HESI RN CRITICAL CARE V2 EXAM UPDATE 2022 LATEST UPDATE

HESI RN CRITICAL CARE V2 EXAM UPDATE 2022 LATEST UPDATE The triage nurse is assessing a victim of a stab wound. According to the paramedics, the victim was stabbed by a male attacker. The knife blade is 6 inches (7.2 cm) in length and 1 inch (2.5 cm) in width. The "point of entry" of the stab wound is two inches above and left of the victim's xiphoid process. Which vital organ(s) are at an increased risk of being in the direct path of injury? (Select all that apply.) . Heart. Correct . Lungs. Correct . Stomach. . Intestines. . Diaphragm. Correct Stab wounds are low velocity wounds that the path of injury to the underlying organs is determined by the direction of the path of the impaled knife and the length and width of the blade. The gender of the attacker is important to know because females tend to stab in a downward direction (trajectory) and males tend to stab in an upward direction (trajectory). A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first? . Metabolic panel with electrolytes. . Complete blood count. . Liver function test. . Blood culture. Correct The client is demonstrating clinical signs and symptoms of infective endocarditis. The key in treating infective endocarditis is identifying the causative infectious agent and treat with the appropriate antibiotics. Blood cultures should identify which bacteria is the offending bacteria causing the endocarditis. What distinguishes infective endocarditis from the other conditions listed is the presence of the heart failure symptoms of edema, and S3 and S4 heart sounds According to the paramedic's report, the victim of a motor vehicle collision was sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped at a traffic light when the vehicle was hit on the left side by another vehicle traveling at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and achiness on (L) side of thorax and body. The significant assessment findings include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding present upon palpation; skin is diaphoretic and extremities cool to touch, capillary refill +4 in extremities, and bruising is present in the (L) flank area and progresses towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. Which potential injuries should the triage nurse assess? (Select all that apply.) . Flailed ribs. . Fractured liver. Correct . Ruptured spleen. Correct . Cardiac tamponade. . Tension pneumothorax. The assessment priorities are based on the report of the mechanism of injury which indicated that the majority of point of impact from the motor vehicle collision was on the client's left side of the body. Along with the physical assessment and vital signs findings the client is displaying signs and symptoms indicating blunt trauma to the liver and the spleen. The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter. How should the nurse interpret this blood gas? . Respiratory acidosis. . Respiratory alkalosis. Correct . Metabolic acidosis. . Metabolic alkalosis. The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In respiratory alkalosis, the pH and HCO3 is increased and the CO2 is decreased. The nurse is analyzing an arterial blood gas of a client who is mechanical ventilated. The ABG results are pH- 7.42; paCO 2- 50 mmHg; HCO 3- 30mEq/liter. How should the nurse interpret this blood gas? . Fully compensated respiratory acidosis. Correct . Fully compensated respiratory alkalosis. . Fully compensated metabolic acidosis. . Fully compensated metabolic alkalosis. The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In fully compensated respiratory acidosis the pH is within normal limits because compensation has occurred. In compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the HCO3 is elevated to compensate for the paCO2. The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? . Change in level of consciousness. Correct . Increase in urinary output. . Onset of Kussmaul respirations. . Decrease in serum potassium level. As blood sugar rises (norm 70 to 110 mg/dl or 3.9-6.1 mmol/L SI), a client with hyperglycemia becomes dehydrated due to excessive urine output that causes a drop in blood volume and cerebral hypoperfusion. A change in the client's level of consciousness should be reported to the healthcare provider immediately. Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 02 The nurse is caring for a client in the critical care unit who has a pituitary tumor and subsequent diabetes insipidus (DI). Which finding indicates the need to place the client on seizure precautions? . Sodium 155 mEq/L or mmol/L. Correct . Arterial pH 7.42. . Calcium 9.5 mEq/L (4.75 mmol/L) . Potassium 4.9 mEq/L or mmol/L. Clients with diabetes insipidus (DI) experience increased urinary output due to decreased antidiuretic hormone (ADH), which may cause dehydration and high serum sodium levels (norm 136 to 145 mEq/L or 136 to 145 mmol/L (SI units). Hypernatremia places the client at risk for seizures. Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 00 A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or mmol/L. Which protocol prescription should the nurse implement first? . Obtain serum sodium levels every 4 hours. Correct . Provide oral sodium chloride supplements. . Monitor fluid restriction and document hourly intake and output. . Initiate normal saline IV at 100 mL/hour. A client diagnosed with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) can experience sodium levels that are dangerously below the norm range of 136 to 145 mEq/L or 136 to 145 mmol/L (SI units). The first action is to evaluate the client's serum sodium levels to determine fluid and electrolyte correction with isotonic saline based on the client's status of hypotonic hyponatremia. Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 98 The nurse is caring for a client in the critical care unit who has type 2 diabetes mellitus and is admitted with hyperglycemic hyperosmolar syndrome (HHS). The health care provider prescribes an insulin drip of 0.1 unit/kg per hour based on a current blood glucose level of 670 mg/dL (35.3 mmol/L) . Which intervention should the nurse perform during this infusion? . Obtain blood glucose levels hourly. Correct . Give potassium chloride 40 mEq per secondary infusion. . Infuse Dextrose 5% with 0.45% NaCl (D 5 1/2 NS). . Initiate a 2,000 calorie diabetic diet. Administering an insulin drip for a client with hyperglycemic hyperosmolar syndrome (HHS) should cause blood glucose levels to drop 50 to 70 mg/dL per hour. The nurse should perform hourly blood glucose monitoring to evaluate the effectiveness of the insulin drip. Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 96 The nurse is caring for a client who is demonstrating signs of impending death. The family is experiencing emotional distress as the client's condition declines. Which information should the nurse provide the family to facilitate the process? . Encourage the family to give the client permission to die. Correct . Revoke the "do not resuscitate" advanced directive. . Send the family to an area to seek spiritual comfort. . Give the client pain medication during the end of life hours. Family members often have difficulty letting go of a dying family member. The nurse should encourage the family to give the client permission to die. Awarded 1.0 points out of 1.0 possible points. 11. 11.ID: 94 The nurse is caring for a client with severe sepsis related to a ruptured appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse observes respirations that are uneven and labored. Arterial blood gas (ABG) results are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the nurse? . Increased pulmonary secretions. . Intercostal muscle retraction. Correct . Decreased breath sounds. . Bronchovesicular breath sounds. Intercostal muscle retraction is a critical sign of respiratory muscle fatigue that is likely to lead to acute respiratory failure, requiringintubation withmechanical ventilation. The ABG results reveal respiratory alkalosis as evidenced by an increased pH and decreased PaCO2 with a normal HCO3. Awarded 1.0 points out of 1.0 possible points. 12. 12.ID: 92 A client who experienced an intracranial hemorrhage is receiving cistracurium to induce a pharmacological state of paralysis. Which intervention should the nurse implement during the therapeutic paralysis? . Administer a sedating medication. Correct . Monitor the client for seizures. . Titrate the drug dose to prevent addiction. . Check the client's gag reflex every 2 hours.. Cisatracurium is a paralytic agent that does not provide sedation or pain relief. The nurse should give a sedative to provide comfort to the client who is unable to move or physically response to pain or anxiety related to the induced paralysis. Awarded 1.0 points out of 1.0 possible points. 13. 13.ID: 90 A client returns to the intensive care unit (ICU) after having a permanent pacemaker inserted. Which finding should the nurse observe for during the immediate hours after insertion? . Beck's triad. Correct . Burns around the site . Hypothermia . Cardiac arrhythmia. Pacemakers and implantable defibrillators both require wires to be placed into the heart muscle and can cause bleeding into the pericardial sac which causes a high risk for cardiac tamponade. Signs of Beck's triad include low arterial blood pressure, distended neck veins, and distant, muffled heart sounds and are indicative of cardiac tamponade. Awarded 1.0 points out of 1.0 possible points. 14. 14.ID: 88 A client with a demand pacemaker has a telemetry tracing with a pacing spike but no corresponding QRS complex. The client's myocardium is illiciting a QRS after a delay of several seconds. Which telemetry interpretation should the nurse conclude? . Loss of capture. Correct . Ventricular fibrillation. . Capture from an ectopic focus. . A normal finding with a demand pacer. If the pacemaker is a demand pacer, a native QRS will be present and the pacer will not fire. If the ventricular automaticity is delayed, the pacemaker will fire. If there is a pacemaker spike that does not producing a QRS, the assessment of the pacemaker is failure to capture. Awarded 1.0 points out of 1.0 possible points. 15. 15.ID: 86 A client who arrived in the emergency department is experiencing status epilepticus. Which medication should the nurse administer immediately? . Lorazepam IV. Correct . Phenytoin PO. . Morphine IV. . Levetiracetim PO. A client who is experiencing status epilepticus requires a CNS depressant to stop continuous seizures that can be life threatening. The nurse should administer lorazepam IV for rapid therapeutic action. Awarded 1.0 points out of 1.0 possible points. 16. 16.ID: 84 A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? . Call the rapid response team for emergency assistance. Correct . Encourage the client to relax as respiratory effort eases. . Document the findings and monitor the client hourly. . Call respiratory therapy to provide cool mist oxygen per mask. A client in the immediate postoperative period after a thyroidectomy can have bleeding into the soft tissue around the incision site that obstructs the airway and causes an inspiratory stridor and laryngospasm. The client is at risk for a life-threatening event, and the nurse should first call the rapid response team for emergency management. Awarded 1.0 points out of 1.0 possible points. 17. 17.ID: 82 A client with chronic kidney disease (CKD) is admitted for strict fluid restriction. Which assessment finding requires additional nursing action? . Crackles in the lungs. Correct . Decreased serum creatinine level. . Increased weakness. . Increase in serum potassium. In CKD, strict fluid restriction is vital to minimize the progression of fluid overload. Fluid restriction that is insufficient to reduce circulatory volume overload can manifest as pulmonary crackles or coarse rales in the lungs that compromises oxygenation and requires additional nursing action. Awarded 1.0 points out of 1.0 possible points. 18. 18.ID: 80 A client with diabetic ketoacidosis is admitted to the intensive care unit and is manifesting respirations that are rapid and deep. Which descriptive term should the nurse use to document the client's breathing pattern? . Kussmaul respirations. Correct . Cheyne stokes respirations. . Apnea. . Orthopnea. Metabolic acidosis in DKA causes compensatory responses to increase the blood pH which results in Kussmaul respiration in a effort to blow off CO2 and adjust blood pH. The nurse should document the client's respiratory rate and Kussmaul respiratory pattern. Awarded 1.0 points out of 1.0 possible points. 19. 19.ID: 78 A client in the intensive care unit receives a STAT prescription for mannitol IV for cerebral edema post closed head injury. Which action should the nurse implement when preparing to administer the medication? . Use a filtered needle to draw up the medication and an in-line filter during infusion. Correct . Place atropine at bedside for use if the client has bradycardia during administration. . Hyperventilate the client prior to administration to decrease intracranial pressure. . Stop all sedation while mannitol is being administered per secondary infusion. Mannitol is a large sugar molecule and is a crystal at room temperature. A needle filter to draw up mannitol or an in- line filter should be used for the administration of mannitol. Awarded 1.0 points out of 1.0 possible points. 20. 20.ID: 76 The nurse reports findings to the healthcare provider for a client who is admitted to the intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse completes the report using the SBAR format, which statement best supports the nurse's reason for calling the healthcare provider? . Prescription for an additional respiratory treatment. Correct . Admission today with difficulty breathing. . History of COPD. . Presence of expiratory wheezes in the lower lobes. The SBAR reporting format uses client information that includes the Situation, Background, Assessment, Recommendation. The nurse should complete the report with a recommendation, such as a prescription for an additional breathing treatment. Awarded 1.0 points out of 1.0 possible points. 21. 21.ID: 74 The nurse is caring for a client who is receiving mechanical ventilation for acute respiratory distress syndrome (ARDS). The ventilator is alarming continuously indicating high peak pressures for the client. Which pathologic changes in the client is causing the ventilator alarms? . Decreased lung compliance. Correct . Increased respiratory rate. . Low volume of expired air. . High tidal volumes. The inflammatory response in the ARDS causes changes in lung compliance. ARDS causes a decreased lung compliance, or stiffer lung, which causes the high peak airway pressures and frequent ventilator alarms. Awarded 1.0 points out of 1.0 possible points. 22. 22.ID: 72 A client is trying to talk with an endotracheal tube in place for mechanical ventilation. Which method is most readily available for the nurse to provide the client for communication? . Communication board or paper pencil to write messages. Correct . Hand gestures that explain what the client wants to say. . Communication by interrupting ventilator for short periods of time. . Touch screen figures or text to voice communication computers. A communication strategy for a client on a ventilator in ICU should be brief, minimally fatiguing, immediately available for use by client and staff and does not compromise the client's respiratory management. Although augmentative alternative communication (AAC) electronic devices are options, the most readily available tool is a communication board, paper pencil, or a letter chart to spell words and messages. Awarded 1.0 points out of 1.0 possible points. 23. 23.ID: 70 The nurse is preparing to suction an intubated client's endotracheal tube (ETT). Which action should the nurse do first prior to suctioning the client's ETT? . Instill sterile normal saline into the ETT. . Hyperoxygenate with 100% FiO 2 for 30 seconds. Correct . Increase the respiratory rate settings on the ventilator. . Adjust the suction apparatus to low intermittent setting. Prior to suctioning an ventilated client's endotracheal tube (ETT), the nurse should hyperoxygenate the client with 100% FiO2 . Do not routinely place sterile normal saline into the ETT prior to suctioning, unless indicated to loosen up mucus plugs or secretions. Studies have shown the use of routine instillation of normal saline prior to suctioning can cause oxygen desaturation and backwash potentially infectious agents deeper into the lungs, increased intracranial pressure, and cause excessive coughing and bronchospasm. Awarded 1.0 points out of 1.0 possible points. 24. 24.ID: 68 Which intervention should the nurse perform prior to the removal of an endotracheal tube from a client? . Suction the endotracheal tube thoroughly. Correct . Pre-medicate the client with pain medication. . Increase the FiO 2 for a minimum of 15 minutes. . Provide positive pressure ventilation prior to extubation. Prior to extubation of a client and removing the endotracheal tube (ETT), the nurse should ensure good airway clearance by suctioning out the ETT thoroughly. Awarded 1.0 points out of 1.0 possible points. 25. 25.ID: 66 A client who is critically ill requests to receive the Sacrament of the Anointing of the Sick. Which clergy member should the nurse contact? . Rabbi. . Priest. Correct . Sharma. . Ayatollah. In the Roman Catholic religion, the "Sacrament of the Anointing of the Sick" is a ritual that is performed on followers when they are seriously ill or dying. In the Roman Catholic community and this is one of the seven sacraments followers received throughout their life. The sacrament is a source of grace and strength for the church member and a sign of God's presence. This sacrament can only be administered by an ordained Roman Catholic priest. Awarded 1.0 points out of 1.0 possible points. 26. 26.ID: 64 A client placed on hospice care is admitted for palliative radiation treatments to the neck. Which assessment should the nurse identify as a priority? . Pain assessment. Correct . Respiratory assessment. . Cardiovascular assessment. . Integumentary assessment. Frequent pain assessments are the most important interventions in delivering end-of-life care for a client. The goal of end-of-life treatment is to manage a client's symptoms to provide a pain-free and stress-free environment to improve a client's quality of life. Awarded 1.0 points out of 1.0 possible points. 27. 27.ID: 62 A client diagnosed with heart failure has hemodynamic monitoring in place. Which actions should the nurse perform to obtain accurate readings from the hemodynamic monitor? (Select all that apply.) . Measure the pressure readings in between the client's breaths. Correct . Place the transducer at the client's atria level and pulmonary artery level. Correct . Maintain a maximum pressure of 100 mmHg for the flush line continuously. . Change out the intravenous solutions infusing via central lines every 12 hours. . Calibrate the hemodynamic monitor by zeroing the transducer at the start of each shift. Correct To ensure accurate hemodynamic pressure readings, the nurse should place the transducer at the client's atria level and pulmonary artery level. The nurse also should calibrate the transducer to "0" mmHg at the beginning of each shift, and measure the pressure readings in between the client's breaths. Awarded 0.99 points out of 0.99 possible points. 28. 28.ID: 60 The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The ABG results are pH - 7.17; paCO2 - 70 mmHg; HCO3 - 30 mEq/liter. How should the nurse interpret this blood gas? . Respiratory acidosis. Correct . Respiratory alkalosis. . Metabolic acidosis. . Metabolic alkalosis. The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In respiratory acidosis, the pH is decreased and the CO2 is increased. Awarded 1.0 points out of 1.0 possible points. 29. 29.ID: 58 The nurse is preparing a client with acute kidney injury (AKI) f or hemodialysis in the intensive care unit (ICU). Which assessment should the nurse obtain prior to beginning the procedure? . Weight using the ICU bed scales. Correct . Arteriovenous (AV) fistula site. . Capillary refill. . Urine color and clarity. Hemodialysis filters excess fluid and toxins from the blood when renal function is severely diminished. The nurse should assess the client's weight before and after dialysis to monitor the amount of fluid removed during the procedure. Awarded 1.0 points out of 1.0 possible points. 30. 30.ID: 56 The nurse is caring for a client who is 4 days postoperative for abdominal surgery. The client reports acute onset of difficulty breathing. The nurse obtains the vital signs which include a heart rate of 120 beats/minute and respirations of 35 breaths/minute. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? . D-dimer blood test. Correct . Coagulation time and platelet count. . Echocardiogram. . Mass spectrometry. Pulmonary embolism (PE) is a postoperative complication due to a peripheral thrombus breaking off and becoming embolic and lodging in the lung microcirculation causing acute difficulty breathing, tachypnea, and tachycardia. The nurse should prepare the client for a D-dimer test which measures the levels of a substance in the bloodstream when a blood clot breaks down. Awarded 1.0 points out of 1.0 possible points. 31. 31.ID: 54 A chest X-ray is prescribed for a client with possible adult respiratory distress syndrome (ARDS). Which radiographic finding represents the pathological processes of pulmonary edema and consolidation of the lungs as ARDS progresses ? . White-out appearance. Correct . Infiltrates. . Calcified cavities. . Multiple nodules. As adult respiratory distress syndrome (ARDS) progresses, a "white-out" appearance on the chest X-ray indicates opacity of pulmonary edema and density of lung consolidation. Awarded 1.0 points out of 1.0 possible points. 32. 32.ID: 52 Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to water seal. The client is using the incentive spirometer hourly while awake. Which assessment finding warrants intervention by the nurse? . Serosanguineous fluid in collection container. . Fluid fluctuation in tubing with respirations. . Water seal level2 cm below the water seal fill line. Correct . Reportof chest tube insertion site tenderness. If the water seal level is above or below the prescribed water seal line, it will increase the client's work of breathing which will increase the risk of a pneumothorax. Awarded 1.0 points out of 1.0 possible points. 33. 33.ID: 50 A client is admitted to the intensive care unit with urosepsis. Which findings should the nurse report to the healthcare who suspects the client is at risk systemic inflammatory response syndrome (SIRS)? . Temperature 102 F (38.9 C), PaCO 2 28, and apical pulse 100 beats per minute. Correct . Temperature 101 F (38.3 C), PaCO 2 55, apical pulse 80 beats per minute. . Temperature 98.7 F (37.1 C), white blood cell count 5.5 cells/mm 3, respiratory rate 20 breaths per minute. . Temperature 100.2 F (37.9 C), white blood cell count 10.0 cells/mm 3, respiratory rate 18 breaths per minute. Diagnositic Criteria for systemic inflammatory response syndrome (SIRS) includes two out of four criteria are present in abnormal vital signs, arterial blood gases, and white blood cell counts. The nurse should notify the healthcare provider about the client's findings of temperature 102oF (38.9oC), PaCO2 28, and apical pulse 100 beats/minute. Awarded 1.0 points out of 1.0 possible points. 34. 34.ID: 48 The nurse is caring for a client admitted to the intensive care unit with a traumatic brain injury from a motor vehicle collision. The client is experiencing increased intracranial pressure (ICP). The healthcare provider explains to the family that the client needs to go to surgery for decompressive craniectomy. Which information should the nurse explain to the client? . An over-lying cranial bone flap is removed to allow swelling brain tissue to expand. Correct . The procedure uses a magnetic resonce imaging-guided laser ablation. . An opening into the skull is made to remove damage tissue. . A burr hole is drilled through the cranil bones to evacuate blood. The nurse should explain to the client that a decompressive craniectomy removes an overlying bone flap to allow for underlying brain tissue to expand and swell without being compressed by the cranial vault. Awarded 1.0 points out of 1.0 possible points. 35. 35.ID: 46 The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries sustained in a motor vehicle collision. The client has a Glasgow Coma Score of 6. Which intervention should the nurse prepare for the client? . Intubation with mechanical ventilation. Correct . Nasogastric tube placement. . Advanced cardiac life support. . 12-lead electrocardiogram (ECG). A Glasgow Coma Scale (GCS) is used to determine the level of consciousness of a client with traumatic brain injury. This client has multiple traumatic injuries and a GCS score of 6 may indicate the need for mechanical ventilation support. The nurse should prepare the client for intubation and mechanical ventilation. Awarded 1.0 points out of 1.0 possible points. 36. 36.ID: 42 The nurse is caring for a client admitted to the surgical intensive care unit (SICU) on the first postoperative day after a kidney transplantation. Which intervention should the nurse include in the plan of care to prevent hypovolemia? . Give IV fluids on a 1:1 ratio from output. Correct . Administer loop diuretics. . Increase sodium intake. . Provide sports drinks for hydration. The transplanted kidney will produce large amounts of urine if the transplanted organ works well, which means the client is at risk for hypovolemia. The plan of care should include protocol prescriptions to replace fluid volume at a 1:1 ratio based on output. Awarded 1.0 points out of 1.0 possible points. 37. 37.ID: 44 The health care provider has determined that a client has irreversible brain damage with subsequent brain death. Organ donation is discussed with the family. Which action should the nurse take prior to contacting the organ procurement organization (OPO)? . Obtain informed consent. Correct . Disconnect the ventilator. . Remove all jewelry. . Contact the medical examiner. When brain death has been determined by the healthcare provider, the organ donation process may be initiated. The nurse should obtain signed informed consent from the family prior to contacting the organ procurement organization (OPO). Awarded 1.0 points out of 1.0 possible points. 38. 38.ID: 40 Two days after surgical repair of an aortic abdominal aneurysm (AAA), the cardiac monitor is displaying sinus bradycardia and blood pressure 82/40 mmHg. Nitroprusside is infusing at 10 mcg/kg/min and 0.9% sodium chloride at 100 mL/hr. Which intervention should the nurse implement first? . Place the client's head flat and elevate the feet. . Stop the nitroprusside infusion. Correct . Rapidly administer 1 liter intravenous fluids. . Increase the 0.9% sodium chloride to 150 mL/hr. The incisional anastomosis is leaking, causing a critical drop in blood pressure and bradycardia. The medication used to control the client's blood pressure, nitroprusside, should be stopped immediately. This client will then need volume and will need to be quickly returned to surgery for repair. Awarded 1.0 points out of 1.0 possible points. 39. 39.ID: 38 The nurse is analyzing an arterial blood gas of a client who is mechanically ventilated. The ABG results are pH - 7.37; paCO2 - 30 mmHg; HCO3 - 28mEq/liter. Which should the nurse recognize as a cause of these findings? . Decreased respiratory rate causing respiratory acidosis. . Decreased respiratory rate causing respiratory alkalosis. . Diarrhea with a fully compensated metabolic acidosis. . Nasogastric suction with a fully compensated metabolic alkalosis. Correct The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In fully compensated respiratory acidosis the pH is within normal limits because compensation has occurred. In compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the CO2 is decreased to compensate for the elevated HCO3. Nasogastric suction removes acid which leads to metabolic alkalosis. Awarded 1.0 points out of 1.0 possible points. 40. 40.ID: 36 A client falls off a ladder approximately 15 feet high and is admitted to the ICU for observation due to a small intracranial bleed noted in the left occipital area of the brain as observed on the CT Scan done in the emergency department. The client has been stable for the past 12 hours. The client reports to the nurse a new onset of pain in the left shoulder. Which action should the nurse do next? . Contact the healthcare provider. . Perform an abdominal assessment. Correct . Observe the client's pupillary response. . Examine the left shoulder's range of motion. Injury to the spleen, especially an encapsulated splenic hemorrhage may be difficult to diagnose initially because the signs of bleeding do not become evident immediately. The fact the client fell approximately 15 feet resulting in a fractured skull and now reports a new onset of left shoulder pain may be indicative of a splenic rupture. The referred shoulder pain is called "Kehr's sign". The nurse should initially assess the abdomen for signs of an abdominal injury. The nurse needs to assess the abdomen for distention, guarding, rebound tenderness, and rigidity. The nurse also needs to closely monitor the client's hemodynamic status for signs of hypovolemic depletion due to the splenic hemorrhage. Awarded 1.0 points out of 1.0 possible points. 41. 41.ID: 34 The nurse is collecting a sample for arterial blood gases (ABGs) for a client with hypoxia due to cardiomyopathy. Which should the nurse assess prior to obtaining the arterial blood sample? . Ulnar blood flow. Correct . Apical heart rate. . Oxygenation level. . Breath sounds. Prior to obtaining a sample for arterial blood gases (ABGs), the nurse should assess ulnar blood flow by performing the Allen test, which evaluates circulation to the wrist. If ulnar blood flow is compromised, the nurse should not obtain ABGs from the artery in the affected wrist. Awarded 1.0 points out of 1.0 possible points. 42. 42.ID: 32 A client returns to the postoperative unit after arteriovenous graft placement. The telemetry is showing tall, peaked T waves on the waveform. Which action should the nurse implement? . Review the client's recent serum potassium level. Correct . Prepare the client for synchronize cardioversion. . Notify Rapid Response Team for ST-elevation myocardial infarction. . Move the telemetry leads to the correct placement on the chest. Hyperkalemia causes the tall, pointed, peaked T waves in the telemetry waveform. The nurse should evaluate the client's recent serum potassium level. Awarded 1.0 points out of 1.0 possible points. 43. 43.ID: 30 A client who is hypotensive is receiving an infusion of dopamine 10 mcg/kg/minute IV through a peripheral line. The client begins to report burning at the IV site. Which action should the nurse implement? . Stop the infusion and notify the healthcare provider of the findings. Correct . Check the line for blood return and irrigate the peripheral IV catheter. . Apply a cold compress to the site and continue the infusion's rate. . Slow the infusion rate and add a secondary IV of 0.9% sodium chloride. Dopamine, a vasopressor, has significant vasoconstrictive action that can cause soft tissues necrosis if extravasation occurs. The nurse should stop the infusion and notify the healthcare provider. Awarded 1.0 points out of 1.0 possible points. 44. 44.ID: 28 The nurse is caring for a client who is recently extubated in the post anesthesia care unit (PACU). The client has humidified oxygen per mask and suddenly develops stridor and respiratory difficulty. Which action should the nurse implement? . Call a rapid response team for emergency airway management. Correct . Encourage the client to take deep breaths,cough, and expectorate. . Increase the flow rate of the humidified oxygen. . Suction the client's mouth and oropharynx thoroughly. Stridor post-extubation is a medical emergency. The nurse should immediately call the rapid response team for airway management. Awarded 1.0 points out of 1.0 possible points. 45. 45.ID: 26 An older client is admitted to the intensive care unit after a small bowel resection. The postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of the PCA? . Push button when pain is first experienced instead of waiting until pain is unbearable. Correct . Family members or visitors can press the button when the client grimaces in pain. . Press the button every 15 minutes even when pain is not present. . Delay pressing the button until the pain level is 8 on a scale of 1 to 10. A client should be awake to self administer PCA analgesia, which is titrated and programmed to prevent overdosing. The client should press the PCA button on demand when pain is first experienced to prevent escalation of pain that can become uncontrollable. Awarded 1.0 points out of 1.0 possible points. 46. 46.ID: 24 The paramedics bring in a client who is a victim of a high speed motor vehicle collision. The client is semi-coherent, fading in and out of consciousness. Two large bore intravenous catheters have been put in place, and one is infusing with normal saline at 100 mL/hr. Which information is the most important for the triage nurse to obtain from the paramedics? . The victim's vital signs upon arrival on the scene. . Status of the other victims involved in the accident. . Description of the motor vehicle collision circumstances. Correct . Police custody status of the victim pending further investigation. It is important for the nurse to obtain the "mechanism of injury". This refers to a description of what happened during the accident, such as where was the victim sitting in the vehicle, was the victim restrained or unrestrained by a seat belt, approximate speed of each vehicle during the impact, and what part of the victim's vehicle was hit. Obtaining this information will help the triage nurse in performing the assessment and looking for potential injuries as they relate to the mechanism of injury. Awarded 1.0 points out of 1.0 possible points. 47. 47.ID: 22 A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasal cannula and has two saline lock intravenous catheters. The nurse performs a 12 lead electrocardiogram (ECG) that shows ST segment elevation in leads II, III, aVF, and V4R. Which action should the nurse implement first? . Give0.3 mg nitroglycerin sublingual. . Administer4 mgIV morphine sulfate. . Measure the ST segment height. . Infuse 0.9% sodium chloridebolus. Correct This 12 lead electrocardiogram (ECG) myocardial injury is in the inferior and right ventricular portion of the heart muscle and requires an intravenous (IV) fluid bolus to fill the right ventricle for the heart to pump.Medications such as morphine sulfate and nitroglycerin will cause profound hypotension due to vasodilation if fluids are not given first. Awarded 1.0 points out of 1.0 possible points. 48. 48.ID: 20 A client diagnosed with gastric ulcers is admitted for a cauterization procedure. Which finding(s) should the nurse report to the healthcare provider? (Select all that apply.) . Decreased level of consciousness. Correct . Hypoactive bowel sounds. . Decreased urine output. Correct . Coffee-ground vomitus. . Positive guaiac stools. Upper GI bleeding can lead to severe blood loss. Hypotension is a late sign of hypovolemic shock. A systolic blood pressure less than 100 mmHg or a heart rate greater than 120 beats/minute is reflective of a blood loss greater than 1000mL. A decline in the level of consciousness or urine output are considered late signs of shock from Awarded 1.0 points out of 1.0 possible points. 49. 49.ID: 18 The nurse is caring for a client who underwent surgical repair of the aorta after sustaining injuries in a fall. Which finding indicates improved blood flow after the surgery? . Movement of lower extremities. Correct . Decreased urinary output. . Maintained weight. . Blood pressure 90/50. The nurse should assess for postoperative transient paralysis due to lack of blood flow during the surgical procedure as a result of aortic cross-clamp time. The ability of the client to move the lower extremities indicates that adequate blood flow has been restored. Awarded 1.0 points out of 1.0 possible points. 50. 50.ID: 16 The nurse receivesreport for a client with a history of heroin and alcohol abuse who has right arm cellulitis from a puncture wound. 0.9% sodium chloride is infusing at 50 mL/hr and oxygen at 2 liters per nasal canula. The client is flushed, diaphoretic, and slow to respond to verbal stimuli. Vital signs include oxygen saturation 94%, temperature 101° F (38.3° C), heart rate 124 beats/minute, respirations 26 breaths/minute, and blood pressure 88/24 mmHg. Which intervention should the nurse implement first? . Administer antipyretic suppository. . Obtain 2 sets of blood cultures. . Increase IV fluids to 150 mL/min. Correct . Monitor client for withdrawal signs. The client is presenting with signs of sepsis. Fluid resuscitation is the initial treatment for hypotension in clients with septic shock. Vital signs of an elevated temperature above 100.5 F (38.1 C), tachycardia and tachypnea, accompanied with a low blood pressure can be indicative of a client who is becoming septic and going into shock. Awarded 1.0 points out of 1.0 possible points. 51. 51.ID: 14 The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation due to acute respiratory failure. The family asks when the client will be extubated. Which information should the nurse provide? . When the client performs spontaneous breathing in between mechanical ventilation. Correct . Once all serum electrolyte and blood chemistry levels normalize. . At the completion of intravenous antibiotic therapy and the infection is resolved. . When the chest x-ray shows that the inflammation is resolved. Prior to weaning, clients must demonstrate the ability to breath on their own (spontaneous breathing). The decision to wean a client from mechanical ventilation is based on the client's spontaneous respiratory rate during trials of interrupted ventilation. Awarded 1.0 points out of 1.0 possible points. 52. 52.ID: 11 The nurse is caring for a client who is diagnosed withdiabetic ketoacidosis (DKA). The client reports abdominal pain and nausea, and presents with fruity-scented breath. The nurse performs a finger stick blood glucose with a reading too high to register. Which intervention is most important for the nurse to implement? . Initiate a one liter bolus of 0.9% sodium chloride. Correct . Set up an IV pump to infuse IV insulin per protocol. . Draw blood to evaluate a complete metabolic panel. . Administer a prn IV dose of prescribed antiemetic. A client who is diagnosed with diabetic ketoacidosis and blood glucose is too high to register on a bedside glucometer, needs to receive immediate bolus of one liter of normal saline infusion, until actual blood glucose, potassium, and phosphorus levels are known from a serum laboratory screening. Awarded 1.0 points out of 1.0 possible points. 53. 53.ID: 09 A client diagnosed with an end-stage terminal illness has decided to discontinue treatment. The client has become very detached and does not want to participate in the plan of care. Which action should the nurse implement first? . Initiate a referral for a mental health consultation. . Encourage the client to participate in their plan of care. . Review the client's medical record for documented religious preference. Correct . Contact the hospital chaplain to provide spiritual counseling and guidance. The nurse needs to confirm the client's religious preference first before initiating any other action. Individuals who follow the teachings of Buddha believe that "detachment" is the way to obtain relief from suffering. The teachings of Buddha also believe dying is natural process and in reincarnation. When an individual dies, the Buddhist believes the person is transitioning into a new life. Awarded 1.0 points out of 1.0 possible points. 54. 54.ID: 06 The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? . Assess for signs of cardiac tamponade. . Begin chest compressions at 120 per minute. Correct . Check for responsivenesswith sternal rub. . Obtain a STAT 12 lead electrocardiogram. The client is in a pulseless electrical activity (PEA) rhythm. No pulse or respirations require immediate chest compressions. The client may have developed a cardiac tamponade because in absence of hypovolemia and a tension pneumothorax, PEA is suggestive of a possible cardiac tamponade. However, the nurse's first action should be chest compressions. Awarded 1.0 points out of 1.0 possible points. 55. 55.ID: 04 The nurse assists the healthcare provider with the insertion of a pulmonary artery (PA)catheter for a client presenting with cardiogenic shock. Which action is most important for the nurse to take to prevent life-threatening complications from pulmonary artery monitoring? . Fast flush the PA distal port for no more than 2 seconds. Correct . Avoid infusing blood products through the PA catheter. . Clear pressure tubing of any blood afterwithdrawing a sample. . Maintain 300 mmHg pressurearound thebagattached to the tubing. Verifying the correct placement of the pulmonary artery (PA)catheter is performed by the fast-flush square waveform test, also referred to the dynamic frequency response test. This test should be performed once a shift, if air bubbles, clots, or tubing is kinked the wave form will appear dampen or flat. Awarded 1.0 points out of 1.0 possible points. 56. 56.ID: 02 The nurse is caring for a client in the critical care unit who is experiencing end-stage chronic obstructive pulmonary disease (COPD). The client is receiving oxygen at 40 L/minute via Vapotherm. The healthcare provider informs the client and family that there is no further treatment available for the COPD. Which intervention should the nurse recommend that is most beneficial to the client and family? . Hospice services. Correct . Intubation with mechanical ventilation. . Organ donation. . Home health care. When the healthcare provider determines that there is no further treatment available for a client with end-stage chronic obstructive pulmonary disease (COPD), hospice services are often the most beneficial to the client and family. Vapotherm is an assisted respiratory device that delivers high flow and high velocity oxygen via nasal cannula to minimizes dead space in the lungs and decreases the work of breathing for the client. Awarded 1.0 points out of 1.0 possible points. 57. 57.ID: 00 A client who has experienced trauma is admitted to the intensive care unit (ICU). The nurse's initial assessment findings include a Glasgow Coma Scale score of (3), pupils fixed and dilated with an absence of corneal reflex, blood pressure of 80/30 mmHg, core temperature of 95.7°F (35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse respond? . "Your spouse's condition indicates irreversible damage." . "Let me contact the health care provider to answer your questions." Correct . "Each person is different and we need to wait and see what happens." . "I need to initiate the volume expanders and warming blanket to stimulate a response." The client's neurological assessment findings of a low Glasgow score of 3, absence of pupil and corneal response, hypothermia, accompanied by hypotensive and low mean arterial pressure is indicative of a clinical brain death. The client's expected outcome is irreversible brain death and the nurse should contact the healthcare provider to talk and inform the spouse of the client's prognosis. It is not within the nurse's scope of practice to diagnose and inform the client's spouse of the clinical brain death diagnosis. Awarded 1.0 points out of 1.0 possible points. 58. 58.ID: 98 The nurse is analyzing an arterial blood gas (ABG) of a client who has a nasogastric tube to low suction. The ABG results are pH - 7.48; paCO 2 - 50 mmHg; HCO 3 - 27mEq/liter. How should the nurse interpret this blood gas? . Partially compensated respiratory acidosis. . Partially compensated respiratory alkalosis. . Partially compensated metabolic acidosis. . Partially compensated metabolic alkalosis. Correct The normal arterial blood gas (ABG) levels are pH: 7.35-7.45; paCO2: 35-45 mmHg; HCO3: 22-26 mEq/liter. In partially compensated metabolic alkalosis the pH is not within normal limits, compensation is attempting to correct the pH. In compensation, the opposite of the disorder compensates to bring the pH to normal range. In this case, the paCO2 is elevated to compensate HCO3 being elevated. Awarded 1.0 points out of 1.0 possible points. 59. 59.ID: 96 The emergency department nurse is triaging a client whose spouse reports a sudden onset of symptoms to include fever, tremors, and decreased level of orientation and psychotic behavior, accompanied with the tachycardia and palpitations. The only significant medical history of the client is 4 days post- operative laparotomy appendectomy without complications and discharged to home 2 days ago. Which intervention should the nurse do first? . Initiate a large bore intravenous catheter. Correct . Perform a twelve-lead electrocardiogram test. . Insert an indwelling urinary catheter drainage system. . Obtain serum elctrolytes and kidney function test laboratory specimens. The thyroid levels of a client experiencing a thyroid storm are elevated and often are reflective of the same elevated levels of a client experiencing hyperthyroidism. The diagnosis of a thyroid storm is based on a client's clinical presentation of symptoms. A sudden onset of very high temperature, tachycardia, palpitations, decreased level of orientation, tremors and psychotic behaviors are often signs of a thyroid storm. The thyroid storm is often brought on by stress related to a present illness, surgery, general anesthesia, or an infection. The nurse should recognize the client's clinical presentation, accompanied with the recent history of surgery. The nurse's first action should be to initiate a large bore intravenous catheter, so propranolol (Inderal) can be started to help antagonize the peripheral effects of the circulating thyroid hormone. Awarded 1.0 points out of 1.0 possible points. 60. 60.ID: 94 A client's blood pressure drops suddenly from 160/90 mmHg to 60/40 mmHg minutes after the nurse administers a 0.3 mg sublingual dose of nitroglycerin when the client reports crushing chest pain. The client is experiencing severe nausea, dizziness, and left arm numbness. Which intervention should the nurse implement? . Give a PRN antiemetic medication. . Administer second dose of nitroglycerin. . Infuse a rapid0.9% normal saline bolus. Correct . Applyexternal pace maker pads to chest. When chest pain is treated with a vasodilator such as nitroglycerin and the blood pressure falls suddenly to a critical level, this may indicate a right ventricular infarction and requires immediate infusion of fluid to prime the right side of the heart. Awarded 1.0 points out of 1.0 possible points. 61. 61.ID: 92 A male client who experienced a myocardial infarction (MI) asks the nurse what could have caused the MI, since he had been following a lifestyle of regular exercise and healthy food choices. Which response should the nurse provide to the client? . A family history of heart disease is a risk factor for MI. Correct . Foods consumed when younger can cause plaque formation. . Immediate medical treatment was a primary factor is survival. . Myocardial tissue after a minor MI can heal with no long-term effects. The best response to the client's question about the causes of myocardial infarction is to explain non-modifiable risk factors for heart disease, which include genetics, age, and gender. Awarded 1.0 points out of 1.0 possible points. 62. 62.ID: 89 What is the nurse's priority action for a client with this ECG tracing? Click for Image . Call the rapid response team and start compressions. Correct . Notify the provider for further orders. . Have the client perform Valsalva maneuvers. . Document the rhythm as the only finding. Incorrect The ECG tracing rhythm is indicating ventricular fibrillation where the heart muscle cells are fibrillating and the ventricle are not contracting effectively to provide cardiac output and eject blood into the circulatory system. After checking the client's pulse to verify no pulse, activate the rapid response team and begin chest compressions. Awarded 0.0 points out of 1.0 possible points. 63. 63.ID: 87 What action should the nurse implement for a client with this ECG tracing. . Document the rhythm. Correct . Notify the provider immediately. . Administer drugs per Advanced Cardiac Life Support protocol. . Call the family and ask if a chaplain should be summond. The ECG tracing rhythm shown is normal sinus rhythm. The nurse should document the interpretation of the rhythm in the client's electronic health record as per medical institution's protocol. The ECG tracing rhythm strip represents a three second strip, there are (4) normal complete "QRS" complexes present on the ECG rhythm strip, indicating normal sinus rhythm (NSR) with a heart rate of 80 beats/minute. Awarded 1.0 points out of 1.0 possible points. 64. 64.ID: 85 Which laboratory test results should the nurse review for a client with this ECG tracing? . Basal metabolic panel (BMP), serum Magnesium, and serum Phosphorus. Correct . Lactic Acid . Cardiac enzymes and Troponins. . Complete blood count. The client is experiencing unifocal premature ventricular contractions (PVCs) that can be caused by an electrolyte imbalances. The nurse should review the client's serum electrolytes such as sodium, potassium, calcium, phosphorous, and magnesium. Abnormal levels of these electrolytes can cause abnormal cardiac rhythms. Client's with hypokalemia and hypomagnesium are at an increased risk for PVCs, along with the absence of known cardiac disease, hypophosphatemia can cause ventricular contractions abnormalities. Awarded 1.0 points out of 1.0 possible points. 65. 65.ID: 83 A client's cardiac rhythm reveals peaked "T" waves, a widening "QRS" complex and the flattening of "P" waves. Which medication should the nurse administer? . Phosphate IV push. . Furosemide IV push. . Calcium gluconate IV push. Correct . Diluted potassium IV push. The client's cardiac rhythm is indicative of a potassium level is greater than 7.0 mEq/L. Hyperkalemia with cardiac rhythm changes should be treated with calcium gluconate. The calcium gluconate will cause an immediate effect on the electrical activity of the heart and the cardiac rhythm tracing will reflect that immediately and lower the risk of the client's cardiac rhythm converting into ventricular fibrillation. Awarded 1.0 points out of 1.0 possible points. 66. 66.ID: 80 The nurse is caring for a client who is prescribed a potassium-sparing diuretic and has a potassium level of 6.1 mEq/L (6.1 mmol/L). Which intervention should the nurse perform? . Obtain a 12-lead electrocardiogram (ECG). Correct . Call a rapid response. . Insert an intravenous (IV) line. . Schedule a cardiac catheterization. An elevated potassium level (normal 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) can lead to rhythm changes of the heart's conduction system. The nurse should obtain a 12-lead ECG to evaluate the impact of hyperkalemia on the cardiac waveform and rhythm. Awarded 1.0 points out of 1.0 possible points. New Question Pool 1. 1.ID: 06 The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? . Assess for signs of cardiac tamponade. . Begin chest compressions at 120 per minute. Correct . Check for responsivenesswith sternal rub. . Obtain a STAT 12 lead electrocardiogram. The client is in a pulseless electrical activity (PEA) rhythm. No pulse or respirations require immediate chest compressions. The client may have developed a cardiac tamponade because in absence of hypovolemia and a tension pneumothorax, PEA is suggestive of a possible cardiac tamponade. However, the nurse's first action should be chest compressions. Awarded 0.05 points out of 0.05 possible points. 2. 2.ID: 20 A client diagnosed with gastric ulcers is admitted for a cauterization procedure. Which finding(s) should the nurse report to the healthcare provider? (Select all that apply.) . Decreased level of consciousness. Correct . Hypoactive bowel sounds. . Decreased urine output. Correct . Coffee-ground vomitus. . Positive guaiac stools. Upper GI bleeding can lead to severe blood loss. Hypotension is a late sign of hypovolemic shock. A systolic blood pressure less than 100 mmHg or a heart rate greater than 120 beats/minute is reflective of a blood loss greater than 1000mL. A decline in the level of consciousness or urine output are considered late signs of shock from increased bleeding and the nurse should notify the healthcare provider of a possibility of increased gastric bleeding. The nurse should be assessing the client's vital signs every 15 minutes. Awarded 0.05 points out of 0.05 possible points. 3. 3.ID: 54 A chest X-ray is prescribed for a client with possible adult respiratory distress syndrome (ARDS). Which radiographic finding represents the pathological processes of pulmonary edema and consolidation of the lungs as ARDS progresses ? . White-out appearance. Correct . Infiltrates. . Calcified cavities. . Multiple nodules. As adult respiratory distress syndrome (ARDS) progresses, a "white-out" appearance on the chest X-ray indicates opacity of pulmonary edema and density of lung consolidation. Awarded 0.05 points out of 0.05 possible points. 4. 4.ID: 68 Which intervention should the nurse perform prior to the removal of an endotracheal tube from a client? . Suction the endotracheal tube thoroughly. Correct . Pre-medicate the client with pain medication. . Increase the FiO 2 for a minimum of 15 minutes. . Provide positive pressure ventilation prior to extubation. Prior to extubation of a client and removing the endotracheal tube (ETT), the nurse should ensure good airway clearance by suctioning out the ETT thoroughly. Awarded 0.05 points out of 0.05 possible points. 5. 5.ID: 16 The nurse receivesreport for a client with a history of heroin and alcohol abuse who has right arm cellulitis from a puncture wound. 0.9% sodium chloride is infusing at 50 mL/hr and oxygen at 2 liters per nasal canula. The client is flushed, diaphoretic, and slow to respond to verbal stimuli. Vital signs include oxygen saturation 94%, temperature 101° F (38.3° C), heart rate 124 beats/minute, respirations 26 breaths/minute, and blood pressure 88/24 mmHg. Which intervention should the nurse implement first? . Administer antipyretic suppository. . Obtain 2 sets of blood cultures. . Increase IV fluids to 150 mL/min. Correct . Monitor client for withdrawal signs. The client is presenting with signs of sepsis. Fluid resuscitation is the initial treatment for hypotension in clients with septic shock. Vital signs of an elevated temperature above 100.5 F (38.1 C), tachycardia and tachypnea, accompanied with a low blood pressure can be indicative of a client who is becoming septic and going into shock. Awarded 0.05 points out of 0.05 possible points. 6. 6.ID: 04 The nurse is caring for a client in the intensive care unit (ICU) with type 1 diabetes mellitus who has a blood glucose level of 600 mg/dL (33.3 mmol/L). Which clinical manifestation is most important for the nurse to report to the healthcare provider if the blood sugar continues to rise? . Change in level of consciousness. Correct . Increase in urinary output. . Onset of Kussmaul respirations. . Decrease in serum potassium level. As blood sugar rises (norm 70 to 110 mg/dl or 3.9-6.1 mmol/L SI), a client with hyperglycemia becomes dehydrated due to excessive urine output that causes a drop in blood volume and cerebral hypoperfusion. A change in the client's level of consciousness should be reported to the healthcare provider immediately. Awarded 0.05 points out of 0.05 possible points. 7. 7.ID: 24 The paramedics bring in a client who is a victim of a high speed motor vehicle collision. The client is semi-coherent, fading in and out of consciousness. Two large bore intravenous catheters have been put in place, and one is infusing with normal saline at 100 mL/hr. Which information is the most important for the triage nurse to obtain from the paramedics? . The victim's vital signs upon arrival on the scene. . Status of the other victims involved in the accident. . Description of the motor vehicle collision circumstances. Correct . Police custody status of the victim pending further investigation. It is important for the nurse to obtain the "mechanism of injury". This refers to a description of what happened during the accident, such as where was the victim sitting in the vehicle, was the victim restrained or unrestrained by a seat belt, approximate speed of each vehicle during the impact, and what part of the victim's vehicle was hit. Obtaining this information will help the triage nurse in performing the assessment and looking for potential injuries as they relate to the mechanism of injury. Awarded 0.05 points out of 0.05 possible points. 8. 8.ID: 26 An older client is admitted to the intensive care unit after a small bowel resection. The postoperative prescriptions include a patient-controlled analgesia (PCA) device with morphine titrated per protocol. Which information should the nurse provide the client about the use of the PCA? . Push button when pain is first experienced instead of waiting until pain is unbearable. Correct . Family members or visitors can press the button when the client grimaces in pain. . Press the button every 15 minutes even when pain is not present. . Delay pressing the button until the pain level is 8 on a scale of 1 to 10. A client should be awake to self administer PCA analgesia, which is titrated and programmed to prevent overdosing. The client should press the PCA button on demand when pain is first experienced to prevent escalation of pain that can become uncontrollable. Awarded 0.05 points out of 0.05 possible points. 9. 9.ID: 12 A client reports to the nurse feeling achy and weak, being tired and coughing all the time, frequent headaches and experiencing night sweats. The client's assessment is significant for crackles scattered throughout the lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure should the nurse prepare to do first? . Metabolic panel with electrolytes. . Complete blood count. . Liver function test. . Blood culture. Correct The client is demonstrating clinical signs and symptoms of infective endocarditis. The key in treating infective endocarditis is identifying the causative infectious agent and treat with the appropriate antibiotics. Blood cultures should identify which bacteria is the offending bacteria causing the endocarditis. What distinguishes infective endocarditis from the other conditions listed is the presence of the heart failure symptoms of edema, and S3 and S4 heart sounds. Awarded 0.05 points out of 0.05 possible points. 10. 10.ID: 66 A client who is critically ill requests to receive the Sacrament of the Anointing of the Sick. Which clergy member should the nurse contact? . Rabbi. . Priest. Correct . Sharma. . Ayatollah. In the Roman Catholic religion, the "Sacrament of the Anointing of the Sick" is a ritual that is performed on followers when they are seriously ill or dying. In the Roman Catholic community and this is one of the seven sacraments followers received throughout their life. The sacrament is a source of grace and strength for the church member and a sign of God's presence. This sacrament can only be administered by an ordained Roman Catholic priest. Awarded 0.05 points out of 0.05 possible points. 11. 11.ID: 84 A client who returns to the postoperative unit after a total thyroidectomy suddenly becomes short of breath and develops stridor. What action should the nurse implement first? . Call the rapid response team for emergency assistance. Correct . Encourage the client to relax as respiratory effort eases. . Document the findings and monitor the client hourly. . Call respiratory therapy to provide cool mist oxygen per mask. A client in the immediate postoperative period after a thyroidectomy can have bleeding into the soft tissue around the incision site that obstructs the airway and causes an inspiratory stridor and laryngospasm. The client is at risk for a life-threatening event, and the nurse should first call the rapid response team for emergency management. Awarded 0.05 points out of 0.05 possible points. 12. 12.ID: 22 A client reports shortness of breath and chest pressure radiating down the left arm. The client is receiving 2 liters of oxygen via nasa