NURS NURSINGcritical care exam

NURS NURSINGcritical care exam A college heath nurse interprets the peak expiratory flow rate for a student who has asthma and fluids that student is in the yellow zone of his asthma action plan. The nurse should base ...

NURS NURSINGcritical care exam A college heath nurse interprets the peak expiratory flow rate for a student who has asthma and fluids that student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (select all that apply.) A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following? A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A nurse is assessing the respiratory pattern of an older adult client who is receiving end of life care. Which of the following assessment findings should the nurse identify as Cheyne-stokes respirations? A nurse is caring for a client who is receiving mechanical ventilation via tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? A nurse is caring for a client following extubation of her endotracheal tube 10 min ago. Which of the followings should the nurse report to the provider immediately? A nurse in an emergency department is planning care for a client who has a flail chest on the right side following a MVA accident. Which of the following should the nurse plan to take? A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The clients heart rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the client requires? A nurse is assessing a client immedietaly after the provider removes the clients endotracheal tube. Which of the following findings should the nurse report to the provider? Alternating periods of hyperventilation and apnea is Cheyne-stokes breathing. A nurse understands that there are three ways to decrease ventilator-assisted pneumonia called a “ventilator bundle”. Which of the following three nursing actions are included in the clients care bundle? a. Hand hygiene, oral care, and HOB elevation A nurse is caring for a client who has respiratory failure, is intubated, and is mechanically ventilated. The client pulls out the edotrachial tube. Which of the following is the priority action? a. Ensure the airway is open A nurse is assessing a clients wife how to take a blood pressure. Which of the following actions by the wife indicates a need for further instructions? a. Place the clients arm above the level of the heart A nurse is monitoring a post-operative client who is unable to respond to questions. Which of the following behviors should the nurse recognize as an indicator of pain? (select all) a. Resltlessness b. Grimacing c. Clenching A nurse is assisting with the discharge plan of a client who has a permanent tracheostomy. The nurse should verify the availability of which of the following equipment? (select all) a. Oxygen b. Suction machine c. Replacement canula A nurse is giving shift report using SBAR to the oncoming nurse on a client who has traumatic brain injury. When reporting information about the client, which of the following are included in the situation of SBAR? a. History of the injury SBAR examples: 1. Gaslow coma scales falls under assessment 2. Intercranial pressure readings falls under assessment 3. Medication that is needed falls under recommendations A nurse is monitoring the cardiac output of a client who has left sided heart failure using pulse pressure analysis. Which of the following findings can compromise the reading? a. The client is experiencing premature atrial contractions. A nurse in the ICU is providing teaching for a client proior to the removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? a. Avoid speaking for long periods A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the clients family about organ donation. The clients spouce states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? a. What do you think your spouse would have wants? A client is performing nasotrachial suctioning for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? a. Preoxygenate the clients with 100% oxygen for up to 3 min. A charge nurse has access to the faciliteies electronic records. It is appropriate for the charge nurse to share her personal password with whom? a. No one A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients? a. A client who has terminal cancer and needs assistance with pain management. A nurse is planning to delegate tasks to a LPN. Which of the following entitles is important for the nurse to understand when delegating to a LPN? a. The state nurse practice act A nurse receives a wrong medication. The nurse who made the medication error should take which of the following actions first? a. Assess the client A charge nurse is observing the actions of an assistive persoel (AP). Which of the following actions by the AP is appropriate? a. Logging off the computer after entering a clients intake and output A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition? a. Hypoxemia or cyanosis A nurse enters a clients room and finds the clients pulseless. The family has requested a DNR order from the provider, but he has not written the order yet. Which of the following actions should the nurse take first? a. Call the emergency response team A nurse is assessing a client for hypoxemia during an athsma attack. Which of the following manifestations should the nurse expect? a. Agitation A nurse is evaluating the CVP of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make? a. Hypovolemia (A low cvp indicates right ventricular preload, which can be seen in clients who are experiencing hypovolemia, excessive blood loss, or overdiuressis) A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is effective? a. Increased urinary output (Doubtamine is administered to clients who have heart failure to improve their hemodynamic status.) A nurse in a ICU caring for a client who is post-op following a right pneumonectomy. After extubation from the ventilator. Which of the following positions should the client be placed? a. Semi-fowlers A nurse is preparing a client for transfer to the ICU for a placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions? a. Hemodynamic status A nurse is caring for a client who has a new diagnosis of CKD. Which of the following statements should the nurse identify as an indication of anticipatory grieving? a. I just cant believe that this dialysis is going to ruin my whole life. (Anger and fear of the upcoming loss) A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (select all) a. Elevate the hob 30 b. Administer pantoprazole as prescribed c. Reposition the endotracheal tube opposite of the mouth daily A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advanced directives. Which of the following statements by the client indicates a need for clarification? A. I have to choose a family member as my health proxy. (the client needs to choose someone they can trust for end of life care, should be a family member, but doesn’t have to be a family member.) A nurse in the emergency department is caring for a client who has compression fracture of a spinal vertebra. During transport to the facility, the client was medicated with intravenous morphine. On arrival, the neurosurgeon determined determined urgent surgical intervention is indicated for the fracture. Staff members have been unable to reach the clients family. Which of the following actions should the nurse anticipate the neurosurgeon taking? a. Invoking implied consent A nurse is admitted to the emergency room with a respiratory rate of 7/min. ABG reveals the following values. Which of the following is an appropriate analysis of the ABG’s? a. Respiratory acidsis A nurse is caring for a female client in the ER who reports SOB and pain in the lung area. She states that she started taking birth control 3 weeks ago and that she smokes. (the question too long to type) a. Administer oxygen via face mask A nurse is planning care for a client who as acute respiratory distress syndrome ARDS. Which of the following should the nurse include in the plan? a. Place in prone position A nurse in a dialysis center caring for a client who has a new diagnosis of ESKD. When he arrives he tells the nurse I decided to come today, but “I am not sure if I need to come back after today.” (too long to type) a. Denial phase of grieving A nurse is caring for an older adult client who was alert and orientated at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the clients safety needs? a. Move the client to a room closer to the nursing station A nurse is monitoring the pulomary artery wedge pressure PAWP for a client. The nurse should identify that a reading of 15 mm Hg is an identification of which of the following conditions? a. Mitral regurgitation ( hemodynamic monitoring allows the nurse to monitor the pressure within the heart and the great vessels. The PAWP reflects left atrial pressure.) A nurse is caring for a client who has meningitis, a temperature of 93.7 C (103.5F), and is prescribed a hypothermia blanket, while using this therapy the nurse must carefully observe for? a. Shivering A nurse in an ER is assessing a client who was bitten by on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take? a. Obtain a prescription for the appropriate anti-venom A nurse enters a clients room and finds him unresponsive. After notifying the rapid response team, which of the following actions should the nurse take first? a. Check for a carotid pulse A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following should the nurse take? a. Place the extremity in a dependent position A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicate that the medicine is effective? a. Increased urine output (shows their hemodynamic status is improved) A nurse enters an adult’s room and finds him unresponsive. After determining that the client is not breathing and does not have a pulse, which of the following actions should the nurse take first? a. Summon the code team A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? a. Administer the abdominal thrust maneuver Life threatening emergency steps 1. Open airway using jaw maneuver 2. Determine effectiveness of ventilator 3. Establish IV access 4. Perform gaslows coma scale 5. Remove clothing for a thorough assessment A nurse is teaching a group of clients about emergency care for a snake bite. Which of the following information should the nurse include in the teaching? a. Immobilize the affected area with a splint A nurse is assessing a client while suctioning the client tracheostomy tube. Which of the following indicates the client is experiencing hypoxia? a. Increased heart rate If patient has an extubation from the ventilator place the client in semi-fowlers position. A nurse is receiving a transfer report from a client who has had a head injury. The client has a Gaslows Coma Scale score of 3 for opening eyes, 5 for best verbal response, and 5 for best motor response. Which of the following is a conclusion of this data? a. The client opens his eyes when spoken to A nurse is assessing a client who has a 8 gaslows coma scale to evaluate LOC. Which of the following statements accurately describes the score? a. Indicates the need for total nursing care A client with right ventricular has a central venous pressure monitoring catheter in place (CVP). The nurse should expect which of the CVP measurements? a. 7 mm HG (a CVP above 6 indicates a reduced right ventricular preload, typically from hypovolemia) A nurse is caring for a client who is immedietly postoperative following a thoracic surgery. The nurse administers a narcotic analgesic to the client frequently for pain. Which of the following should the nurse recognize as the primary reason for this action? a. It facilitates the clients deep breathing A nurse is in a cardiac care unit is caring for a client with acute heart failure. Which of the findings should the nurse expect? a. Elevated CVP pressure A nurse is caring for a client who has shallow rapid respirations, paradoxal pulse, CVP 4 cm H20, BP 90/50 mm Hg, skin cold and pale, and urinary output 55ml over the last 2 hours. From these findings, the nurse concludes that he may be developing which of the following? a. Hypovolemic shock A nurse in the emergency department is implementing a plan of care for a conscious patient who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement? (select all) a. Assess adequacy of RR b. Obtain vitals c. Stabilize head and neck d. Assess for visceral damage A nurse is responding to a client who has esophageal varicies from portal hypertension. The client has IV fluids infusing and has a blood pressure of 68/48 after vomiting up 500ml of blood. Which of the following actions may the nurse plan to do first? a. Increase IV fluid rate A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG? a. Atrial fibrillation The nurse is caring for a client who just had cardiac catherization. The post procedure nursing care of plan for this client should include which of the following nursing interventions? a. Have the client rest in bed for 2-6 hours (Clients who had manual or mechanical pressure after catheter removal require 6hr of bed rest.) A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse expect? a. Oluguria A nurse is caring for a client who has quadriplegia from a spinal cord injury who reports having a “severe headache”. Upon assessment the nurse obtains a blood pressure reading of 210/108mm Hg. Suspecting that the client is experiencing autonomic dysresflexia. Which of the following actions should the nurse perform first? a. Place the client in high-fowlers position (this will help decrease the clients b/p) A nurse in an ICU unit is caring for a client with acute respiratory distress syndrome ARDS and is receiving mechanical venetaltion via and endotracheal tube. The provider plans to extubate her within the next 24 hours. Which of the following is an important criteria when extubating this client? a. Adequate tidal volume without positive pressure (typical weaning criteria include the ability to maintain adequate vital capacity, tidal volume, and minute ventilation without positive pressure or any othe manually assisted breaths) A nurse is dining at a restaurant when a woman begins to scream that her husband is choking. Which of the following should the nurse do first? a. Ask the victim can he speak Hypovolemic shock indication – HR suddently increases ex: ( goes from 88-110)