NR 340 Week 7 Exam Three Critical Care Nursing

  1. Question: A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would …. contraindicated in this client in which of the following circumstances?
  2. Question: A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?
  3. Question:  A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?
  4. Question: Which of the following values is considered normal for ICP?
  5. Question: Which of the following signs and symptoms of increased ICP after head trauma would appear first?
  6. Question: The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?
  7. Question: The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?
  8. Question: A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:
  9. Question: The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?
  10. Question: The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:
  11. Question: During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would … most appropriate to institute?
  12. Question: Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
  13. Question: The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.
  14. Question:  A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?
  15. Question: A nurse is reviewing the record of a client with increased ICP and notes that the client has exhibited signs of decerebrate posturing. On assessment of the client, the nurse would expect to note which of the following if this type of posturing was present?
  16. Question: If a client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:
  17. Question: After striking his head on a tree while falling from a ladder, a young man, age 18, is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would … the most dangerous for the client?
  18. Question: The nurse is performing a mental status examination on a client diagnosed with subdural hematoma. This test assesses which of the following?
  19. Question: Shortly after admission to an acute care facility, a client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
  20. Question: A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign highest priority to which nursing diagnosis?
  21. Question: A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
  22. Question: The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
  23. Question:  A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first?
  24. Question: A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
  25. Question: You are providing care for a patient with an acute hemorrhage stroke. The patient’s husband has … reading a lot about strokes and asks why his wife did not receive alteplase. What is your best response?
  26. Question: While working in the ICU, you are assigned to care for a patient with a seizure disorder. Which of these nursing actions will you implement first if the patient has a seizure?
  27. Question: A 70-year-old alcoholic patient with acute lethargy, confusion, and incontinence is admitted to the hospital ED. His wife tells you that he fell down the stairs about a month ago, but “he didn’t have a scratch afterwards.” She feels that he has become gradually less active and sleepier over the last 10 days or so. Which of the following collaborative interventions will you implement first?
  28. Question: The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient’s blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the priority intervention?
  29. Question: The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is:
  30. Question: What is the total amount of fluid (in the first 24 hours) that will need to … administered to a 70-kg man with a burn injury that covers 50% of his body surface area?
  31. Question: Which of the following is an essential nursing action for a patient who has circumferential full-thickness burns on an extremity?

  1. Question 9 Type: MCMA – A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate?
  2. Question 12 Type: MCSA – The nurse has adequately managed a patient’s airway, breathing, and circulation. What is the next nursing action?
  3. Question 15 Type: MCMA – The nurse is providing care to a farmworker who was pinned against a steel gate by a horse. Deformation of the patient’s pelvis and femurs is obvious, but little blood is present on the patient’s clothing. Initial blood pressure is 110/68 mm Hg. What nursing interventions are indicated?
  4. Question 19 Type: MCSA – The nurse is caring for a patient who sustained a lacerated spleen from a motorcycle accident. Which complication is this patient most prone to experience because of the trauma?
  5. Question 20 Type: MCSA – A patient is in the intensive care unit with a pulmonary contusion sustained from a motor vehicle accident. Which post-traumatic complication should the nurse focus on when providing care to this patient?
  6. Question 2 Type: MCSA – A patient recovering from a frontal craniotomy is positioned with the head of the bed elevated 45 degrees at all times. What rationale would the nurse provide for this position?
  7. Question 3 Type: MCSA – The nurse is providing care for a patient who sustained a severe head injury. The nurse would intervene to prevent which occurrence that increases cerebral blood flow?
  8. Question 4 Type: MCSA – The nurse is providing care for a patient who is at risk for developing an increase in intracranial pressure due to swelling of the brain. The nurse is aware that this increased brain size must … accompanied by which other change if intracranial pressure is to remain stable?
  9. Question 5 Type: MCSA – A nurse is monitoring the intracranial pressure of a patient with a closed-head injury. Which pressure would the nurse evaluate as requiring no additional intervention?
  10. Question 7 Type: MCSA – A patient with a head injury has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 20 mm Hg. Which cerebral perfusion pressure would the nurse document for this patient?
  11. Question 8 Type: MCSA – A nurse is monitoring a patient who sustained a head injury. The nurse recognizes which finding as the earliest sign of change in neurologic status?
  12. Question 9 Type: MCSA – A nurse is monitoring a patient’s Glasgow Coma Scale (GSC). At which point would the nurse document that the patient is comatose?
  13. Question 19 Type: MCSA – A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should … taken by the nurse?
  14. Question 1 Type: MCMA – The nurse is providing community education regarding stroke. Which information should … included?
  15. Question 2 Type: MCSA – A patient comes into the emergency department with complaints of partial loss of vision in one eye, numbness and tingling of the arm and leg, and dizziness. Which additional information should the nurse initially seek from the patient?
  16. Question 3 Type: MCSA – When developing a teaching plan for a patient who had an embolic stroke, the nurse considers which history as a significant risk factor?
  17. Question 4 Type: MCSA – When planning nursing care for a patient with a cerebral vascular accident, the nurse should consider which primary goal of medical management?
  18. Question 12 Type: MCSA – A patient who has been admitted with symptoms of stroke is to have a CT scan. What rationale for this testing would the nurse provide to the patient and family?
  19. Question 13 Type: MCMA – A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which nursing interventions are indicated?
  20. Question 1 Type: MCSA – A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic “about 6 weeks ago.” The nurse would ask additional assessment questions regarding which condition?
  21. Question 2 Type: MCSA – The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon?
  22. Question 5 Type: MCSA – A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient?
  23. Question 6 Type: MCSA – A patient is admitted with a traumatic brain injury. The nurse would anticipate participating in interventions toward which immediate goal?
  24. Question 7 Type: MCMA – A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in level two interventions to reduce intracranial pressure (ICP) through which uses of this catheter?
  25. Question 8 Type: MCSA – A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which level four intervention?
  26. Question 10 Type: MCSA – A patient being treated for increased intracranial pressure from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient?
  27. Question 11 Type: MCMA – The admission orders for a patient with traumatic brain injury say to keep the patient’s head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement?
  28. Question 12 Type: MCSA – A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention?
  29. Question 13 Type: MCMA – The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation?
  30. Question 15 Type: MCSA – A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective?
  31. Question 14 Type: MCSA – A patient in the intensive care unit begins to seize. The nurse would anticipate initial management of this seizure to include which intravenous medication?
  32. Question 7 Type: MCSA – A patient is admitted with the diagnosis of possible acute pancreatitis. Upon assessment, the nurse notes faint bruising over the patient’s flank region. How would the nurse report and document this finding?
  33. Question 12 Type: MCSA – A patient with acute pancreatitis is demonstrating signs of hypovolemic shock. The nurse will conduct additional assessment for which expected cause of this hypovolemia?
  34. Question 13 Type: MCMA – The nurse is caring for a patient with acute pancreatitis demonstrating signs of hypovolemic shock. Which interventions will … included in this patient’s plan of care?
  35. Question 15 Type: MCSA – The nurse is caring for a patient with acute pancreatitis experiencing pain. How would the nurse expect to treat this pain?
  36. Question 19 Type: MCSA – A patient with acute pancreatitis has been treated to minimize pancreatic stimulation, but vomiting continues. The nurse would anticipate which intervention?
  37. Question 2 Type: MCSA – A patient with acute pancreatitis asks the nurse why everyone is concerned about his blood glucose level. Which nursing response is appropriate?
  38. Question 5 Type: MCSA – The nurse is preparing to administer an intravenous insulin drip to a patient admitted with diabetic ketoacidosis. Which laboratory is of most concern to the nurse?
  39. Question 6 Type: MCSA – The nurse is planning the care for a patient admitted with diabetic ketoacidosis. How does the nurse anticipate this condition will … medically managed?
  40. Question 8 Type: MCSA – The nurse is preparing to administer an intravenous infusion containing regular insulin for a patient diagnosed with diabetic ketoacidosis. Which nursing intervention added to the patient’s plan of care has the highest priority?
  41. Question 9 Type: MCSA – A patient with type 2 diabetes mellitus, lethargy, and a blood glucose level of 650 mg/dL has been diagnosed with hyperglycemic hyperosmolar syndrome. The nurse monitors this patient for the development of which complication?
  42. Question 14 Type: MCMA –  A patient is brought to the emergency department by her son who reports that she was recently diagnosed with diabetes and “is not acting like herself” today. Which additional findings would the nurse consider as suggesting hyperglycemic hyperosmolar state?
  43. Question 15 Type: MCMA –  A patient diagnosed with hyperglycemic hyperosmotic syndrome (HHS) will …. started on rehydration fluids. How will the nurse anticipate managing this treatment?
  44. Question 5 Type: MCSA –  A patient comes into the emergency department with severe burns over the face, arms, legs, and back after spending the day boating with friends. The skin is dry and very red with brisk capillary refill. How would the nurse classify this patient’s burn injuries?
  45. Question 9 Type: MCSA –  The nurse is caring for a 154-pound patient with 50 percent total body surface area burns. If using the Parkland formula, the nurse will calculate which amount of intravenous solution to provide this patient in the first 24 hours of care?
  46. Question 10 Type: MCSA –  A patient, recovering from being struck by lightning 36 hours prior to admission, is demonstrating an acute onset of confusion and muscle weakness. Which rationale would the nurse provide for this assessment?
  47. Question 16 Type: MCSA –  The nurse caring for a patient admitted for burns over his torso and upper arms has clothing adhered to the skin. Which nursing action is indicated?
  48. Question 19 Type: MCSA –  A patient is rehabilitating after a severe burn 6 months ago that left her with scars across her chest and abdomen. She says, “I don’t care what people think, I am going to the beach in a bikini next week.” What most important information should the nurse provide?
  49. Question 20 Type: MCSA –  A female patient recovering from a burn to the left side of her face tells the nurse that she has no idea how she is going to return home and resume her regular life since she is so “ugly and disfigured.” What nursing response is indicated?
  50. Question 5 Type: MCSA –  A patient with history of chronic liver disease is admitted with acute hemorrhage from esophageal varices. The nurse would expect treatment interventions for which causative condition?
  51. Question 6 Type: MCSA –  A patient with acute hepatic dysfunction has abdominal ascites. The nurse would anticipate which laboratory finding?
  52. Question 7 Type: MCMA –  A patient with acute hepatic dysfunction is prescribed lactulose (Cephulac) 45 mL by mouth four times a day. Which findings will the nurse evaluate as indicating the medication is having its desired effect?
  53. Question 9 Type: MCMA –  A patient with acute hepatic dysfunction is experiencing a gastrointestinal bleed. The nurse should … prepared to administer which products?
  54. Question 11 Type: MCSA –  A male patient admitted with a gastrointestinal bleed and a hematocrit level of 40% receives fluid resuscitation. In a few hours, the hematocrit level drops to 32%. How should the nurse evaluate this finding?
  55. Question 13 Type: MCMA –  A patient was admitted with acute abdominal and back pain. Which test results would the nurse evaluate as indicating additional testing for acute pancreatitis is likely?

  1. Question: What is the likely depth of injury in a patient with injuries described as moist, red, with some blister formation, and very painful?
  2. Question: Which of the following causes can lead to excessive burn edema and shock in the patient with injuries totaling more than 50% total body surface area (TBSA) burn?
  3. Question: A patient involved in a house fire is brought by ambulance to your emergency department. He is breathing spontaneously but appears agitated. He does not respond appropriately to questions. You assume he has inhaled carbon monoxide and is suffering from carbon monoxide (CO) poisoning. Your first action is to
  4. Question: A 68-year-old patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette and the couch ignited. What do you do first?
  5. Question: Which of the following conditions is most likely to result in increased ICP?
  6. Question: Which of the following medications is prescribed to decrease cerebral vasospasm?
  7. Question: Mr. P becomes flaccid with fixed and dilated pupils. His ICP falls from 65 mm Hg to 12 mm Hg. What should the nurse suspect is happening?
  8. Question: The patient has had a stroke or brain attack, believed to … ischemic in nature. The causes of an ischemic stroke are least likely to include which of the following?
  9. Question: A patient is being cared for in the CCU after a ruptured cerebral aneurysm. The nurse finds new onset of hemiparesis, slight lethargy, and complaints of diplopia. What complication does the nurse suspect?
  10. Question: A patient has been diagnosed with partial seizures. What behaviors during this patient’s seizures that would not occur during a generalized seizure does the nurse expect?

Critical Care – Nervous System Alterations
  1. Mr. Jones is in the intensive care unit following a motor vehicle crash. He is oriented to person, place, and time; can move all extremities; and follows commands. His pulse is 75 beats/min, his blood pressure is 120/70 mm Hg, and his respirations are 18 breaths/min and regular. Which assessment finding by the nurse best indicates the earliest finding that Mr. Jones’ intracranial pressure is increasing?
  2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. Her blood pressure is 144/90 mm Hg, and her mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?
  3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?
  4. The nurse is caring for a patient with a sustained ICP of 18 mm Hg for the past 30 minutes during the morning assessment and hygiene interventions. What is the best nursing action?
  5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action?
  6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15. One hour later the nurse assesses a GCS score of 3. What is the best nursing action?
  7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse indicates an appropriate response to therapy?
  8. The nurse is caring for a mechanically ventilated, brain injured patient. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?
  9. The nurse assesses a patient’s GCS score to .. 3. What is the best interpretation by the nurse? 10. The nurse is caring for a patient with a previous GCS score of 15. Nursing assessment 4 hours later notes a GCS score of 8. The nurse anticipates which action?
  10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?
  11. An awake, alert patient arrives at the ED following a fall down a flight of stairs. The physician suspects a basilar skull fracture. Which assessment findings should the nurse anticipate?
  12. While caring for a patient with a closed head injury, the nurse assesses the patient to … alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18/min, and a temperature of 102° F. To reduce the risk of increased ICP in this patient, what are the priority nursing actions?
  13. Ten days following surgery to clip an anterior communicating artery aneurysm, a transcranial Doppler detects cerebral vasospasm in a patient. The nurse anticipates which therapeutic intervention?
  14. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24/min, and 50 mL of urine via Foley catheter for the past 4 hours. What is the best action by the nurse?
  15. The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action?
  16. The nurse admits a patient to the ED with a suspected cervical spine injury. What is the priority nursing action?
  17. The nurse is preparing to monitor ICP with a fluid-filled monitoring system. The nurse understands which principles and/or components to … essential when implementing ICP monitoring (choose all that apply)?
  18. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient’s plan of care (choose all that apply)?

  • 9) Question: The nurse would expect to find which assessment finding for a patient with a tension pneumothorax?
  • 12) Immediate intervention for a sucking chest wound would include which of the following? (Select all that
  • apply.)
  • 17) Question: A nurse notes that a patient with a traumatic brain injury is having a rapid decline in level of consciousness. If
  • the nurse suspects, cerebral herniation, the most appropriate intervention would …. to:
  • 18) Question: Which of the following goals would receive highest priority for the patient with a cervical spine injury?
  • 19) Question: The mother of a patient just admitted with a spinal cord injury is asking if her son will … given steroids. Which of the following would …. an accurate way for the nurse to explain the role of steroids in treating spinal cord injuries?

Chapter 9 Care of the Patient Experiencing an Intracranial Dysfunction
  1. A patient with a head injury has a pO2 of 88 and a pCO2 of 58. The nurse realizes that which of the following will occur?
  2. When providing care to a patient who has increased intracranial pressure, the nurse should … concerned about which of the following patient findings because it is likely to result in an additional increase in intracranial pressure?
  3. A patientʹs mean arterial pressure (MAP) decreases to 50 while his ICP is 20. The nurse realizes that this drop in MAP is likely to lead to:
  4. The nurse is preparing to conduct an hourly neurological assessment on a patient in the intensive care unit. Which of the following would … included in this assessment?
  5. A patient in the neurological intensive care unit has an endotracheal tube. When the nurse does the hourly Glasgow Coma Scale assessment, what rating would this patient have for verbal response?
  6. The nurse is providing care to a patient with an intracranial pressure monitoring device. Which of the following should …. a priority when providing care to this patient?
  7. A patient is admitted with a fracture to the base of his skull. Which of the following might the nurse assess in this patient?
  8. A patient with a skull fracture was admitted unconscious, became conscious, and has since moved into unconsciousness again. This patient is demonstrating findings indicative of:
  9. 16) A ventilated patient with a head injury needs to … suctioned. Which of the following should the nurse do to limit problems related to suctioning?
  10. The nurse is planning care for a patient with increased intracranial pressure. Which of the following interventions would … appropriate for this patient?
  11. A patient comes into the emergency department with a fever, stiff neck, and change in mental status. On assessment it is learned that this patient also has a positive Kernigʹs sign. These findings suggest the patient:
  12. A patient with acute meningitis is receiving antibiotic therapy. The nurse realizes that another medication is used as adjuvant therapy. This medication is:
  13. The nurse is providing medication to a patient with status epilepticus. The medication of choice for this patient would:
  14. The nurse is preparing to administer a medication to help decrease the cerebral edema around a patientʹs brain tumor. This medication is most likely a(n):
  15. A patient is diagnosed with an intracerebral hemorrhage. Which of the following is the most common cause of this disorder?
  16. A patient tells the nurse that he is experiencing the ʺworst headacheʺ he has ever had. The nurse realizes that this description is often seen in:
  17. A patient is diagnosed with an ischemic stroke with the onset of symptoms within the last 2 hours. The best course of treatment for this patient would … to:
  18. A patient being treated with Coumadin experiences an intracerebral hemorrhage. Which of the following should … considered to aid in the care of this patient?
  19. A patient with portal hypertension with hepatic encephalopathy has been started on a protein restricted diet. The patient asks why he is only being allowed a certain amount of meat. The nurse should explain that a reduced protein diet will:
  20. A patient with esophageal varices is being treated with an esophageal tamponade (Blakemore) tube. Which of the following should receive the highest priority by the nurse taking care of the patient?
  21. A patient with bleeding esophageal varices is scheduled to receive a bolus followed by a continuous infusion of octreotide (Sandostatin). The nurse preparing the medication should:

Chapter 12 Care of the Patient with an Acute Gastrointestinal Bleed or Pancreatitis

1) A patient arrives in the emergency department with clinical manifestations consistent with a lower
gastrointestinal bleed. Which of the following should the nurse assess to determine the patientʹs stability? The patientʹs:
2) A nurse has completed a shift assessment on a patient who has been hospitalized for treatment of a lower gastrointestinal bleed. During the assessment the nurse notes that the patient has a capillary refill of 3 seconds, urinary output of 20 mL/hour, heart rate 88, and reports ʺfeeling tired.ʺ Which of these findings should the nurse report to the physician?
3) An ED nurse is advised that a patient with a serious gastrointestinal bleed is en route via ambulance and the physician intends to initiate aggressive intravenous therapy. Which of the following solutions should the nurse anticipate would …. utilized to manage this patientʹs condition?
4) A patient has been transferred to the nursing unit after stabilization in the emergency department for a gastrointestinal bleed. During the initial assessment, the nurse documents the following: Temperature 97.2°F, blood pressure 99/70 mm Hg, heart rate 74 bpm, capillary refill of 3 seconds, and oxygen saturation 94%. Four hours after admission to the unit, the nurse performs a second assessment and notes changes in the patientʹs condition. Which of the following changes is associated with complications from management of the condition? (Select all that apply.)
9) The nurse is preparing to administer pantoprazole (Protonix) to the patient. The patient asks the nurse for an explanation about the medication. Which of the following responses by the nurse is most appropriate?
12) A patient presents to the physicianʹs office with complaints consistent with pancreatitis. During the history and physical, the patient indicates feeling ill for the past week. Which of the following tests will likely provide the most definitive diagnosis of pancreatitis?
14) The patient with severe acute pancreatitis has had aggressive fluid replacement therapy. Which of the following assessment findings is indicative of successful management?
16) A patient with acute pancreatitis voices concerns that she will become addicted to the morphine prescribed for pain management. What response by the nurse is appropriate?
20) The ICU nurse is caring for a patient with an active gastrointestinal bleed. The patientʹs vitals are BP 80/50 mm Hg, heart rate of 102 bpm, respiratory rate of 24, and oxygen saturation of 80%. The patient is currently receiving a large bolus of normal saline. The physician states that the patient is to receive a transfusion. What component of blood does the nurse anticipate the physician to order?
21) The ICU nurse is reviewing the labs of a patient newly diagnosed with acute pancreatitis. Which lab values would the nurse expect to _ elevated?
22) The critical care nurse is admitting a patient with the diagnosis of acute pancreatitis. The nurse would expect to find the patient has a history of:
23) The nurse in the emergency department is assisting in the care of a patient with acute gastrointestinal bleeding. The patient has two large-bore IVs in place and is receiving 0.9% normal saline at 200 mL/hour in both IVs. What assessment findings would the nurse need to report to the physician immediately?


Chapter 13 Care of the Patient with Endocrine Disorders
  1. The patient has an admitting diagnosis of diabetic ketoacidosis. Which of the following problems causes the cascade to diabetic ketoacidosis (DKA)?
  2. The nurse is explaining the pathophysiology of hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which statement is most accurate? HHNS:
  3. When comparing diabetic ketoacidosis (DKA) to hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which statement is accurate?
  4. When differentiating between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which evaluation would ….. accurate?
  5. When planning care for the patient with diabetes in diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS), which goals would … included in the plan of care? (Select all that apply.)
  6. Which of the following nursing diagnoses would the nurse NOT use for the plan of care of a patient with diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
  7. What should the nurse assess before beginning insulin therapy in a newly admitted patient with diabetes with hyperglycemic hyperosmolar nonketotic syndrome (HHNS)?
  8. What is the rationale for decreasing serum glucose levels gradually (50-70 mg/dL/hour) in the presence of DKA/HHNS?
  9. Which of the following statements explains the reason for seizure precautions in a patient with diabetic ketoacidosis (DKA)? The patient may … at risk for seizures because:
  10. A patient rescued from a small house fire is brought to the emergency department. There is no burn injury to the patientʹs skin. Lab results show the only abnormality as a CO level of 22%. Which intervention would the nurse expect to implement?
  11. In assessing a first-degree burn, the nurse would consider which of the following assessments to … accurate?
  12. A patient comes to the emergency department with thermal burns to the left arm and shoulder. Which of the following findings requires immediate attention?
  13. A patient in ICU with a burn circling the left upper leg suddenly experiences excruciating pain, pallor in the lower extremity, and loss of pedal pulse. The nurse would immediately notify the physician that this patient has developed which of the following?
  14. An alert patient at the scene of an explosion has a respiratory rate of 24 breaths per minute, a faint stridor, and soot on his face. His heart rate is 120 beats per minute. Which of the following actions would … most appropriate to implement first?
  15. A middle-aged man who weighs 220 pounds incurred burns to 40% of his total body surface area. Using the Parkland formula, calculate his fluid resuscitation needs for the first 24 hours.
  16. A patient is complaining of increased pain to a third-degree burn covering the entire arm. The nurse suspects compartment syndrome. Which of the following treatments should the nurse immediate prepare in treating this?

  1. A patient has a spinal cord injury at C6-T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? (SATA)
  2. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury … categorized?
  3. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury …. categorized?
  4. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?
  5. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response?
  6. At what point after a burn injury should the nurse … most alert for the complication of hypokalemia?
  7. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?
  8. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?
  9. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?
  10. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action?
  11. On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?
  12. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action?
  13. All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately?
  14. The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?
  15. In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?
  16. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?
  17. The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action?
  18. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?
  19. Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the:

  1. Critically ill patients, especially those with trauma, burns, and sepsis should receive prophylaxis for:
  2. Esophageal varices occur as a result of:
  3. Which of the following assessments may … seen in the first 24 hours after acute gastrointestinal bleeding?
  4. The patient is admitted with acute pancreatitis. He is complaining of severe abdominal pain and nausea. He has hyperactive bowel sounds and abdominal distention. His temperature is 103° F and his blood pressure is 86/40 mm Hg. His WBC count is over 20,000/mL. He is jaundiced and the nurse notes a bluish discoloration around the umbilical area. Which of the following is indicated first in managing this patient?
  5. The patient with acute pancreatitis would likely have which of the following laboratory values?
  6. In patients with pancreatitis, which of the following laboratory results represents the physiological effects of fluid shifts?
  7. A priority treatment for patients with severe pancreatitis is:
  8. Your patient with ascites has the following nursing diagnoses. Which is your highest nursing priority to address?
  9. A patient with hepatic failure becomes increasingly confused. What is a likely diagnosis, and what test is done to confirm the diagnosis?

  1. Which of the following are treatments for hepatic encephalopathy (choose all that apply)?
  2. Collaborative management of the patient with acute pancreatitis includes which of the following (choose all that apply)?
  3. The patient is admitted with esophageal varices. Which of the following medications are considered first line-medications in the treatment of varices (choose all that apply)?

  1. Why are narcotics given intravenously to manage pain during initial management of the patient with burns?
  2. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient … intubated at the scene. What is the reasoning for the immediate intubation?
  3. You are caring for a patient with circumferential burns on his right leg. You note that the capillary refill in his right big toenail is not as brisk as it was 2 hours ago and that the pedal and tibial pulses are only noted by Doppler. What is your best plan of action?
  4. Silver is an ingredient in many burn dressings. It is used because it:
  5. Patients with electrical injury are at a high risk for renal failure secondary to:
  6. Which of the following statements about the pain management of a burn victim are true (choose all that apply)?

  1. Which of the following interventions would not … appropriate for a patient who is admitted with a suspected basilar skull fracture?
  2. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by:
  3. A patient with multiple traumatic injuries receives fluid to maintain a systolic blood pressure at 90 mm Hg. Despite the administration of 3 L of crystalloids, his systolic blood pressure is in the 80s and is very labile. A focused assessment with sonography for trauma (FAST) test identifies peritoneal hemorrhage. What action is anticipated at this time?
  4. You are caring for a patient who sustained rib fractures after hitting the steering wheel of his car. He is spontaneously breathing and receiving oxygen via a face mask. His oxygen saturation is 95%. During your assessment, the oxygen saturation drops to 80%. The patient’s blood pressure has dropped from 128/76 mm Hg to 84/50 mm Hg. You do not auscultate any breath sounds on the left side of the chest. You notify the physician and anticipate:
  5. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?
  6. Which of the following interventions is a strategy to prevent fat embolism syndrome?
  7. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of:
  8. Fluid resuscitation is an important component of managing the trauma patient. Which of the following statements are true regarding the care of a trauma patient (choose all that apply)?
  9. During your assessment of a patient after a motor vehicle crash, which of the following assessments would increase your suspicion of a basilar skull fracture (choose all that apply)?
  10. Which of the following patients would require greater amounts of fluid resuscitation to prevent renal failure associated with rhabdomyolysis (choose all that apply)?

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