pulse oximetry and serial arterial blood gas measurements
c. Insulin drip for hyperglycemia and hyperkalemia
d. Monitor electrolyte blood levels
e. Assess for signs of cerebral edema
ANS: B, D, E
The patient may experience a variety of other complications, including cerebral
edema, cardiac dysrhythmias, acute respiratory failure, sepsis, and acute kidney
injury. Cerebral
edema and increased intracranial pressure develop as a result of breakdown of the blood–
brain barrier and astrocyte swelling. Circulatory failure that mimics sepsis is common in
acute liver failure and may exacerbate low cerebral perfusion pressure. Hypoxemia,
acidosis, electrolyte imbalances, and cerebral edema can precipitate the development of
cardiac dysrhythmias. Acute respiratory failure, progressing to acute respiratory distress
syndrome, intrapulmonary shunting, ventilation–perfusion mismatch, sepsis, and aspiration
may be attributed to the universal arterial hypoxemia.
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Chapter 23: Endocrine Clinical Assessment and Diagnostic Procedures
Test Bank
MULTIPLE CHOICE
1. Which of the following laboratory results is found in a patient with hyperglycemia?
a. Insulin level of 25 /mL
b. Absence of ketones in the urine
c. Presence of ketones in the blood
d. Serum osmolality of 270 mOsm/kg H2O
ANS: C
In diabetic ketoacidosis, fat breakdown (lipolysis) occurs so rapidly that fat metabolism is
incomplete, and the ketone bodies (acetone, -hydroxybutyric acid, and acetoacetic acid)
accumulate in the blood (ketonemia) and are excreted in the urine (ketonuria). It is recommended
that all patients with diabetes perform self-test or have their blood or urine tested for the
presence of ketones during any alteration in level of consciousness or acute illness with elevated
blood glucose.
2. A hydration assessment consists of checking a variety of parameters, including
a. skin turgor.
b. serum potassium level.
c. capillary refill.
d. serum protein level.
ANS: A
A hydration assessment includes observations of skin integrity, skin turgor, and buccal membrane
moisture. Moist, shiny buccal membranes indicate satisfactory fluid balance. Skin turgor that is
resilient and returns to its original position in less than 3 seconds after being pinched or lifted
indicates adequate skin elasticity. Skin over the forehead, clavicle, and sternum is the most reliable
for testing tissue turgor because it is less affected by aging and thus more easily assessed for
changes related to fluid balance.
3. Glycosylated hemoglobin levels provide information about
a. the average blood glucose level over the previous 3 to 4 months.
b. blood glucose levels in comparison with serum hemoglobin.
c. serial glucose readings after ingestion of a concentrated glucose solution.
d. the difference between serum and urine glucose levels.
ANS: A
The glycated hemoglobin test (also known as the glycosylated hemoglobin, or HbA1C or A1C),
provides information about the average amount of glucose that has been present in the patient’s
bloodstream over the previous 3 to 4 months. During the 120-day life span of red blood cells
(erythrocytes), the hemoglobin within each cell binds to the available blood glucose through a
process known as glycosylation.
4. Which of the following laboratory studies or diagnostic procedures is most useful in
identifying central diabetes insipidus (DI)?
a. Skull radiographs
b. Serum glucose level
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c. Water deprivation test
d. Antidiuretic hormone (ADH) stimulation test
ANS: D
Serum antidiuretic hormone ADH levels are compared with the blood and urine osmolality to
differentiate syndrome of inappropriate antidiuretic hormone (SIADH) from central diabetes insipidus
(DI). Increased ADH levels in the bloodstream compared with a low serum osmolality and elevated
urine osmolality confirms the diagnosis of SIADH. Reduced levels of serum ADH in a patient with
high serum osmolality, hypernatremia, and reduced urine concentration signal central DI.
5. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by
new-onset type 1 diabetes mellitus. Which of the following signs and symptoms obtained as part of
the patient’s history might indicate the presence of hyperglycemia?
a. Recent episodes of tachycardia and missed heart beats
b. Decreased urine output accompanied by peripheral edema
c. Periods of hyperactivity with weight gain
d. Increased thirst and increased urinary output
ANS: D
The patient or family member may relay information about recent, unexplained changes in weight,
thirst, hunger, and urination patterns.
6. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused by
new-onset type 1 diabetes mellitus. The nurse notes a sweet-smelling odor on the patient’s exhaled
breath. This is a result of
a. compensation for metabolic alkalosis.
b. ketoacidosis.
c. prior ingestion of high-calorie foods.
d. decreased serum osmolality.
ANS: B
If ketoacidosis occurs, the patient’s breathing becomes deep and rapid (Kussmaul
respirations), and the breath may have a fruity odor.
7. A 16-year-old young woman is admitted to the critical care unit with severe hyperglycemia caused
by new-onset type 1 diabetes mellitus. The patient is complaining of headache and blurred vision.
The nurse knows that these are signs that may indicate
a. kidney stones.
b. diabetes insipidus.
c. hypoglycemia.
d. hyperglycemia.
ANS: D
Because severe hyperglycemia affects a variety of body systems, all systems are assessed. The patient
may complain of blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, and
abdominal pain.
8. The patient has a fasting glucose level of 150 mg/dL. The nurse knows this value is
a. normal.
b. diagnostic of diabetes, but it should be re-evaluated for accuracy.
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c. lower than what the nurse would expect in a patient receiving intravenous fluids.
d. elevated, indicating diabetic ketoacidosis.
ANS: B
A normal fasting glucose (FPG) level is between 70 and 110 mg/dL. An FPG level between
110 and 126 mg/dL identifies a person who is prediabetic. An FPG level of greater than 126 mg/dL
(7 mmol/L) is diagnostic of diabetes. In nonurgent settings, the test is repeated on another day to
make sure the result is accurate.
9. A normal HbA1c level for a normal person is
a. less than 5.4%.
b. less than 6.5%.
c. between 5.4% and 6.5%.
d. between 3% and 5.4%.
ANS: A
A normal HbA1C value is less than 5.4%, with an acceptable target level for patients with
diabetes below 6.5%.
10. The patient weighed 62 kg on admission yesterday. Today the patient weighs 60 kg. The nurse knows
this reflects a fluid loss of
a. 1 L. b. 2 L.
c. 4 L.
d. 10 L.
ANS: B
Daily weight changes coincide with fluid retention and fluid loss. Sudden changes in weight could
result from a change in fluid balance; 1 L of fluid lost or retained is equal to approximately 2.2 lb,
or 1 kg, of weight gained or lost.
11. When preparing the patient for a serum ADH level, the nurse must withhold
a. insulin and furosemide.
b. morphine and carbamazepine.
c. Lanoxin and potassium.
d. heparin and beta-blockers.
ANS: B
To prepare the patient for the test, all drugs that may alter the release of antidiuretic hormone (ADH)
are withheld for a minimum of 8 hours. Common medications that affect ADH levels include
morphine sulfate, lithium carbonate, chlorothiazide, carbamazepine, oxytocin, nicotine, alcohol, and
selective serotonin reuptake inhibitors.
12. The nurse knows that a serum osmolality of 378 mOsm/kg indicates a patient who is
a. overhydrated.
b. normal.
c. dehydrated.
d. hypokalemic.
ANS: C
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Values for serum osmolality in the bloodstream range from 275 to 295 mOsm/kg H2O.
Increased serum osmolality stimulates the release of antidiuretic hormone, which in turn
reduces the amount of water lost through the kidney.
13. The nurse knows that the best test to differentiate between central and nephrogenic DI is
a. the water deprivation test.
b. serum osmolality.
c. computed tomography scan.
d. the ADH test.
ANS: D
The antidiuretic hormone test is used to differentiate between neurogenic diabetes insipidus (DI)
(central) and nephrogenic (kidney) DI. In severe central DI, in which the pituitary is affected, the
urine osmolality shows a significant increase (becomes more concentrated),
which indicates that the cell receptor sites on the kidney tubules are responsive to vasopressin. Test
results in which urine osmolality remains unchanged indicate nephrogenic DI, suggesting kidney
dysfunction because the kidneys are no longer responsive to ADH.
14. The nurse knows that an abnormal response to the ADH test would be
a. a slight increase in urine osmolality.
b. a decrease in urine output.
c. a decrease in serum osmolality.
d. no change in urine osmolality.
ANS: D
If the urine osmolality remains unchanged after administering vasopressin, the target cells are no
longer receptive to antidiuretic hormone.
15. When evaluating the patient for a pituitary tumor, attention on the computed tomography scan
should be focused on the
a. frontal lobe.
b. sella turcica.
c. temporal lobe.
d. anterior fossa.
ANS: B
The sella turcica at the base of the skull is the area to focus on to visualize the pituitary gland.
MULTIPLE RESPONSE
1. Which of the following findings would you expect to see in the patient with hyperglycemia?
(Select all that apply.)
a. Anorexia
b. Abdominal pain
c. Bradycardia
d. Fluid overload
e. Change in level of consciousness
f. Kussmaul respirations
ANS: A, B, E, F
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More than likely the patient with hyperglycemia will be fluid volume depleted and
tachycardic.
Chapter 24: Endocrine Disorders and Therapeutic Management
Test Bank
MULTIPLE CHOICE
1. A patient with diabetes in the critical care unit is at risk for developing diabetic ketoacidosis
(DKA) secondary to
a. excess insulin administration.
b. inadequate food intake.
c. physiologic and psychologic stress.
d. increased release of antidiuretic hormone (ADH).
ANS: C
Major neurologic and endocrine changes occur when an individual is confronted with physiologic
stress caused by any critical illness, sepsis, trauma, major surgery, or underlying cardiovascular
disease.
2. The hallmark of hyperglycemic hyperosmolar syndrome (HHS) is
a. hyperglycemia with low serum osmolality.
b. severe hyperglycemia with minimal or absent ketosis.
c. little or no ketosis in serum with rapidly escalating ketonuria.
d. hyperglycemia and ketosis.
ANS: B
The hallmarks of HHS are extremely high levels of plasma glucose with resulting elevations in
serum hyperosmolality and osmotic diuresis. The disorder occurs mainly in patients with type II
diabetes.
3. The primary intervention for hyperglycemic hyperosmolar syndrome (HHS) is
a. rapid rehydration.
b. monitoring vital signs.
c. high-dose intravenous (IV) insulin.
d. hourly urine sugar and acetone testing.
ANS: A
The goals of medical management are rapid rehydration, insulin replacement, and correction of
electrolyte abnormalities, specifically potassium replacement. The underlying stimulus of HHS must
be discovered and treated. The same basic principles used to treat patients with diabetic ketoacidosis
are used for patients with HHS.
4.
a.
b.
c.
d.
Characteristics of diabetes insipidus (DI) are
hyperglycemia and hyperosmolarity.
hyperglycemia and peripheral edema.
intense thirst and passage of excessively large quantities of dilute urine.
peripheral edema and pulmonary crackles.
ANS: C
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The clinical diagnosis is made by the dramatic increase in dilute urine output in the absence of
diuretics, a fluid challenge, or hyperglycemia. Characteristics of DI are intense thirst and the passage of
excessively large quantities of very dilute urine.
5. Patients with central DI are treated with
a. vasopressin.
b. insulin.
c. glucagon.
d. propylthiouracil.
ANS: A
Patients with central DI who are unable to synthesize antidiuretic hormone (ADH) require
replacement ADH (vasopressin) or an ADH analog. The most commonly prescribed drug is the
synthetic analog of ADH, desmopressin (DDAVP). DDAVP can be given intravenously,
subcutaneously, or as a nasal spray. A typical DDAVP dose is 1 to 2 mcg intravenously or
subcutaneously every 12 hours.
6. In the syndrome of inappropriate antidiuretic hormone (SIADH), the physiologic effect is
a. massive diuresis, leading to hemoconcentration.
b. dilutional hyponatremia, reducing sodium concentration to critically low levels.
c. hypokalemia from massive diuresis.
d. serum osmolality greater than 350 mOsm/kg.
ANS: B
Patients with SIADH have an excess of antidiuretic hormone secreted into the bloodstream, more
than the amount needed to maintain normal blood volume and serum osmolality. Excessive water is
resorbed at the kidney tubule, leading to dilutional hyponatremia.
7. Which of the following nursing interventions should be initiated on all patients with SIADH?
a. Placing the patient on an air mattress
b. Forcing fluids
c. Initiating seizure precautions
d. Applying soft restraints
ANS: C
The patient with SIADH has an excess of ADH secreted into the bloodstream, more than the amount
needed to maintain normal blood volume and serum osmolality. Excessive water is resorbed at the
kidney tubule, leading to dilutional hyponatremia. Symptoms of severe hyponatremia include an
inability to concentrate, mental confusion, apprehension, seizures, a decreased level of consciousness,
coma, and death.
8. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit
with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic
ketoacidosis (DKA). Which of the following symptoms is most suggestive of DKA?
a. Irritability
b. Excessive thirst
c. Rapid weight gain
d. Peripheral edema
ANS: B
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DKA has a predictable clinical presentation. It is usually preceded by patient complaints of malaise,
headache, polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive
hunger). Nausea, vomiting, extreme fatigue, dehydration, and weight loss follow. Central nervous
system depression, with changes in the level of consciousness, can lead quickly to coma.
9. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit
with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic
ketoacidosis. Which of the following statements best describes the rationale for administrating
potassium supplements with the patient’s insulin therapy?
a. Potassium replaces losses incurred with diuresis.
b. The patient has been in a long-term malnourished state.
c. IV potassium renders the infused solution isotonic.
d. Insulin drives the potassium back into the cells.
ANS: D
Low serum potassium (hypokalemia) occurs as insulin promotes the return of potassium into the cell
and metabolic acidosis is reversed. Replacement of potassium by administration of potassium
chloride (KCl) begins as soon as the serum potassium falls below normal. Frequent verification of the
serum potassium concentration is required for patients with DKA who are receiving fluid
resuscitation and insulin therapy.
10. A patient has a 10-year history of diabetes mellitus. The patient is admitted to the critical care unit
with complaints of increased lethargy. Serum laboratory values validate the diagnosis of diabetic
ketoacidosis (DKA). The treatment of DKA involves
a. extensive hydration.
b. oral hypoglycemic agents. c.
large doses of IV insulin. d. limiting
food and fluids.
ANS: A
Rapid IV fluid replacement requires the use of a volumetric pump. Insulin is administered
intravenously to patients who are severely dehydrated or have poor peripheral perfusion to ensure
effective absorption. Patients with DKA are kept on NPO (nothing by mouth) status until the
hyperglycemia is under control. Critical care nurses are responsible for monitoring the rate of plasma
glucose decline in response to insulin.
11. The most common problem in the patient with type 2 diabetes is a(n)
a. lack of insulin production.
b. imbalance between insulin production and use.
c. overproduction of glucose.
d. increased uptake of glucose in the cells.
ANS: B
Type 2 diabetes results from a progressive insulin secretory defect in addition to insulin
resistance.
12. A patient weighs 140 kg and is 60 in. tall. The patient’s blood sugar is being controlled by glipizide.
As the nurse discusses discharge instructions, the primary treatment goal with this type 2 diabetes
patient would be
a. signs of hypoglycemia.
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b. proper injection technique.
c. weight loss.
d. increased caloric intake.
ANS: C
This patient weighs 308 lb and is 5 feet tall. Diet management and exercise are interventions to
facilitate weight loss in patients with type 2 diabetes.
13. A patient is admitted to the unit with extreme fatigue, vomiting, and headache. This patient has type 1
diabetes but has been on an insulin pump for 6 months. He states, “I know it could not be my diabetes
because my pump gives me 24-hour control.” The nurse’s best response would be
a. “You know a lot about your pump, and you are correct.”
b. “You’re right. This is probably a virus.”
c. “We’ll get an abdominal CT and see if your pancreas is inflamed.”
d. “We’ll check your serum blood glucose and ketones.”
ANS: D
Subcutaneous insulin pumps can malfunction. It is critical to assess glucose and ketone levels to
evaluate for diabetic ketoacidosis.
14. A patient who has type 2 diabetes is on the unit after aneurysm repair. His serum glucose levels have
been elevated for the past 2 days. He is concerned that he is becoming dependent on insulin. The best
response for the nurse would be
a. “This surgery may have damaged your pancreas. We will have to do more
evaluation.”
b. “Perhaps your diabetes was more serious from the beginning.”
c. “You will need to discuss this with your physician.”
d. “The stress on your body has temporarily increased your blood sugar levels.”
ANS: D
Adrenal hormones released during stress elevate blood sugar by increasing insulin resistance and
increasing hepatic gluconeogenesis.
15. The nurse knows that the dehydration associated with diabetic ketoacidosis results from
a. increased serum osmolality and urea.
b. decreased serum osmolality and hyperglycemia.
c. ketones and potassium shifts.
d. acute renal failure.
ANS: A
Hyperglycemia increases the plasma osmolality, and the blood becomes hyperosmolar. Cellular
dehydration occurs as the hyperosmolar extracellular fluid draws the more dilute intracellular and
interstitial fluid into the vascular space in an attempt to return the plasma osmolality to normal.
16. The nurse knows that the dehydration in diabetic ketoacidosis stimulates catecholamine release,
which results in
a. decreased glucose release.
b. increased insulin release.
c. decreased cardiac contractility.
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d. increased gluconeogenesis.
ANS: D
Dehydration stimulates catecholamine production in an effort to provide emergency support.
Catecholamine output stimulates further glycogenolysis, lipolysis, and gluconeogenesis, pouring
glucose into the bloodstream.
17.
a.
b.
c.
d.
The major electrolyte disturbances that result from diuresis are
low calcium and high phosphorus levels.
low potassium and low sodium levels.
high sodium and low phosphorus levels.
low calcium and low potassium levels.
ANS: B
Serum sodium may be low as a result of the movement of water from the intracellular space into
the extracellular (vascular) space. The serum potassium level is often normal; a low
serum potassium level in diabetic ketoacidosis suggests that a significant potassium deficiency may
be present.
18. The patient admitted in diabetic ketoacidosis has dry, cracked lips and is begging for
something to drink. The nurse’s best response would be to
a. keep the patient NPO.
b. allow the patient a cup of coffee.
c. allow the patient water.
d. allow the patient to drink anything he chooses.
ANS: C
The thirst sensation is the body’s attempt to correct the fluid deficit. Water is the best
replacement.
19. A patient in diabetic ketoacidosis has the following arterial blood gasses: pH 7.25; pCO2 30 mm
Hg; HCO3 16. The patient has rapid, regular respirations. The nurse’s best response would be to
a. ask the patient to breathe into a paper bag to retain CO2.
b. administer sodium bicarbonate.
c. administer insulin and fluids intravenously.
d. prepare for intubation.
ANS: C
Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic
acidosis. In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into
glucose.
20. A patient in diabetic ketoacidosis is very lethargic and has a “funny” odor to his breath. The nurse
would suspect this to be a result of
a. alcohol intoxication.
b. hyperglycemia.
c. hyperphosphatemia.
d. acetone.
ANS: D
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Acid ketones dissociate and yield hydrogen ions (H+) that accumulate and precipitate a fall in serum
pH. The level of serum bicarbonate also decreases consistent with a diagnosis of metabolic acidosis.
Breathing becomes deep and rapid (Kussmaul respirations) to release carbonic acid in the form of
carbon dioxide. Acetone is exhaled, giving the breath its characteristic “fruity” odor.
21. A patient in diabetic ketoacidosis is comatose with a temperature of 102.2° F. The nurse would
suspect
a. head injury.
b. infarct of the hypothalamus.
c. infection.
d. heat stroke.
ANS: C
A patient in diabetic ketoacidosis can experience a variety of complications, including fluid
volume overload, hypoglycemia, hypokalemia or hyperkalemia, hyponatremia, cerebral edema,
and infection.
22. A nondiabetic patient presents ketoacidosis. Reasons may include
a. starvation and alcoholism.
b. drug overdose.
c. severe vomiting.
d. hyperaldosteronism.
ANS: A
Other nondiabetic causes of ketoacidosis are starvation ketosis and alcoholic ketoacidosis.
23. As a patient with diabetic ketoacidosis receives insulin and fluids, the nurse knows careful
assessment must be given to which of the following electrolytes?
a. Potassium
b. Sodium
c. Phosphorus
d. Calcium
ANS: A
Replacement of potassium by administration of potassium chloride (KCl) begins as soon as the serum
potassium falls below normal. Frequent verification of the serum potassium concentration is required
for the patient with diabetic ketoacidosis receiving fluid resuscitation and insulin therapy.
24. The top priority in the initial treatment of diabetic ketoacidosis (DKA) is
a. lowering the blood sugar.
b. giving fluids.
c. giving sodium bicarbonate to reverse the acidosis.
d. determining the reason for the DKA.
ANS: B
A patient with DKA is dehydrated and may have lost 5% to 10% of body weight in fluids. A fluid
deficit up to 6 L can exist in severe dehydration. Aggressive fluid replacement is provided to
rehydrate both the intracellular and the extracellular compartments and prevent circulatory collapse.
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25. The nurse knows that during the resuscitation of a patient with diabetic ketoacidosis, the IV
line should be changed to a solution containing glucose when the
a. patient becomes more alert.
b. IV insulin has been infusing for 4 hours.
c. blood glucose drops to 200 mg/dL.
d. blood glucose drops to 100 mg/dL.
ANS: C
When the serum glucose level decreases to 200 mg/dL, the infusing solution is changed to a
50/50 mix of hypotonic saline and 5% dextrose. Dextrose is added to replenish depleted cellular
glucose as the circulating serum glucose level falls.
26. The nurse knows that the patient with DKA will need
a. subcutaneous insulin.
b. IV insulin.
c. subcutaneous and IV insulin.
d. combination 70%/30% insulin.
ANS: C
The patient needs IV insulin for rapid onset but will also need subcutaneous insulin about 1 hour
before the IV insulin is discontinued.
27. When a patient in diabetic ketoacidosis (DKA) has insulin infusing intravenously, the nurse expects
a drop in the serum levels of
a. sodium and potassium.
b.
potassium and phosphate. c.
bicarbonate and calcium. d. sodium
and phosphate.
ANS: B
Frequent verification of the serum potassium concentration is required for patients with DKA
receiving fluid resuscitation and insulin therapy. The serum phosphate level is sometimes low
(hypophosphatemia) in DKA. Insulin treatment may make this more obvious as phosphate is returned
to the interior of the cell. If the serum phosphate level is less than 1 mg/dL, phosphate replacement is
recommended.
28. To assist the nurse in evaluating the patient’s hydration status, assessment would include
a. orthostatic hypotension and neck vein filling.
b. pupil checks and Kernig sign. c.
Chvostek and Trousseau signs. d. S4
gallop and edema.
ANS: A
Assessment for orthostatic hypotension and neck vein filling is an important way to evaluate
hydration status.
29. A patient with diabetic ketoacidosis has an insulin drip infusing, and the nurse has just administered
subcutaneous insulin. The nurse is alert for signs of hypoglycemia, which would include
a. Kussmaul respirations and flushed skin.
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b. irritability and paresthesia.
c. abdominal cramps and nausea.
d. hypotension and itching.
ANS: B
Irritability and paresthesia are seen in hypoglycemia.
30. A patient was admitted with diabetic ketoacidosis 1 hour ago and is on an insulin drip.
Suddenly, the nurse notices frequent premature ventricular contractions (PVCs) on the
electrocardiogram. The expected intervention would be to
a. administer a lidocaine bolus.
b.
administer a lidocaine drip. c.
synchronize cardioversion. d. evaluate
electrolytes.
ANS: D
Hyperkalemia occurs with acidosis or with overaggressive administration of potassium replacement
in patients with renal insufficiency. Severe hyperkalemia is demonstrated on the cardiac monitor by
a large, peaked T wave; flattened P wave; and widened QRS complex.
31. A patient with type 2 diabetes is admitted. He is very lethargic and hypotensive. A diagnosis of
hyperglycemic hyperosmolar syndrome (HHS) is made based on laboratory values of
a. decreased serum glucose and increased serum ketones.
b. increased urine ketones and decreased serum osmolality.
c. increased serum osmolality and increased serum potassium.
d. increased serum osmolality and increased serum glucose.
ANS: D
Laboratory findings are used to establish the definitive diagnosis of HHS. Plasma glucose levels are
strikingly elevated (greater than 600 mg/dL). Serum osmolality is greater than 320 mOsm/kg.
32. An older patient presents with a serum glucose level of 900 mg/dL, hematocrit of 55%, and no serum
ketones. Immediate attention must be given to
a. clotting factors.
b. rehydration.
c. administration of insulin.
d. sodium replacement.
ANS: B
The physical examination may reveal a profound fluid deficit. Signs of severe dehydration
include longitudinal wrinkles in the tongue, decreased salivation, and decreased central
venous pressure, with increases in heart rate and rapid respirations (Kussmaul air hunger does not
occur). In older patients, assessment of clinical signs of dehydration is challenging.
33. A patient with hyperglycemic hyperosmolar syndrome (HHS) has a serum glucose level of
400 mg/dL and a serum sodium level of 138 mEq/L. The intravenous fluid of choice would be
a. D5W.
b. 0.45% NS. c.
0.9% NS. d. D5/NS.
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ANS: C
The fluid deficit may be as much as 150 mL/kg of body weight. The average 150-lb adult can lose
more than 7 to 10 L of fluid. Physiologic saline solution (0.9%) is infused at 1 L/hr, especially for
patients in hypovolemic shock if there is no cardiovascular contraindication. Several liters of volume
replacement may be required to achieve a blood pressure and central venous pressure within normal
range. Infusion volumes are adjusted according to the patient’s hydration state and sodium level.
34. The most common maintenance dose of intravenous insulin for a patient with hyperglycemic
hyperosmolar syndrome (HHS) would be
a. 0.1 U/kg/hr. b. 1.0
U/kg/hr. c. 2.0 U/kg/hr.
d. 5.0 U/kg/hr.
ANS: A
Regular insulin infusing at an initial rate calculated as 0.1 unit per kg hourly (7 units/hr for a person
weighing 70 kg) should lower the plasma glucose by 50 to 70 mg/dL in the first hour of treatment. If
the measured glucose does not decrease by this amount, the insulin infusion rate may be doubled
until the blood glucose is declining at a rate of 50 to 70 mg/dL per hour.
35. A patient is admitted with a long history of mental illness. Her husband states she has been drinking
up to 10 gallons of water each day for the past 2 days and refuses to eat. The patient is severely
dehydrated and soaked with urine. The nurse suspects
a. central diabetes insipidus (DI).
b. nephrogenic DI.
c. psychogenic (dipsogenic) DI.
d. iatrogenic DI.
ANS: C
Psychogenic diabetes insipidus (DI) is a rare form of the disease that occurs with compulsive drinking
of more than 5 L of water a day. Long-standing psychogenic DI closely mimics nephrogenic DI
because the kidney tubules become less responsive to antidiuretic hormone as a result of prolonged
conditioning to hypotonic urine.
36. A patient presenting with diabetes insipidus (DI) exhibits
a.
hyperosmolality and hypernatremia. b.
hyperosmolality and hyponatremia. c. hypoosmolality and hypernatremia. d.
hypo-
osmolality and hyponatremia.
ANS: A
In central DI, there is an inability to secrete an adequate amount of antidiuretic hormone (arginine
vasopressin) in response to an osmotic or nonosmotic stimuli, resulting in inappropriately dilute urine.
Hypernatremia is usually associated with serum hyperosmolality.
37. The onset of seizures in the patient with DI indicates
a. increased potassium levels.
b. hyperosmolality.
c. severe dehydration.
d. toxic ammonia levels.
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ANS: C
This excessive intake of water reduces the serum osmolality to a more normal level and prevents
dehydration. In the person with decreased level of consciousness, the polyuria leads to severe
hypernatremia, dehydration, decreased cerebral perfusion, seizures, loss of consciousness, and death.
38. A priority for patient education when discharged with long-term antidiuretic hormone
deficiency is
a. daily intake and output.
b. attention to thirst. c. a lowsodium diet. d. daily weights.
ANS: D
Daily weights on the same scale are an excellent assessment of fluid status. A weight gain or loss of 1
kg (2.2 lb) is equal to 1 L of fluid.
39. A patient with bronchogenic oat cell carcinoma has a drop in urine output. The laboratory reports a
serum sodium level of 120 mEq/L, a serum osmolality level of 220 mOsm/kg, and urine specific
gravity of 1.035. The nurse would suspect
a. diuresis.
b. DI.
c. SIADH.
d. hyperaldosteronism.
ANS: C
A decreased urine output, hyponatremia, hypoosmolality, and high urine specific gravity are classic
signs of SIADH. Oat cell carcinoma is a precipitating factor for SIADH.
40. The patient at risk for developing SIADH may be taking
a. adenosine (Adenocard).
b. diltiazem (Cardizem).
c. heparin sodium.
d. acetaminophen.
ANS: D
Tylenol increases the release of ADH.
41. In evaluating the patient’s hyponatremia, the nurse understands the problem is
a. increased cortisol release.
b. decreased aldosterone release.
c. increased glucocorticoid release.
d. decreased glucagon release.
ANS: B
In SIADH, the increased levels of circulating ADH are unrelated to the serum sodium
concentration. Aldosterone production from the adrenal glands is also suppressed.
42. After a patient has been diagnosed with SIADH, the nurse would expect the first line of
treatment to include
a. fluid restriction.
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b. hypotonic intravenous fluid.
c. D5W.
d. fluid bolus.
ANS: A
Reduction in fluid intake is one component of the treatment plan for SIADH.
43. During the first 24 hours when the nurse administers hypertonic saline in a patient with
SIADH, the serum sodium should be raised no more than
a. 5 mEq/day. b. 12
mEq/day. c. 20
mEq/day. d. 25
mEq/day.
ANS: B
One recommended regimen is an IV rate that provides sufficient sodium to raise serum sodium levels
by up to 12 mEq/day for the first 24 hours (no more than 0.5 mEq each hour), with a total increase of
18 mEq/L in the initial 48 hours.
44. While a patient with SIADH is receiving hypertonic saline, the nurse assesses for signs that the
saline must be stopped. These signs would include
a. decreased CVP and decreased PAP.
b. bradycardia and thirst.
c. hypotension and wheezing.
d. hypertension and lung crackles.
ANS: D
Hypertension and lung crackles are signs of fluid overload. The hypertonic solution may pull fluid out
of cells and tissues. Whereas weight gain signifies continual fluid retention, weight loss indicates loss
of body fluid.
45. Patients who have sustained head trauma or have undergone resection of a pituitary tumor have an
increased risk of developing
a. type 1 diabetes. b. type
2 diabetes. c. DI.
d. myxedema coma.
ANS: C
Any patient who has head trauma or resection of a pituitary tumor has an increased risk of
developing DI.
46. The diagnosis of SIADH is made when which of the following conditions is present?
a. Decreased ADH level and hyperkalemia b.
Decreased ADH level and hypernatremia c.
Increased ADH level and serum ketones
d. Increased ADH level and low serum osmolality
ANS: D
SIADH occurs when there are increased levels of ADH in the blood compared with a low serum
osmolality.
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47.
a.
b.
c.
d.
Decreased urine osmolality is a sign of
hyperglycemia.
diabetes insipidus.
thyroid crisis.
SIADH.
ANS: B
Decreased urine osmolality is a sign of DI.
MULTIPLE RESPONSE
1. The neuroendocrine stress response produces which of the following? (Select all that apply.)
a. Elevated blood pressure
b. Decreased gastric motility
c. Tachycardia
d. Heightened pain awareness
e. Increased glucose
ANS: A, B, C, E
The fight-or-flight response, or sympathetic nervous response, releases catecholamine that causes
an increased heart rate and blood pressure. Blood is shunted form nonessential organs such as the
stomach, glucose is made available to the brain cells, and pain awareness is decreased.
2. A patient was admitted to the critical care unit with diabetic ketoacidosis (DKA). Glucose is
349 mg/dL, K+ is 3.7 mEq/L, and pH is 7.10. Which of the following interventions would you
expect? (Select all that apply.)
a. NS 1.5 L IV fluid bolus
b. Insulin infusion at 5 units/hr
c. Sodium bicarbonate 50 mmol IV push
d. Vasopressin 10 units IM every 3 hr
e. Potassium 20 mEq/L of IV fluid
ANS: A, B, E
Dehydration is a common presenting issue in DKA, so the administration of fluids and insulin will
help correct the hyperglycemia and acidosis. Sodium bicarbonate is not recommended unless the pH
is less than 6.9. As dehydration is reversed, potassium moves back into the
cells, and hypokalemia can result, so administration of replacement potassium is necessary.
Chapter 27: Hematologic Disorders and Oncologic Emergencies
Test Bank
MULTIPLE CHOICE
1. The intrinsic coagulation pathway is activated when
a. local blood vessels constrict at the injury site.
b. damaged endothelium comes into contact with circulating blood.
c. tissue factor is released by injured cells.
d. fibrinogen is converted to fibrin.
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ANS: B
The extrinsic pathway begins when vascular injury causes the release of tissue factor. The intrinsic
pathway begins when damaged endothelium comes into contact with circulating blood. The two
pathways converge when fibrinogen and prothrombin are converted to their active forms and a clot
is established.
2. The most common cause of disseminated intravascular coagulation (DIC) is
a. sepsis caused by gram-positive organisms. b. sepsis
caused by gram-negative organisms. c.
sickle cell
anemia.
d. burns.
ANS: B
Although all of these answers can cause DIC, sepsis, particularly that caused by gram- negative
organisms, can be identified as the culprit in as many as 20% of cases, making it the most common
cause of DIC.
3. A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is
continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic
blood pressure cuff. On his laboratory work, his platelets are normal, and his international normalized
ratio is elevated. What other laboratory value would be most valuable in definitively diagnosing the
patient’s condition?
a. Fibrin split products
b. D-Dimer level
c. Bleeding time
d. White blood cell count
ANS: B
D-Dimers are exclusively indicative of clot degradation and assist in determining the degree of
coagulopathy.
4. A patient was admitted to the critical care unit with gram-negative sepsis 5 days ago. Today there is
continual oozing from his intravenous sites, and ecchymosis of the skin is noted beneath his automatic
blood pressure cuff. On his laboratory work, his platelets are normal, and his international
normalized ratio is elevated. The primary treatment goal for this patient is to
a. maintain adequate organ perfusion.
b. suppress antibody response that is destroying platelets.
c. treat life-threatening metabolic disturbances.
d. begin hypothermic therapy to prevent cerebral hemorrhage.
ANS: A
The primary intervention in disseminated intravascular coagulation (DIC) is prevention. Being aware
of the conditions that commonly contribute to the development of DIC and treating
them vigorously and without delay provide the best defense against this devastating condition. After
DIC is identified, maintaining organ perfusion and slowing consumption of coagulation factors are
paramount to achieving a favorable outcome.
5. Sickle cell anemia is not prevalent in persons of which descent?
a. West African
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b. Sole European
c. Middle Eastern
d. Asian or Pacific Islander
ANS: D
This genetic trait is primarily found in people of West African descent. The disease has also been
linked to persons of sole European or Middle Eastern ancestry; however, this is extremely rare. The
disease is not prevalent in persons of Asian or Pacific Islander descent.
6. A patient is admitted into the critical care unit with symptoms of a low-grade fever, joint pain,
tachycardia, hepatomegaly, photophobia, and an inability to follow commands. The patient is becoming
more agitated and complaining of pain. The nurse suspects that the patient has
a. ITP.
b. heparin-induced thrombocytopenia.
c. sickle cell anemia.
d. DIC.
ANS: C
A variety of clinical manifestations are associated with sickle cell anemia. The patient may present
with a low-grade fever, bone or joint pain, pinpoint pupils, inability to follow commands,
photophobia, tachycardia, tachypnea, decreased respiratory excursion, hepatomegaly, nonpalpable
spleen, and pretibial ulcers.
7.
a.
b.
c.
d.
Type 2 heparin-induced thrombocytopenia is characterized by
formation of thrombi, causing vessel occlusion.
spontaneous epistaxis.
elevated prothrombin times.
massive peripheral ecchymoses.
ANS: A
Patients with immune-mediated heparin-induced thrombocytopenia (HIT) are at greater risk for
thrombosis than bleeding. Vessel occlusion can result in the need for limb amputation, stroke, acute
myocardial infarction, and even death. The resultant formation of fibrin platelet– rich thrombi is the
primary characteristic of HIT that distinguishes it from other forms of thrombocytopenia and gives rise
to its more descriptive name: white clot syndrome.
8. Pulmonary embolism, a serious complication of HIT, is manifested by which of the following clinical
signs?
a. Blanching of fingers and toes and loss of peripheral pulses
b. Chest pain, pallor, and confusion
c. Headache, impaired speech, and loss of motor function
d. Dyspnea, pleuritic pain, and rales
ANS: D
The presence of blanching and the loss of peripheral pulses, sensation, or motor function in a limb
indicate peripheral vascular thrombi. Neurologic signs and symptoms such as confusion, headache, and
impaired speech can signal the onset of cerebral artery occlusion and stroke. Acute myocardial
infarction may be heralded by dyspnea, chest pain, pallor, and alterations in blood pressure. Thrombi in
the pulmonary vasculature may be evidenced by pleuritic pain, rales, and dyspnea.
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9. The high-risk period for developing HIT is a. 5 to
10 hours after initiation of heparin. b. 5 to 14
hours after initiation of heparin. c. 5 to 14 days
after initiation of heparin. d. 30 to 60 days after
initiation of heparin.
ANS: C
Current guidelines suggest that for high-risk patients, platelet count monitoring should be performed
every 2 or 3 days from day 4 to day 14. When a decrease in the platelet count is detected, heparin
therapy should be discontinued immediately, and the patient should be tested for the presence of
heparin antibodies.
10. Which of the following previous medical conditions would indicate a patient at risk for
developing HIT?
a. Sepsis
b. Deep vein thrombosis
c. Cardiac arrest
d. Pneumonia
ANS: B
Ascertaining a medical history that includes previous heparin therapy, deep vein thrombosis, or
cardiovascular surgery that included the use of cardiopulmonary bypass can alert the nurse to
potential problems.
11. The primary mechanism in the development of tumor lysis syndrome is
a. destruction of platelets by lymphocytic antibodies.
b. destruction of malignant cells through radiation or chemotherapy.
c. formation of heparin antibodies.
d. damage to the endothelium.
ANS: B
The primary mechanism involved in the development of tumor lysis syndrome is the destruction of
massive numbers of malignant cells, either by chemotherapy or radiation. This mass destruction
results in the release of large amounts of potassium, phosphorus, and nucleic acids, leading to severe
metabolic disturbances such as hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia.
12. Which of the following pathophysiologic events contributes to renal failure associated with tumor
lysis syndrome?
a. Hypocalcemia
b. Elevated white blood cell count
c. Metabolic acidosis
d. Crystallization of uric acid in the renal tubules
ANS: D
When therapy is initiated, tumor cell destruction releases nucleic acids, which are metabolized into
uric acid. Metabolic acidosis ensues, resulting in crystallization of the uric acid in the distal tubules of
the kidneys and leading to obstruction of urine flow. Glomerular filtration rates drop as the kidneys
are unable to clear the increasing amounts of uric acid.
Consequently, acute kidney injury eventually occurs.
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13. Which of the following would be appropriate for treating hypocalcemia?
a. Calcium gluconate
b. Insulin
c. Sodium bicarbonate
d. Dialysis
ANS: A
Calcium gluconate is administered to treat hypocalcemia. Insulin and sodium bicarbonate treat
hyperkalemia. Dialysis is the treatment for hyperuricemia.
14. Hospital-acquired anemia is an increasing problem in critically ill patients. Which of the
following nursing interventions can be most beneficial in preventing this problem?
a. Administering fluids and inotropic agents to optimize blood pressure
b. Using blood salvage devices
c. Obtaining smaller blood samples through the use of pediatric blood tubes and pointof-care testing
d. Decreasing afterload through the use of vasodilators
ANS: C
Frequent blood draws in critically ill patients have been associated with the development of anemia.
Blood losses correspond to actual volume of samples and discards when drawing from venous
access lines. Critical care nurses can be instrumental in significantly decreasing blood loss in this
arena. The use of pediatric collection tubes and point-of-care testing are techniques that yield valid
diagnostic results but require smaller amounts of blood.
15. Medication used to increase the level of fetal hemoglobin in the RBCs and reduce the
concentration of sickle hemoglobin is known as
a. transfusion therapy.
b. hydroxyurea.
c. Kayexalate.
d. oxygen.
ANS: B
Hydroxyurea is an oral agent that is a safe and effective treatment for children and adults who have
sickle cell anemia. It works by increasing the level of fetal hemoglobin in the red blood cells, thereby
reducing the concentration of sickle hemoglobin and sickling itself. Kayexalate is an oral or rectal
medication to decrease potassium levels in the blood.
16. Hydroxyurea is increased by what dosage until the maximum of 35 mg/kg is reached?
a. 5 mg/kg every 4 weeks b. 10
mg/kg every 8 weeks c. 5 mg/kg
every 12 weeks
d. 15 mg/kg every 15 weeks
ANS: C
The patient is usually started at a dose of 15 mg/kg by mouth once a day. The dose is increased by 5
mg/kg every 12 weeks until 35 mg/kg is reached as long as the patient’s blood count remains within
an acceptable range.
17. Medical intervention to prevent metabolic imbalances associated with tumor lysis syndrome
includes
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a.
b.
c.
d.
give Kayexalate for hypokalemia.
keep urine pH below 7.0.
fluid restriction.
dietary restriction of potassium and phosphorus foods.
ANS: D
Electrolytes and arterial blood gases are closely monitored. Dietary restrictions of potassium and
phosphorus may be necessary. The goals in treating hyperuricemia are to inhibit uric acid formation
and to increase renal clearance. These can be accomplished through the administration of sodium
bicarbonate to increase the pH of the urine to above 7.0, which increases the solubility of uric acid,
preventing subsequent crystallization. Allopurinol administration can also inhibit uric acid
formation. Administration of intravenous fluids may be necessary early in the course of treatment if
inadequate hydration exists. If potassium levels rise dangerously, Kayexalate (sodium polystyrene
sulfonate) may be given orally, or if the patient is unable to tolerate oral medications because of
nausea and vomiting, rectal instillation may be used.
18. Place these pathophysiologic mechanisms of DIC in the order in which they occur.
1. Activation of the fibrinolytic system
2. Breakdown of thrombi; spontaneous hemorrhage
3. Consumption of coagulation factors; failure of regulatory mechanisms
4. Endothelial damage; release of tissue factor
5. Thrombin formation; clots form along epithelial walls
a. 4, 1, 5, 2, 3
b. 4, 1, 3, 2, 5
c. 5, 1, 2, 4, 3
d. 2, 3, 1, 5, 4
ANS: A
Endothelial damage triggers the release of tissue factor. Thrombin is released, and clots form,
consuming coagulation factors. The fibrinolytic system is triggered to break down the clots, which
leads to spontaneous hemorrhage.
MULTIPLE RESPONSE
1. Common findings in tumor lysis syndrome (TLS) include (Select all that apply.)
a. increased calcium.
b. decreased potassium.
c. dysrhythmias.
d. elevated blood urea nitrogen (BUN) and creatine.
e. edema.
ANS: C, D, E
Common findings in TLS are as follows. Clinical: Weight gain, edema, diarrhea, lethargy, muscle
cramps, nausea and vomiting, paresthesia, weakness, oliguria, uremia, seizures. Laboratory:
Increased potassium, phosphorus, uric acid, BUN, and creatine; decreased calcium, creatinine
clearance, pH, bicarbonate, and PaCO2. Diagnostic: Positive Chvostek and Trousseau signs,
hyperactive deep tendon reflexes, dysrhythmias, and ECG changes.
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2. Which of the following nursing interventions would be used if a patient was put under bleeding
precautions? (Select all that apply.)
a. Avoid injections as appropriate.
b. Encourage the patient to eat foods high in calcium and vitamin C.
c. Use a soft toothbrush or toothettes for oral care. d. Provide
a therapeutic mattress and pad side rails. e. Use an electric
razor for shaving.
ANS: A, C, D, E
Bleeding precautions include all of these options except encouraging the patient to eat foods high in
calcium and vitamin C. Rather, patients should be instructed to increase intake of foods rich in vitamin
K.
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Chapter 24: Trauma
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE
CHOICE
1. An unresponsive trauma patient has been admitted to the emergency
department. Which statement regarding opening the airway is accurate?
a. Airway assessment must incorporate cervical spine immobilization.
b. Hyperextension of the neck is the only acceptable technique.
c. Flexion of the neck protects the patient from further injury.
d. Airway patency takes priority over cervical spine immobilization.
ANS: A
Airway assessment must incorporate cervical spine immobilization. The patient’s head
should
not be rotated, hyperflexed, or hyperextended to establish and maintain an airway.
The cervical spine must be immobilized in all trauma patients until a cervical
spinal cord injury has been definitively ruled out.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Implementation
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
2. A patient with severe traumatic brain injury has been admitted to the critical care unit.
What is one intervention to minimize secondary brain injury?
a. Hyperventilate the patient to keep PCO2 less than 30.
b. Restrict fluids to keep central venous pressure less than 6 cm H2O.
c. Maintain the patient’s bodG
yR
teA
mDpE
erS
atM
urOeRmEo.
reCtO
haMn 37.5°C.
d. Administer fluids to keep the mean arterial pressure greater than 60 mm Hg.
ANS: D
Heart rate and blood pressure are continually monitored, with the goal of
achieving MAP greater than 60 mm Hg (minimum) to ensure adequate perfusion
to the brain. Secondary injury is the biochemical and cellular response to the
initial trauma that can exacerbate the primary injury and cause additional damage
and impairment in brain recovery. Secondary injury can be caused by ischemia,
hypotension, hypercapnia, cerebral edema, or metabolic derangements.
Hyperventilation will decrease cerebral blood flow. Restricting fluids will
contribute to hypovolemia and subsequently hypotension. Elevating the patient’s
body temperature will increase the cerebral metabolic rate and contribute to
cerebral ischemia.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Implementation
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
3. A patient has sustained an epidural hematoma after a 10-foot fall from a roof.
The nurse understands that an epidural hematoma is a condition that has which
characteristic?
a. Most often associated with middle meningeal artery lacerations
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b. Collection of blood between the dura mater and the arachnoid membrane
c. Associated with a permanent loss of consciousness
d. Signs and symptoms include bilateral pupil dilation
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ANS: A
Epidural hematoma (EDH) is a collection of blood between the inner table of the skull
and the outermost layer of the dura. EDHs are most often associated with skull
fractures and middle
meningeal artery lacerations (two-thirds of patients). The classic clinical
manifestations of EDH include brief loss of consciousness followed by a period of
lucidity. Rapid deterioration in the level of consciousness should be anticipated,
because arterial bleeding into the epidural space can occur quickly. The patient may
complain of a severe, localized headache and may be sleepy. A dilated and fixed pupil
on the same side as the impact area is a hallmark of EDH.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. A patient is admitted with a severe diffuse axonal injury (DAI) secondary to a motor
vehicle
crash. The patient’s plan of care would involve which nursing action?
a. Perform neurologic assessments once a shift.
b. Obtain a computed tomography (CT) scan every day.
c. Monitor blood pressure and temperature every hour.
d. Initiate warming measures to keep temperature greater than 37.5°C.
ANS: C
Severe DAI usually manifests as a prolonged, deep coma with periods of
hypertension, hyperthermia, and excessive diaphoresis. Treatment of DAI
includes support of vital functions. Neurologic assessment is performed every
hour. DAI may not be visible on CT scan. Warming measures are generally not
needed but cooling measure may be needed.
PTS: 1
DIF: Cognitive Level:
Analyzing
OBJ: Nursing Process Step:
AeDntEatSioMn ORE.COM
ImG
plR
em
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
5. A patient is admitted with a C5-C6 subluxation fracture. He is able to move his legs
better than he can move his arms. The nurse suspects the patient may have which
type of injury? a.
Posterior cord syndrome
b. Brown- Séquard syndrome
c. Diffuse axonal injury
d. Central cord syndrome
ANS: D
Central cord syndrome is associated with cervical hyperextension/flexion injury and
hematoma formation in the center of the cervical cord. This injury produces a motor
and sensory deficit more pronounced in the upper extremities than in the lower
extremities. Posterior cord syndrome is associated with cervical hyperextension injury
with damage to the posterior column. This results in the loss of position sense,
pressure, and vibration below the level of injury. Brown-Séquard syndrome is
associated with damage to only one side of the cord. This produces loss of voluntary
motor movement on the same side as the injury, with loss of pain, temperature, and
sensation on the opposite side. Diffuse axonal injury (DAI) is a term used to describe
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prolonged posttraumatic coma that is not caused by a mass lesion, although DAI with
mass lesions has been reported.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A patient has been admitted with a flail chest. What findings would the nurse
expect to observe supporting this diagnosis?
a. Tracheal deviation toward the unaffected side
b. Jugular venous distention
c. Paradoxical respiratory movement
d. Respiratory alkalosis
ANS: C
Tracheal deviation and jugular venous distention are findings associated with tension
pneumothorax. Respiratory acidosis is usually present because of the ineffective
breathing pattern. In a flail chest, a free-floating segment of the chest wall moves
independently from the rest of the thorax and results in paradoxical chest wall
movement during the respiratory cycle. During inspiration, the intact portion of the
chest wall expands while the injured part is sucked in. During expiration, the chest
wall moves in, and the flail segment moves out.
PTS: 1
DIF: Cognitive Le el: Applying
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. A patient has been admitted with a pulmonary contusion. Which finding will cause a
nurse to
suspect that the patient’s condition is deteriorating?
a. Increased bruising on the chest wall
b. Increased need for pain medication
c. The development of respiratory alkalosis
d. Increased work of breathing
GRADESMOR
E.COM
ANS: D
A contusion manifests initially as a hemorrhage followed by alveolar and interstitial
edema. Patients with severe contusions may continue to show decompensation, such
as respiratory acidosis and increased work of breathing, despite aggressive nursing
management. Increased bruising and the need for pain medication are not signs of
deterioration.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Evaluation
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. A patient who was an unrestrained driver in a high-speed, head-on motor vehicle
collision presents with dyspnea, tachycardia, hypotension, jugular venous distention,
tracheal deviation to the left, and decreased breath sounds on the right side. The nurse
suspects these findings are indicative of which disorder?
a. Tension pneumothorax
b. Cardiac tamponade
c. Simple pneumothorax
d. Ruptured diaphragm
ANS: A
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Clinical manifestations of a tension pneumothorax include dyspnea, tachycardia,
hypotension, and sudden chest pain extending to the shoulders. Patients with cardiac
tamponade will not have unilateral decreased breath sounds. Neither a simple
pneumothorax nor a ruptured diaphragm will result in hypotension, jugular venous
distention, or tracheal deviation unless it goes untreated.
PTS: 1
DIF: Cognitive Level: Evaluating
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. A patient is admitted with a blunt cardiac injury (BCI) with no evidence of
rupture. The nursing management plan should include which intervention?
a. Administer nitroglycerine for chest pain as needed.
b. Monitor the patient for new onset dysrhythmias.
c. Monitor serial biomarkers for evidence of further damage.
d. Do not administer antidysrhythmic medications as they are ineffective.
ANS: B
The patient should be monitored for new onset of dysrhythmias. The patient may
complain of chest pain that is similar to anginal pain, but it is not typically relieved
with nitroglycerin. Chest pain is usually caused by associated injuries. Use of
biomarkers, such as troponin, offers very little diagnostic help for BCI. Medical
management is aimed at preventing and
treating complications. This approach includes hemodynamic monitoring in a critical
care unit and possible administration of antidysrhythmic medications.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological InG
teR
grA
itD
y:ERS
edMuO
ctR
ioE
n.
ofCROisM
k Potential
10. A patient is admitted with acute abdominal trauma. The patient has a positive
Focused Assessment with Sonography for Trauma (FAST scan) and is
hemodynamically unstable. What procedure should the nurse anticipate next?
a. Emergency surgery
b. Diagnostic peritoneal lavage (DPL)
c. Computed tomography scan
d. Intra-abdominal pressure monitoring
ANS: A
Hemodynamically unstable patients with a positive FAST scan generally undergo
emergency surgery to achieve hemostasis. Diagnostic peritoneal lavage (DPL) is
undertaken less frequently in many trauma centers. CT scanning is the mainstay of
diagnostic evaluation in
the hemodynamically stable patient with abdominal trauma; however, when the
patient is hemodynamically unstable, the patient is taken to surgery. Intraabdominal pressure monitoring is done in the presence of intra-abdominal
hypertension.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
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11. A patient is admitted to the ICU for observation of his grade II splenic laceration.
Which signs and symptoms suggest that the patient has had a delayed rupture of his
splenic capsule and is now in hemorrhagic shock?
a. BP, 110/70 mm Hg; HR, 120 beats/min; Hct, 42 mg/dL; UO, 40 mL/hr;
skin that is pink, warm, and dry with capillary refill of 3 seconds
b. BP, 90/70 mm Hg; HR, 140 beats/min; Hct, 21 mg/dL; UO, 10 mL/hr;
pale, cool, clammy skin; confused
c. BP, 100/60 mm Hg; HR, 100 beats/min; Hct, 35 mg/dL; UO, 30 mL/hr;
pale, cool, dry skin; alert and oriented
d. BP, 110/60 mm Hg; HR, 118 beats/min; Hct, 38 mg/dL; UO, 60 mL/hr;
flushed, warm, diaphoretic skin; agitated and confused
ANS: B
The first set of vital signs is normal. Patients who are in hemorrhagic shock are
significantly tachycardic with a narrowed pulse pressure and oliguric, and their skin is
pale, cool, and clammy. They also have a low hematocrit and are confused.
Hemodynamically stable patients may be monitored in the critical care unit by means
of serial hematocrit values and vital signs. Progressive deterioration may indicate the
need for operative management.
PTS: 1
DIF: Cognitive Le el: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. A patient with multisystem trauma has been in the ICU for 6 days. The patient is still
intubated and mechanically ventilated and has a chest tube, urinary drainage catheter,
nasogastric tube, and two abdominal drains. The patient’s vital signs include: BP—
92/66 mm Hg; HR—118 beats/min; T—38.7°C; and CVP—5 mm Hg. What is the
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most likely cause of this hemodynamic picture?
a. Septic shock
b.
Hemorrhagic
shock c.
Cardiogenic
shock d.
Neurogenic
shock
ANS: A
The patient with multiple injuries is at risk for overwhelming infections and sepsis.
The source of sepsis in the trauma patient can be invasive therapeutic and diagnostic
catheters or wound contamination with exogenous or endogenous bacteria. The
source of the septic nidus must be promptly evaluated. Gram stain and cultures of
blood, urine, sputum, invasive catheters, and wounds are obtained.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. Older trauma patients have a higher mortality than younger trauma patients.
The nurse understands that this fact is probably related to what physiologic
change?
a. Deterioration of cerebral and motor skills
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b. Poor vision and hearing
c. Diminished pain perception
d. Limited physiologic reserve
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ANS: D
Older adults have limited ability to increase their heart rate in response to blood loss,
obscuring one of the earliest signs of hypovolemia—tachycardia. Loss of physiologic
reserve
and the presence of preexisting medical conditions are likely to produce further
conflicting hemodynamic data. An older patient’s lack of physiologic reserve makes
it imperative that early nutritional support is initiated.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. The nurse is working on an organization-wide falls prevention project. The nurse
understands that the majority of falls accounting for traumatic injury occur in what
population?
a. Construction workers
b. Adolescents
c. Older adults
d. Young adults
ANS: C
Older persons experience most of the falls that result in injuries, and these falls are
likely to occur from level surfaces or steps. Because many of the falls may be caused
by an underlying medical condition (e.g., syncope, myocardial infarction,
dysrhythmias), management of an older patient who has fallen must include an
evaluation of events and conditions immediately preceding the fall.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Trauma
OdMaptation
MSC: NCLEX: Physiological InG
teR
grA
itD
y:EPS
hyMsiO
olR
ogEi.
caC
lA
15. A patient with multisystem trauma has been in the critical care unit for 2 days. The
patient is still intubated and mechanically ventilated and has a chest tube, urinary
drainage catheter, nasogastric tube, and two abdominal drains. The nurse understands
that immobility places the patient at risk for developing which complication?
a. Hypovolemic shock
b. Acute kidney injury
c. Venous thromboembolism
d. Malnutrition
ANS: C
Patients with major trauma are at very high risk for VTE. Factors that form the basis
of VTE pathophysiology are common in trauma, including endothelial injury (as a
result of trauma), hypercoagulopathy (as a result of trauma-induced coagulopathy),
and blood stasis (as a result of immobility). The patient should have already been
treated for hypovolemic shock. While the patient is at risk for acute kidney injury and
malnutrition but not from immobility.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
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16. A nurse and a new graduate nurse are discussing the secondary survey of the trauma
patient.
The nurse asks the new graduate to identify the most important aspect of a secondary
survey. Which response would indicate the new graduate nurse understood the
information?
a. Check circulatory
status. b. Check
electrolyte profile. c.
Insert a urinary
catheter. d. Obtain
patient history.
ANS: D
During the secondary survey, a head-to-toe approach is used to thoroughly examine
each body region. The history is one of the most important aspects of the secondary
survey. Additional interventions during the resuscitation phase involve placement of
urinary and gastric
catheters. During resuscitation from traumatic hemorrhagic shock, normalization of
standard clinical parameters such as blood pressure, heart rate, and urine output are
not adequate. Circulatory status is part of the primary survey.
PTS: 1
DIF: Cognitive Le el: Applying
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
17. A nurse and a nursing student are discussing management of the trauma patient.
The nurse asks the student what the AVPU method is used for during the primary
survey. Which response would indicate the new graduate nurse understood the
information?
a.
Used to assess
respiratory status b. Used to
assess circulatory status c.
Used to assess pain status
d. Used to assess level of consciousness
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ANS: D
The AVPU method can be used to quickly describe the patient’s level of
consciousness: A:
alert, V: responds to verbal stimuli, P: responds to painful stimuli, and U:
unresponsive.
PTS: 1
DIF: Cognitive Level:
Understanding OBJ: Nursing Process Step:
Diagnosis
TOP: Trauma MSC: NCLEX:
Health Promotion and Maintenance
18. A trauma patient’s condition has deteriorated. The nurse observes changes in the
patient’s condition including trachea shift, absence of breath sounds on the left side,
and hypotension. The nurse suspects that the patient has developed what
complication?
a. Cardiac tamponade
b. Hemothorax
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c. Open pneumothorax
d. Ruptured diaphragm
ANS: B
Assessment findings for patients with a hemothorax include hypovolemic shock.
Breath sounds may be diminished or absent over the affected lung. With hemothorax,
the neck veins are collapsed, and the trachea is at midline. Massive hemothorax can
be diagnosed on the
basis of clinical manifestations of hypotension associated with the absence of breath
sounds or dullness to percussion on one side of the chest.
PTS: 1
DIF:
Cognitive Level: Analyzing
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OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. A patient developed a hemothorax after a blunt chest trauma. The practitioner inserted
a chest tube on the left side and 1800 mL of blood was evacuated from the chest. The
nurse expects that the patient will be taken to surgery for what procedure?
a. Thoracotomy
b. Pericardiocentesis
c. Splenectomy
d. Pneumonectomy
ANS: A
Thoracotomy may be necessary for patients who require persistent blood transfusions
or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL
on initial tube insertion) or when there are injuries to major cardiovascular structures.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Planning
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
20. The nurse understands that certain trauma patients are at risk for developing fat
embolism syndrome. Which type of trauma is this complication usually associated
with?
a. Liver trauma
b. Kidney trauma
c. Orthopedic trauma
d. Spinal cord trauma
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ANS: C
Fat embolism syndrome can occur as a complication of orthopedic trauma.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. Major trauma patients are at high risk of developing deep venous thrombosis and
pulmonary embolism. The nurse understands that trauma patients are at risk due to
which factors? (Select all that apply.)
a. Blood stasis
b. Hypernatremia
c. Injury to the intimal surface of the vessel
d. Hyperosmolarity
e. Hypercoagulopathy
f. Immobility
ANS: A, C, E, F
The factors that form the basis of venous thromboembolism pathophysiology are
blood stasis, injury to the intimal surface of the vessel, and hypercoagulopathy.
Trauma patients are at risk for VTE because of endothelial injury, coagulopathy, and
immobility. Hypernatremia and hyperosmolarity are associated with acute kidney
injury.
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PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Diagnosis
TOP: Trauma
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. A patient has been admitted with muscle trauma and crush injuries. The nurse
understands that this patient is at high risk for the development of acute kidney
injury secondary to rhabdomyolysis. Which findings would suggest the patient is
developing this complication? (Select all that apply.)
a. Dark tea–color urine
b. Decreased urine output
c. Decreased oxygen saturation
d. Diminished pulses
e. Increased serum creatine kinase level
ANS: A, B, E
Circulating myoglobin can lead to the development of acute kidney injury by three
mechanisms: decreased renal perfusion, cast formation with tubular obstruction,
and direct toxic effects of myoglobin in the kidney tubules. Dark tea–colored urine
suggests myoglobinuria. The most rapid screening test is a serum creatine kinase
level. Urine output and serial creatine kinase levels should be monitored.
Decreased oxygen saturation and diminished pulses are not associated with
rhabdomyolysis.
PTS: 1
DIF: Cognitive Le el: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
GtRwAitDhEexStM
3. The nurse is caring for a patien
enOsiRvE
e.
traCuOmMa to the lower extremities. The
nurse understands that patient is at risk for compartment syndrome. Which findings
would the nurse expect to observe as evidence of this complication? (Select all that
apply.)
a. Paresthesia
b. Decreased pulses
c. Pain in the affected extremity
d. Swelling in the affected extremity
e. Decreases capillary refill
ANS: A, C, D
Clinical manifestations of compartment syndrome include obvious swelling and
tightness of
an extremity, paresthesia, and pain of the affected extremity. Diminished pulses and
decreased capillary refill do not reliably identify compartment syndrome because they
may be intact
until after irreversible changes have occurred. Elevated intracompartmental pressures
confirm the diagnosis.
PTS: 1
DIF: Cognitive Le el: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
4. The nurse is caring for a patient with blunt abdominal trauma. The nurse
understands that patient is at risk for abdominal compartment syndrome. Which
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findings would the nurse expect to observe as evidence of this complication?
(Select all that apply.)
a. Decreased cardiac output
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b.
c.
d.
e.
Increased peak pulmonary pressures
Decreased urine output
Hypoxemia
Bradycardia
ANS: A, B, C, D
Clinical manifestations of abdominal compartment syndrome include decreased
cardiac output, decreased tidal volumes, increased peak pulmonary pressures,
decreased urine output, and hypoxemia.
PTS: 1
DIF: Cognitive Le el: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Trauma
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
5. Patients immobilized because of spinal trauma are at a high risk for contractures. The
nursing management plan for these patients should include which preventive
measures? (Select all that apply.)
a. Consultation by PT and OT early in the treatment of the patient
b. Turning and repositioning the patient every 2 hours as ordered by the practitioner
c. Range of motion exercises 1 month after the spine has been stabilized
d. Removal of splints every 4 hours and at bedtime
e. Hand splints for patients with paraplegia
f. Hand and foot splints for patients with quadriplegia
ANS: A, B, F
Physical therapy and occupational therapy personnel should be consulted early in the
patient’s course. Range of motion exercises are initiated as soon as the spine has been
stabilized. Foot drop splints should be appliedGoR
nA
adDmEiS
ssM
ioO
nRtoEp.rC
evOenMt contractures
and prevent skin breakdown of the heels. Hand splints should be applied for patients
with quadriplegia. Hand and foot splints should be removed every 2 hours.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
TOP: Trauma
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Chapter 25: Kidney Clinical Assessment and Diagnostic Procedures
Urden: Critical Care Nursing, 9th
EditionEdition
MULTIPLE
CHOICE
1. A patient was admitted with multiple trauma who has been volume resuscitated. The nurse
suspects the patient is fluid overloaded. Which assessment findings would confirm the
nurse’s suspicion?
a. Venous filling of the hand veins greater than 5 seconds
b. Distended neck veins in the supine position
c. Presence of orthostatic hypotension
d. Presence of a third heart sound
ANS: D
Auscultation of the heart requires not only assessing rate and rhythm but also listening for
extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which
is best heard with the bell of the stethoscope.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
2. Loss of albumin from the vascular space may result in which condition?
a. Peripheral
edema b. Extra
heart sounds c.
Hypertension
d. Hyponatremia
ANS: A
Decreased albumin levels in the vascular space result in a plasma-to-interstitium fluid shift,
creating peripheral edema. A decreased albumin level can occur as a result of proteincalorie malnutrition, which occurs in many critically ill patients in whom available stores
of albumin are depleted. A decrease in the plasma oncotic pressure results, and fluid shifts
from the vascular space to the interstitial space.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 627
3. A patient was admitted with acute heart failure who has been receiving diuretic therapy.
The nurse suspects the patient is hypovolemic. What auscultatory parameter would
confirm the nurse’s suspicion?
a. Hypertension
b. Third or fourth heart sound
c. Orthostatic hypotension
d. Vascular bruit
ANS: C
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A drop in systolic blood pressure of 20 mm Hg or more, a drop in diastolic blood pressure of
10 mm Hg or more, or a rise in pulse rate of more than 15 beats/min from lying to sitting or
from sitting to standing indicates orthostatic hypotension. The drop in blood pressure occurs
because a sufficient preload is not immediately available when the patient changes position.
The heart rate increases in an attempt to maintain cardiac output and circulation.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
4. Percussion of kidneys is usually done to assess what parameter?
a. Size and shape of the kidneys
b. Presence of pain in the renal area
c. Presence of a fluid wave
d. Patient’s overall fluid status
ANS: B
Percussion is performed to detect pain in the area of a kidney or to determine excess
accumulation of air, fluid, or solids around the kidneys. Percussion of the kidneys
also provides information about kidney location, size, and possible problems.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
5. In a patient with a distended abdomen, differentiating ascites from solid bowel contents
is accomplished by performing what assessment?
a. Auscultation of bowel
sounds b. Palpation of the liver
margin c. Measuring
abdominal girth
d. Eliciting a fluid wave
ANS: D
Differentiating ascites from distortion by solid bowel contents is accomplished by
producing what is called a fluid wave. The fluid wave is elicited by exerting pressure to the
abdominal midline while one hand is placed on the right or left flank. Tapping the opposite
flank produces a wave in the accumulated fluid that can be felt under the hands.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
6. A patient has been admitted with acute kidney injury. The nurse knows the most
important consideration for evaluating the patient’s fluid status is what parameter?
Daily weights
Urine and serum osmolality
Intake and output
Hemoglobin and hematocrit levels
a.
b.
c.
d.
ANS: A
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One of the most important assessments of kidney and fluid status is the patient’s weight. In
the critical care unit, weight is monitored for each patient every day and is an important
vital
signs measurement.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
7. A patient has been admitted in acute heart failure. Which parameter would indicate to
the nurse that the patient is fluid overloaded?
Central venous pressure of 4 mm Hg
Pulmonary artery occlusion pressure (PAOP) of 18 mm Hg
Cardiac index of 2.5 L/min/m2
Mean arterial pressure of 40 mm Hg
a.
b.
c.
d.
ANS: B
The pulmonary artery occlusion pressure (PAOP) represents the left atrial pressure required
to fill the left ventricle. When the left ventricle is full at the end of diastole, this represents
the volume of blood available for ejection. It is also known as left ventricular preload and
is measured by the PAOP. The normal PAOP is 5 to 12 mm Hg. In fluid volume excess,
PAOP rises. In fluid volume deficit, PAOP is low.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 624
8. As serum osmolality rises, intravascular fluid equilibrium will be maintained by the release
of what substance?
Ketones
Glucagon
Antidiuretic hormone
Potassium
a.
b.
c.
d.
ANS: C
When the serum osmolality level increases, antidiuretic hormone is released from the
posterior pituitary gland and stimulates increased water resorption in the kidney tubules.
This expands the vascular space, returns the serum osmolality level back to normal, and
results in more concentrated urine and an elevated urine osmolality level.
PTS: 1
DIF: Cognitive Level: Remembering
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 626
9. A patient was admitted with acute kidney failure. Which urinalysis value reflects a
decreased ability of the kidneys to concentrate urine?
pH of 5.0
Specific gravity of 1.000
No casts
Urine sodium of 140 mEq/24 h
a.
b.
c.
d.
ANS: B
Specific gravity measures the density or weight of urine compared with that of distilled
water. The normal urinary specific gravity is 1.005 to 1.025. For comparison, the specific
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gravity of distilled water is 1.000. Because urine is composed of many solutes and
substances suspended in water, the specific gravity should always be higher than that of
water.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 627
10. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient
reports that over the past few weeks, his urine output has decreased, and he has developed
peripheral edema and ascites. The nurse suspects the main cause of ascites is what
condition?
a. Hypervolemia
b. Dehydration
c. Volume overload
d. Liver damage
ANS: C
Individuals with kidney failure may have ascites caused by volume overload, which forces
fluid into the abdomen because of increased capillary hydrostatic pressures. However,
ascites may or may not represent fluid volume excess. Severe ascites in persons with
compromised liver function may result from decreased plasma proteins. The ascites occurs
because the increased vascular pressure associated with liver dysfunction forces fluid and
plasma proteins from the vascular space into the interstitial space and abdominal cavity.
Although the individual may exhibit marked edema, the intravascular space is volume
depleted, and the patient is hypovolemic.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 623
11. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient
reports that over the past few weeks, his urine output has decreased, and he has developed
peripheral edema and ascites. Which diagnostic tests would provide the best information
about the internal kidney structures, such as the parenchyma, calyces, pelvis, ureters, and
bladder?
a.
Kidney–ureter–bladder
(KUB) b.
Intravenous
pyelography (IVP) c.
Renal
ultrasonography (ECHO) d.
Renal angiography
ANS: B
Intravenous pyelography allows visualization of the internal kidney parenchyma, calyces,
pelvis, ureters, and bladder. Kidney–ureter–bladder flat-plate radiography of the abdomen
determines the position, size, and structure of the kidneys, urinary tract, and pelvis. It is
useful for evaluating the presence of calculi and masses and is usually followed by
additional tests.
In ultrasonography, high-frequency sound waves are transmitted to the kidneys and urinary
tract, and the image is viewed on an oscilloscope. This noninvasive procedure identifies
fluid accumulation or obstruction, cysts, stones or calculi, and masses. It is useful for
evaluating the kidneys before biopsy. Angiography is injection of contrast into arterial
blood perfusing the kidneys. It allows for visualization of renal blood flow and may also
visualize stenosis, cysts, clots, trauma, and infarctions.
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PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 630|Table 25-4
12. A patient is admitted with renal failure. The patient’s weight upon admission was 176 lb,
and the next day it is 184 lb. What is the approximate amount of fluid retained with this
weight gain?
a. 800
mL b.
2200 mL
c. 3600
mL d.
8000 mL
ANS: C
One liter of fluid equals 1 kg, which is 2.2 lb; 8 lb equals 3.6 kg, which is 3.6 L; 3.6 L is
equal to 3600 mL.
PTS: 1
DIF: Cognitive Level: Analyzing
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 624
13. When calculating the anion gap, what is the predominant cation?
a. Sodium
b. Potassium
c. Chloride
d. Bicarbonate
ANS: A
The anion gap is a calculation of the difference between the measurable extracellular
plasma cations (sodium and potassium) and the measurable anions (chloride and
bicarbonate). In plasma, sodium is the predominant cation, and chloride is the
predominant anion.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Intervention TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 626
14. A patient was admitted with acute heart failure a few days ago. Today the patient’s urine
has a specific gravity of 1.040. What could be the potential cause for this value?
Volume overload
Volume deficit
Acidosis
Urine ketones
a.
b.
c.
d.
ANS: B
Specific gravity ranges from 1.003 to 1.030. Possible causes for increased values
include volume deficit, glycosuria, proteinuria, and prerenal acute kidney injury (AKI).
Possible causes for decreased values include volume overload and interrenal AKI.
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 628|Table 25-3
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15. A patient was admitted with heart failure. The nurse is assessing the patient for peripheral
edema. The nurse presses two fingers over the tibial area, and it takes 1 minute before
the indention disappears. What would the nurse note in the medical record?
a.
+1 pitting
edema b.
+2
pitting edema c.
+3 pitting edema
d.
+4 pitting
edema
ANS: C
The pitting edema scale includes +1 = 2-mm depth; +2 = 4-mm depth (lasting up to 15
seconds); +3 = 6-mm depth (lasting up to 60 seconds); and +4 = 8-mm depth (lasting
longer than 60 seconds).
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622|Table 25-1
16. The patient complains of a metallic taste and loss of appetite. The nurse is concerned that
the patient has developed what problem?
a.
Glycosuria
b.
Proteinuria
c.
Myoglobin
d. Uremia
ANS: D
A history of recent onset of nausea and vomiting or appetite loss caused by taste changes
(uremia often causes a metallic taste) may provide clues to the rapid onset of kidney
problems. Glycosuria is the presence of glucose in the urine. Proteinuria is the presence of
protein in the urine. Myoglobin is the presence of red blood cells in the urine.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 620
17. A patient has been on complete bed rest for 3 days. The practitioner has left orders to get
the patient out of bed for meals. The patient complains of feeling dizzy and faint while
sitting at the bedside. The nurse suspects that the patient is experiencing what problem?
a.
Orthostatic
b.
hypertension
Orthostatic hypotension c.
Hypervolemia
d. Electrolyte imbalance
ANS: B
Orthostatic hypotension produces subjective feelings of weakness, dizziness, or faintness.
Orthostatic hypotension occurs with hypovolemia or prolonged bed rest or as a side effect
of medications that affect blood volume or blood pressure.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 622
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MULTIPLE
RESPONSE
1. What causes the presence of myoglobin in urine? (Select all that
apply.)
a. Bleeding
b. Traumatic damage to the skeletal muscle
c.
Asthmatic
d.
attack
Rhabdomyolysis
e. Cocaine abuse
ANS: A, B, D, E
Although a few red blood cells (RBCs) in the urine are normal, discernibly bloody urine
usually indicates bleeding within the urinary tract or kidney trauma. The presence of
myoglobin can make the urine appear red. Microscopic examination of the urine fails to
reveal RBCs, with myoglobin being present instead. Myoglobin in the urine may result
from skeletal muscle damage (eg, traumatic crush injury) or rhabdomyolysis.
Rhabdomyolysis may develop in patients admitted to a critical care unit for many reasons,
including traumatic injury,
cocaine abuse, status epilepticus, heat prostration, or collapse during intense physical
exercise
(eg, running a marathon race on a hot day).
PTS: 1
DIF: Cognitive Level: Understanding
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 629
2. Which findings may be present in the patient with significant fluid volume overload?
(Select all that apply.)
a. S3 or S4 may develop.
b. Distention of the hand veins will disappear if the hand is elevated.
c. When testing the quality of skin turgor, the skin will not return to the
normal position for several seconds.
d. Tachycardia with hypotension may be present.
e. Dependent edema may be present.
ANS: A, E
A gallop and dependent edema are indicative of fluid excess; the other signs are indicative
of fluid volume deficit.
PTS:
OBJ:
TOP:
MSC:
1
DIF: Cognitive Level: Analyzing
Nursing Process Step: Assessment
Renal Clinical Assessment and Diagnostic Procedures
NCLEX: Physiologic Integrity
REF: p. 625|Box 25-3
3. A patient is admitted in acute heart failure secondary to renal insufficiency. The patient
reports that over the past few weeks, his urine output has decreased, and he has developed
peripheral edema and ascites. A diagnosis of renal failure is made. The nurse would expect
to see
elevated values in which laboratory results? (Select all that apply.)
a. Blood urea nitrogen (BUN)
b. Creatinine
c. Glucose
d. Hemoglobin and hematocrit
e. Protein
ANS: A, B, D
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With kidney dysfunction, the blood urea nitrogen (BUN) is elevated because of a decrease
in the glomerular filtration rate and resulting decrease in urea excretion. Elevations in the
BUN can be correlated with the clinical manifestations of uremia; as the BUN rises,
symptoms of uremia become more pronounced. Creatinine levels are fairly constant and are
affected by fewer factors than BUN. As a result, the serum creatinine level is a more
sensitive and specific indicator of kidney function than BUN. Creatinine excess occurs most
often in persons with kidney failure resulting from impaired excretion. Decreased
hematocrit value can indicate
fluid volume excess because of the dilutional effect of the extra fluid load. Decreases also
can result from anemias, blood loss, liver damage, or hemolytic reactions. In individuals
with acute kidney failure, anemia may occur early in the disease.
PTS: 1
DIF: Cognitive Level: Applying
OBJ: Nursing Process Step: Assessment TOP: Renal
MSC: NCLEX: Physiologic Integrity
REF: p. 625|p. 627
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Chapter 26: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Test Bank
MULTIPLE
CHOICE
1. Shock syndrome can best be described as a
a. physiologic state resulting in hypotension and tachycardia.
b. generalized systemic response to inadequate tissue perfusion.
c. degenerative condition leading to death.
d. condition occurring with hypovolemia that results in irreversible hypotension.
ANS: B
Shock is a complex pathophysiologic process that often results in multiple organ
dysfunction syndrome and death. All types of shock eventually result in ineffective tissue
perfusion and the development of acute circulatory failure.
2. Hypovolemic shock that results from an internal shifting of fluid from the intravascular
space to the extravascular space is known as
a. absolute hypovolemia.
b. distributive hypovolemia.
c. relative hypovolemia.
d. compensatory hypovolemia.
ANS: C
Hypovolemia results in a loss of circulating fluid volume. A decrease in circulating volume
leads to a decrease in venous return, which results in a decrease in end-diastolic volume or
preload.
3. The nursing measure that can best enhance large volumes of fluid replacement
in hypovolemic shock is
insertion of a large-diameter peripheral intravenous catheter.
positioning the patient in the Trendelenburg position.
forcing at least 240 mL of fluid each hour.
administering intravenous lines under pressure.
a.
b.
c.
d.
ANS: A
Measures to facilitate the administration of volume replacement include insertion of
large- bore peripheral intravenous catheters; rapid administration of prescribed fluids;
and positioning the patient with the legs elevated, trunk flat, and head and shoulders
above the chest.
4. The main cause of cardiogenic shock is
a. an inability of the heart to pump blood forward.
b. hypovolemia, resulting in decreased stroke volume.
c. disruption of the conduction system when re-entry phenomenon occurs.
d. an inability of the heart to respond to inotropic agents.
ANS: A
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Cardiogenic shock is the result of failure of the heart to effectively pump blood forward. It
can occur with dysfunction of the right or the left ventricle or both. The lack of adequate
pumping function leads to decreased tissue perfusion and circulatory failure.
5. Which of the following hemodynamic parameters supports the diagnosis of
cardiogenic shock?
Increased right atrial pressure
Decreased pulmonary artery wedge pressure
Increased cardiac output
Decreased cardiac index
a.
b.
c.
d.
ANS: D
Assessment of the hemodynamic parameter of patients in cardiogenic shock
reveals a decreased cardiac output and a cardiac index less than 2.2 L/min/m2.
6. With anaphylactic shock, which mechanism results in a decreased cardiac output?
a. Peripheral vasodilation
b. Increased cardiac output
c. Decreased alveolar ventilation
d. Fluid retention resulting in congestive heart failure
ANS: A
Peripheral vasodilation results in decreased venous return. This decreases
intravascular volume and the development of relative hypovolemia. Decreased venous
return results in decreased stroke volume and a fall in cardiac output.
7. Which of the following drugs promotes bronchodilation and vasoconstriction?
a. SoluMedrol b.
Gentamicin c.
Atropine
d. Epinephrine
ANS: D
Epinephrine is given in anaphylactic shock to promote bronchodilation and
vasoconstriction and inhibit further release of biochemical mediators.
8. The patients at highest risk for neurogenic shock are those who have had
a. a stroke.
b. a spinal cord injury.
c. Guillain-Barré syndrome.
d. a craniotomy.
ANS: B
The most common cause is spinal cord injury (SCI). Neurogenic shock may mistakenly be
referred to as spinal shock. The latter condition refers to loss of neurologic activity below
the level of SCI, but it does not necessarily involve ineffective tissue perfusion.
9. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary
catheter was inserted. Complete blood cell count results have revealed escalating white
blood cell counts. The patient is transferred to the critical care unit when her condition
deteriorates. Septic shock is diagnosed. A pulmonary artery catheter is placed. Which of the
following hemodynamic values would you expect to find?
a. Cardiac output of 8 L/min
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b. Right atrial pressure of 17 mm Hg
c. Pulmonary artery wedge pressure of 23 mm Hg
d. Systemic vascular resistance of 1100
ANS: A
Increased cardiac output and decreased systemic vascular resistance are classic signs of
septic shock.
10. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary
catheter was inserted. Complete blood cell count results have revealed escalating white
blood cell counts. The patient is transferred to the critical care unit when her condition
deteriorates. Septic shock is diagnosed. Which of the following is the pathophysiologic
mechanism that results in septic shock?
a. Bacterial toxins lead to vasodilation.
b. Increased white blood cells are released to fight invading bacteria.
c. Microorganisms invade organs such as the kidneys and heart.
d. An increase of white blood cells leads to decreased red blood cell production
and anemia.
ANS: A
The syndrome encompassing severe sepsis and septic shock is a complex systemic
response that is initiated when a microorganism enters the body and stimulates the
inflammatory or immune system. Shed protein fragments and the release of toxins and
other substances from the microorganism activate the plasma enzyme cascades
(complement, kinin and kallikrein, coagulation, and fibrinolytic factors), as well as
platelets, neutrophils, monocytes, and macrophages.
11. A patient has been on the medical floor for 1 week after a vaginal hysterectomy. A urinary
catheter was inserted. Complete blood cell count results have revealed escalating white
blood cell counts. The patient is transferred to the critical care unit when her condition
deteriorates. Septic shock is diagnosed. The medical management of the patient’s condition
is aimed toward
a. limiting fluids to minimize the possibility of congestive heart failure.
b. finding and eradicating the cause of infection.
c. discontinuing invasive monitoring as a possible cause of sepsis.
d. administering vasodilator substances to increase blood flow to vital organs.
ANS: B
Effective treatment of severe sepsis and septic shock depends on timely recognition. The
diagnosis of severe sepsis is based on the identification of three conditions: known or
suspected infection, two or more of the clinical indications of the systemic inflammatory
response, and evidence of at least one organ dysfunction. Clinical indications of systemic
inflammatory response and sepsis were included in the original American College of
Chest Physicians/Society of Critical Care Medicine consensus definitions.
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12. Signs of hypovolemia in the trauma patient include
a. distended neck veins.
b. a decreased level of consciousness.
c. bounding radial and pedal pulses.
d. a widening pulse pressure.
ANS: B
Signs of underperfusion include flattened neck veins, a decreased level of
consciousness, weak and thready peripheral pulses, and a narrowed pulse pressure.
13. Which medications are not effective in the immediate treatment of acute anaphylaxis?
a. Epinephrine
b. Vasopressors
c. Diphenhydramine (Benadryl) IV
d. Corticosteroids
ANS: D
Epinephrine is the first-line treatment of choice for anaphylaxis and should be
administered when initial signs and symptoms occur. Several medications are used as
second-line adjunctive therapy. Inhaled -adrenergic agents are used to treat
bronchospasm unresponsive to epinephrine. Diphenhydramine (Benadryl) given 1 to 2
mg/kg (25?0–50 mg) by a slow intravenous line is used to block histamine response.
Ranitidine, given in conjunction with diphenhydramine at a dose of 1 mg/kg intravenously
over 10 to 15 minutes, has been found helpful. Corticosteroids are not effective in the
immediate treatment of acute anaphylaxis but may be given with the goal of preventing a
prolonged or delayed reaction.
14. A vasoconstrictor used to treat shock is
a. adrenaline.
b. Nipride.
c. Dobutrex.
d. adenosine.
ANS: A
Adrenaline is a vasoconstrictor, Nipride is a vasodilator, Dobutrex is an inotrope,
and adenosine is an antidysrhythmic.
15. Which of the following clinical manifestations is not suggestive of systemic
inflammatory response syndrome (SIRS)?
Temperature of 37.5° C
Heart rate of 95 beats/min
Respiratory rate of 24 breath/min
White blood cell (WBC) count of 15,000 cells/mm3
a.
b.
c.
d.
ANS: A
SIRS occurs when two or more of four clinical manifestations are present in the patient at
high risk. These manifestations are temperature less than 36° C or greater than 38° C, heart
rate greater than 90 beats/min, respiratory rate greater than 20 breaths/min or PaCO2 less
than
32 mm Hg, or WBC greater than 12,000 cells/mm3 or less than 4000 cells/mm3 or greater
than
10% immature (band forms).
16. When SIRS is the result of infection, it is called
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a.
b.
c.
d.
inflammation.
anaphylaxis.
sepsis.
pneumonia.
ANS: C
When SIRS is the result of infection, the term sepsis is used.
17. The difference between primary and secondary multiple organ dysfunction syndrome
(MODS) is that primary MODS is the result of
a. widespread systemic inflammation that results in dysfunction of organs
not involved in the initial insult.
b. direct organ injury.
c. disorganization of the immune system response.
d. widespread disruption of the coagulation system.
ANS: B
Organ dysfunction may be the direct consequence of an initial insult (primary MODS) or
can manifest latently and involve organs not directly affected in the initial insult (secondary
MODS). Patients can experience both primary and secondary MODS. Primary MODS
results from a well-defined insult in which organ dysfunction occurs early and is directly
attributed to the insult itself.
18. The gastrointestinal system is a common target organ for MODS related to
a. anorexia.
b. limited or absent food ingestion.
c. disruption of the mucosal barrier from hypoperfusion.
d. a decrease in hydrochloric acid secretion.
ANS: C
With microcirculatory failure to the gastrointestinal tract, the gut’s barrier function may be
lost, which leads to bacterial translocation, sustained inflammation, endogenous
endotoxemia, and MODS.
19. Clinical manifestations of ischemic hepatitis show up 1 to 2 days after the insult.
Which symptom below is indicative of hepatic insufficiency?
Elevated serum creatinine
Decreased bilirubin
Jaundice
Decreased serum transaminase
a.
b.
c.
d.
ANS: C
Clinical manifestations of hepatic insufficiency are evident 1 to 2 days after the insult.
Jaundice and transient elevations in serum transaminase and bilirubin levels occur.
Hyperbilirubinemia results from hepatocyte anoxic injury and an increased production
of bilirubin from hemoglobin catabolism.
20. A patient is admitted to the intensive care unit after she develops disseminated
intravascular coagulation (DIC) after a vaginal delivery. DIC is known to occur in
patients with retained placental fragments. What is the result of DIC?
a. Hypersensitive response to an antigen, resulting in anaphylaxis
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b. Depletion of clotting factors and excessive fibrinolysis, resulting in
simultaneous microvascular clotting and hemorrhage
c. Vasodilatation, resulting in hypotension
d. Septic shock, resulting in vasodilation and decreased perfusion
ANS: B
DIC results simultaneously in microvascular clotting and hemorrhage in organ systems,
leading to thrombosis and fibrinolysis in life-threatening proportions. Clotting factor
derangement leads to further inflammation and further thrombosis. Microvascular damage
leads to further organ injury. Cell injury and damage to the endothelium activate the
intrinsic or extrinsic coagulation pathways.
21. Laboratory values for DIC show abnormalities in
a. liver function tests.
b. tests for renal function.
c. platelet counts.
d. blood glucose levels.
ANS: C
Low platelet counts and elevated D-dimer concentrations and fibrinogen degradation
products are clinical indicators of DIC.
22. Which medication is not recommended in the treatment of shock-related lactic acidosis?
a. Glucose
b. Sodium bicarbonate
c. Vasoconstrictor
d. Large quantity of crystalloids fluids
ANS: B
Sodium bicarbonate is not recommended in the treatment of shock-related lactic acidosis.
Glucose control to a target level of 140 to 180 mg/dL is recommended for all critically ill
patients. Vasoconstrictor agents are used to increase afterload by increasing the systemic
vascular resistance and improving the patient’s blood pressure level. Crystalloids are
balanced electrolyte solutions that may be hypotonic, isotonic, or hypertonic. Examples of
crystalloid solutions used in shock situations are normal saline and lactated Ringer solution.
23. The most common site for sepsis and septic shock is
a. the respiratory system.
b. the gastrointestinal system.
c. the genitourinary system.
d. the circulatory system.
ANS: A
The respiratory system is the most common site of infection producing severe sepsis
and septic shock followed by the genitourinary and gastrointestinal systems.
24. Profound weight loss in patients with SIRS or MODS is the result of
a.
hypometabolism. b.
hypermetabolism.
c. hyperglycemia.
d. intolerance to enteral feedings.
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ANS: B
Hypermetabolism in SIRS or MODS results in profound weight loss, cachexia, and loss of
organ function. The goal of nutritional support is the preservation of organ structure and
function. Although nutritional support may not definitely alter the course of organ
dysfunction, it prevents generalized nutritional deficiencies and preserves gut integrity.
Enteral nutrition may exert a physiologic effect that downregulates the systemic immune
response and reduces oxidate stress.
25. One theory suggests that organ dysfunction in MODS occurs in a sequential or progressive
pattern. Place the following organs in the order in which they are affected:
1. Bone marrow
2. Cardiac
3. Gut
4. Kidneys
5. Liver
6. Lungs
a. 6, 5, 2, 1, 3, 4
b. 5, 4, 6, 1, 2, 3
c. 6, 5, 3, 4, 2, 1
d. 6, 3, 4, 5, 2, 1
ANS: C
Organ dysfunction may occur in a sequential or progressive pattern. Organ dysfunction may
begin in the lungs, the most commonly affected major organ, and progress to the liver, gut,
and kidneys. Cardiac and bone marrow dysfunction may follow. Neurologic and autonomic
system impairment may occur and propagate the progression of organ failure, which is
associated with illness severity and mortality. Organs may fail simultaneously; for example,
kidney dysfunction may occur concurrently with hepatic dysfunction. After the initial insult
and resuscitation, patients develop persistent hypermetabolism, a metabolic consequence of
sustained systemic inflammation and physiologic stress followed closely by pulmonary
dysfunction, manifested as acute respiratory distress syndrome.
MULTIPLE RESPONSE
1. The key to treatment of septic shock is finding the cause of the infection. Which of the
following cultures are obtained before antibiotic therapy is initiated? (Select all that apply.)
a. Blood cultures x 2
b. Wound cultures
c. Urine cultures
d. Sputum cultures
e. CBC with differential
ANS: A, B, C, D
A key measure in the treatment of septic shock is finding and eradicating the cause of the
infection. At least two blood cultures plus urine, sputum, and wound cultures should be
obtained to find the location of the infection before antibiotic therapy is initiated. Antibiotic
therapy should be started within 1 hour of recognition of severe sepsis without delay for
cultures.
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2. Which of the following historical findings would indicate a high risk for latex allergy?
(Select all that apply.)
Allergic reaction to anesthetics
Eczema of the hands
Congenital urologic disorder
Asthma
Health care worker
a.
b.
c.
d.
e.
ANS: A, B, C, E
Prevention of anaphylactic shock is one of the primary responsibilities of nurses in critical
care areas. Preventive measures include the identification of patients at risk and cautious
assessment of each patient’s response to the administration of medications, blood, and blood
products. A complete and accurate history of each patient’s allergies is an essential
component of preventive nursing care. In addition to a list of the allergies, a detailed
description of the type of response for each one should be obtained.
3. Evidence-based guidelines for the treatment of septic shock include which of the following?
(Select all that apply.)
a. Fluid resuscitation to maintain central venous pressure at 8 mm Hg or greater
b. Low-dose dopamine for renal protection
c. High-dose corticosteroids
d. Administration of activated protein C
e. Achieve central venous oxygen saturation of 70% or more
ANS: A, D, E
There is no evidence to support the use of dopamine; low-dose steroids are part of the
sepsis management bundle.
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