PCCN Questions and Answers with complete solutions

Two days following a near-drowning accident, a pt is dyspneic, using accessory muscles, expectorating large amounts of secretions and reporting feeling of impending death. Changes to the assessment data include RR- 24 TO 36 CXR clear to bilateral diffuse infiltrates ABG 40% face mask or 100% non-rebreather mask pO2 120 mm Hg to 56 mm Hg pCO2 33 mmHg to 56 mmHg pH 7.42 to 7.35 HCO3 24 meq/L to 27 mEq/L Which of the ff do these changes most likely represent A. aspiration pneumonia B. pulmonary embolism C. interstitial pneumonitis D. ARDS - ANSWER-D. The onset of symptoms occured within 48 hours of the incident. THe bilateral diffuse infiltrates and ABG results indicating hypoxemia and CO2 retention are all consistent with ARDS. Aspiration pneumonia should include hypoxxemia, respiratory alkalosis. The CXR results would reveal an area of opacity with aspiration pneumonia rather than diffuse infiltrates. Interstitial lung disease invlolves an inflammation of supportive tissue between the air sacs rather than inflammation in the air sacs themselves. Symptoms would be SOB and a dry cough. A pt reports chest pain that is sharp, constant, worse when lying down and alleviated with sitting up and leaning forward. The most likely cause of these findings is A. ACS B. pericarditis C. PE D. AAA - ANSWER-B Pericarditis is inflammation of the pericardial sac. The damaged epicardium becomes rough and inflamed and irritates the pericardium lying adjacent to it, precipitating pericarditis. Pain is the most common symptom of pericarditis. THe pain is sharp, constant and is alleviated when sitting up and leaning forward. A pt tells a nurse, "I don't know how I'm going to pay for this hospitalization." The nurse should A. arrange a meeting with hospital social services staff B. Notify the business office so a payment plan can be designed C. redirect the pt toward meeting psychologic needs D. give the pt applications for public assistance medical coverage - ANSWER-A. Collaboration with a social worker is indicated in this case the social worker can assist the pt in identifying ways to address the financial implications of this hospitalization and help identify methods of payments. A cardiac pt with with DNR status is being managed medically. The nurse notes a new cough, thick yellow sputum and a temperature of 101.4 (38.4) Coarse crackles are present in the right upper field. The nurse should most immediately anticipate A. blood and sputum cultures followed by a broad spectrum abx B. mucolytics and judicious IV fluid administration C. an antyipyretic and conservative management D. NPO status and encouragement of frequent activity - ANSWER-A. This pt symptoms are consistent with pneumonia. Management should include abx therapy, oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory failure develops, fluid management for hydration, nutritional support, and treatment of associated medical problems and complications. Which of the ff findings is most indicative of a ruptured aortic aneurysm A. Back pain B. bounding peripheral pulses C. intermittent claudication D. warm, flushed skin - ANSWER-A. An aneurysm is the localized dilation of an artery. Should an aneurysm rupture, blood will build up under pressure in the tissues surrounding the aorta, which can result in acute pain and tenderness in theses areas. This is particularly the case if the aneurysm leaks from the back of the aorta. Ruptured AAA presents with a classic triad of pain in the flank or back, hypotension and a pulsatile abdominal mass; however, only about half of the full triad. The pt will complain of the pain and may feel cold, sweaty and faint on standing. The pt may also report abdominal pain. A small percentage may have vomiting According to recommendations based on research findings, pain assessment should occur A. based on changes in vital signs B. only when the pt movements indicate the pt is seeking attention C. routinely, regardless of physical findings D. only when the presence of pain can be validated - ANSWER-C. Pain is considered the fifth vital sign and must be assessed regularly. Presence of physical findings may be part of the comprehensive assessment of pain. However, physical findings may not be present in all patients with pain A pt with a tracheostomy requires frequent suctioning for thick sputum, A nurse finds a colleague instilling saline in the endotracheal tube prior to suctioning. The most appropriate response by the nurse would be to A. report the colleague to the charge nurse or manager B. noted the practice on the pt chart to ensure consistency of suctioning techniques C. ask the attending physician to review the suctioning policy. D. collaborate with the colleague to review the evidence about this practice. - ANSWER-D. In addition to an unappreciable increase in sputum recovery, use of NS adversely affects arterial and global tissue oxygenation and dislodges bacterial colonies, thus contributing to lower airway contamination. Other harmful pt outcomes have been reported in the nursing literature, including delays in return to baseline vital signs, Spo2 and intracranial pressure. Because no solid scientifically based benefits for routine use of normal saline have been shown, it is highly recommended that this potentially harmful practice be abandoned. Instead, treatment considerations should center on ways to prevent the development of thick tenacious secretions. A review of these data should take place with the colleague to help mitigate continuation of this dangerous practice Upon admission to the PCU, you screen a pt to determine whether to administer an influenza vaccine. Which of the following is a contraindication to the vaccine? A. Guillian-Barre syndrome B. chronic renal failure C. COPD D. cirrhosis - ANSWER-A. Persons who developed Guillain-Barre syndrome after receiving an influenza vaccine should not receive the influenza vaccine without checking with their provider Emergency treatment of ventricular dysrhythmias for the pt who has an ICD pacemaker includes which of the following A. If a pt develops vfib, the nurse should not defibrillate with external paddles B. if the ICD is firing correctly and the pt does not have pulse, CPR is not indicated C. when preparing for external defibrillation, avoid placing the paddle directly over the ICD pulse generator D. when you need to turn off all functions of the ICD or pacemaker, apply a magnet - ANSWER-C. Defibrillation has been known to cause malfunction of an ICD or pacemaker. Care should be taken to ensure the defibrillation paddle/ pads are applied at least 4-finger breaths away from the device. The anterior-lateral and anterior-posterior positions for paddle/pad placement are acceptable in a pt with a permanent ICD or pacemaker. The pads may also be placed safely away from the ICD with 1 pad at the apex left mid-axillary, 5th ICS., and the other pad right of the sternum just below the clavicle. Based on the device implanted and the manufacturer, application of a magnet may turn device off or reset to the default settings. A pt is admitted following mitral valve replacement. Which of the following should most likely be included in the patent's plan of care A. positive inotropic agent B. anticoagulant C. prophylactic antibiotic D. ACE inhibitor - ANSWER-B. Anticoagulatn therapy recommendations are based on the valve apparatus and the pt risk factors (afib, LV dyfunction, previous thromboembolism, and hypercoagulable condition). Mechanical valve replacement require lifelong anticoagulant therapy, while most pt with bioprosthetic valve replacement require short term anti-coagulation (3 months). In pt with NSR and no risk factors for thrombus, only aspirin therapy is recommended after bioprosthetic valve replacement. A pt with multiple rib fractures sustained in a motor vehicle collision 4 days ago reports sudden chest pain and difficulty breathing. Chest xray reveals a right hemothorax. The pt appears anxious and has decreased breath sounds on the affected side. Which of the ff procedures should the nurse anticipate A. needle decompression, 2nd ICS at midclavicular line B. bronchoscopy with broncial lavage C. placement of a right-side chest tube in the 6th ICS at the posterior axillary line D. CT scan for further evaluation and diagnosis - ANSWER-C. Blunt or penetrating thoracic trauma can cause bleeding into the pleural space, resulting in a hemothorax. This life-threatening condition must be treated immediately. Resuscitation with intravenous fluids is initiated to treat the hypovolemic shock. A chest tube is placed on the affected side to allow drainage of the affected side to allow drainage of blood. A pt with which of the ff is at greatest risk for torsades de pointes A. depressed ST segment B. development of peaked T waves C. prolonged QT interval D. development of a U wave - ANSWER-C. The normal QTc is less than 0.46 second (460 msec) in women and less than 0.45 second (450 msec) in men. A prolonged QT interval is significant because it can predispose the pt to the development of polymorphic VT, also known as torsades de pointes. When drugs associated with a high risk of torsades de pointes are started, it is important to record the QT and QTc interval and to continue to monitor the QT and QTc interval during treatment. Prolongation of the absolute QT interval beyond 0.5 second (500 msec) increases the risk of polymorphic VT. A pt is confused about time and place, despite frequent reorientation. For the pt safety, the nurse should initially A. put a vest restraint on the pt B. ask a family member to stay with the pt C. administer a mild sedative D. increase the frequency of pt observation - ANSWER-D. Pt have a right to receive safe care in a safe environment. However, the use of restraints is inherently risky. THe decision to use a restrain or seclusion is not driven by diagnosis, but by a comprehensive patient assessment. FOr a given pt at a particular point in time, this assessment determines whether the use of less restrictive measures poses a greater risk than the risk of using a restraint. Increasing the frequency of observation may be all that is required to keep this pt safe. The comprehensive assessment to identify medical problems that may be causing behavior changes in the pt. For example, temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and adverse effects may cause confusion, agitation and combative behavior. Addressing these medical issues may eliminate or minimize the need for restraint. A pt with ACS who has undergone cardiac surgery 2 days ago develops new onset of JVD, muffled heart tones, palpitations, difficulty breathing and chest pain that worsens with coughing. Decreased peripheral pulses are noted. Vital signs are as follows BP 110/60 to 90/50 HR 96 to 134 RR 20 to 28 Which of the following should the nurse anticipate A. needle decompression B. echocardiogram C. administration of dopamine D. spiral Ct - ANSWER-B. This pt is at risk for and is demonstrating signs of cardiac tamponade. Cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (CVP, PADP, PAOP), decreased cardiac output, respiratory rate, jugular venous distention, pulsus paradoxus, and muffled heart sounds. Transesophageal or transthoracic echocardiography may be used to diagnose or confirm cardiac tamponade. A pt is admitted with a severe headache, nausea and vomiting. BP on arrival is 280/140 mm Hg. The nurse should anticipate immediate administration of A. atniemetics B. labetalol C. mannitol D. analgesics - ANSWER-B. Hypertensive urgencies may be treated with rapid-acting oral antihypertensive agents. There are many drug categories available, including ACEIs, ARBs, calcium channel blockers and beta-blockers. Labetalol is an example of a beta-blocker that may be used in this situation. A pt who is extubated following 3 days of mechanical ventilation is noted to have hot and flushed skin and is expectorating thick yellow sputum. Auscultation reveals bilateral crackles halfway up posterior. Data are as follows BP 112/60 HR 138 RR 30 T 102 (38.9) o2 SAT 93% ON 2 l nc Which of the ff orders should the nurse anticipate A. lasix 40 mg ivp and increase 02 to 4 L/min B. albuterol inhaler and methylprednisolone 125 mg IVP C. serum BNP and HCTZ D. blood culture and IV antibiotics - ANSWER-D. This pt is demonstrating symptoms of pneumonia. Rapid administration of antibiotics contributes to improved outcomes. Obtaining blood cultures will help the provider determine the appropriateness of selected antibiotics. When caring for a 15 year old pt, The nurse should A. answer questions with simple and practical information B. dispel fantasies and encourage questions C. encourage pt to talk about life experiences D. allow the pt peers to visit - ANSWER-D. Teens want to be with people their own age- their peers. Peers are often more accepting of the feelings, thoughts and actions associated with the teen's search for self-identity. The influence of peers- whether positive or negative- is critical importance in an adolescent's life. A pt with a history of heroin and alcohol abuse is admitted for treatment of cellulitis. The pt has flushed, slightly moist skin and is slow to respond to verbal stimuli. The affected arm is edematous and hard to the touch, with yellow exudate noted from puncture wounds on the skin. Vital signs are BP 88/50 HR 120 RR 26 T 102 (38.9) The nurse should anticipate orders for which of the ff A. abx and crystalloid administration B. antipyretic and dopamine administration C. CT scan of the head and a drug screen D. colloid followed by norepineprhine administration - ANSWER-A. This pt has risk factors and is exhibiting signs of sepsis. The main goals are to control infection and provide immediate resuscitation of the hypoperfused state. Early goal-directed therapy during the first 6 hours of resuscitation improves survival. This they includes aggressive fluid resuscitation to augment intravascular volume and increase preload until a CVP of 8 to 12 mm Hg. (12 to 15 mm Hg in mechanically ventilated pt). is acheived. Crystalloids or colloids may be used. A fluid challenge for hypovolemia should be initiated. A pt with HTN, dyslipidemia and CAD has leg pain and decreased skin temperature in the legs and feet. The pt legs have pallor and decreased pulses that become fainter when the legs are elevated. The nurse should suspect. A. DVT B. chronic venous insufficiency C. acute arterial occlusion D. PAD - ANSWER-D. The symptoms described in this scenario are consistent with PAD. This pt also has risk factors for PAD. Risk factors for PAD include DM and impaired glucose tolerance, smoking, hypertension, hyperlipidemia and hyperhocysteinemia A pt with history of COPD and anterior wall MI that occurred 1 year ago is now SOB and expectorating pink frothy sputum. The pt has a rapid, irregular heart-beat with an O2 sat of 89%. The most likely cause of these S/S is A. pulmonary edema B. cardiac tamponade C. pneumococcal pneumonia D. ARDS - ANSWER-A. History and current symptoms are consistent for pulmonary edema Which of the ff patients in the PCU should be further evaluated for malnutrition? The pt with A. a third episode of ARF and poor pulmonary function tests B. hypoactive bowel sounds and normal albumin levels C. sepsis who hasa 10 kg water weight gain and is receiving diuretics D. elevated BMI and Hgb of 14.6 - ANSWER-A. Malnutrition and respiratory failure are closely lined. Critically ill pt with respiratory failure are vulnerable to complication of underfeeding or overfeeding. A pt with ESRD and HF is receiving HD through an AV graft. VS are BP 190/94, HR 104, RR 26. The pt has crackles bilaterally and is bleeding from the graft site. The nurse should A. asses for bruit and thrill every 30 min for 2 hours and reasses B. notify the interventional radiologist C. ask the nephrologist to insert a temp catheter into the contralateral arm D. collaborate with the nephrologists regarding not using heparin during dialysis treatment - ANSWER-B. If the bleeding is not controlled following application of direct pressure to the site, repair by an interventional radiologist is indicated. A pt presents with a temperature of 105.6 F (40.9) and nuchal rigidity. A nurse obtains blood culture and administers antibiotics. The patient remains febrile, and the family questions the adequacy of the interventions. The nurse's best response should be to A. arrange a social service consult B. assure the family that everything will be explained later. C suggest that the family discuss their concerns with the physician D. acknowledge the family's concerns while explaining rationales for the interventions - ANSWER-D. The nurse demonstrating high levels of caring practices and facilitation of learning will acknowledge and address the family's learning A pt who is newly admitted is hemodynamically stable, had sustained a stroke and had been on mechanical ventilation via tracheostomy tube, a continuous sedation infusion and enteral feedings in the ICU for several days. The pt is now off sedation and receiving O2 via a trach collar. Gastric residual volumes of 250 ml every 6 hours over the past 3 days have been noted. Upon collaborating with the nutritionist and physician, the nurse should anticipate which of the ff A. dilution of the enteral feeds by 50% with water B. administration of a prokinetic agent C. decreasing the rate of enteral feedings by 50% D. initiation of pernteral nutrition - ANSWER-B. In a studr of 206 critically ill pt, 2 or more GRVs of at least 200 mL and 1 or more GRVs of at least 250 mL were found significantly more often in pt who experienced frequent aspiration. Prokinetics have been advocated to improve gastric emptying. Which of the ff electrolye abnormalities should the PCU nurse anticipate in caring for a pt with chronic alcohol abuse A. hypomagnesemia B. hyperphosphatemia C. hypercalcemia D. hyponatremia - ANSWER-A. Pt with chronic alcohol abuse are at risk of reasons (1) their diet is typically low in magnesium, (2) alcohol diuresis pulls magnesium out of the body, and (3) there is associated poor GI absorption of dietary magnesium in chronic alcohol abuse. A pt develops SVT hypotension and chest pain. The goal of therapy will be to A. reduce HR to increase diastolic filling time B. produce arteriolar constriction to increase perfusion pressure C. dilate coronary arteries to increase myocardial O2 delivery D. promote venous constriction to increase preload - ANSWER-A. Rapid heart rates can lead to hemodynamic instability, because the fast rate prevents adequate ventricular filling during diastole and increases myocardial oxygen demand, while decreasing time available for coronary artery filling Which of the following would be the most important immediate concern when managing a pt with an acute ischemic stroke A. preventing pressure ulcers from limited mobility related to hemiparesis B. avoiding HTN while maintaining adequate cerebral perfusion C. performing a CT scan to evaluate for bleeding form tPA infusion D. intubation and mechanical ventilation for airway protection - ANSWER-B. The main goals for managing the pt with acute ischemic stroke are twofold: (1) enhancement of cerebral blood flow and (2) neuroprotection, with the aim to reduce the intrinsic vulnerability of brain tissue to ischemia A pt with history of taking gentamicin (Garamycin) is admitted with oliguria, confusion, lethargy, nausea and vomiting. Lab data are as follows BUN 26 Cr 1.6 Na 130 K 4.9 Calcium 7.8 Which of the following should the nurse suspect A. dehydration B. acute tubular necrosis C. GI infection D. chronic renal failure - ANSWER-B. This pt has received a nephrotoxic agent, which puts the pt at risk for development of ATN. Lab data support this diagnosis with an elevated BUN, creatinine and potassium. Calcium and sodium levels will be decreased. After a STEMI, a pt suddenly experiences a decreased level consciousness, a weak and thready pulse and posterior crackles in the lower half of the lung fields bilaterally. Data are as follows BP 76/43 HR 139 RR 24 UO 5 ml for the past hour O2 sat 88% on 2 L via nasal (from 97%) The nurse should suspect which of the ff causes A. CVA B. cardiogenic shock c. pulmonary embolus D. ARDS - ANSWER-B. This pt has a primary risk factor (STEMI) and signs of cardiogenic shock. The hypotension is caused by a decrease in contractility of cardiac muscle. Compensatory mechanisms of tachycardia and tachypnea result. A decrease in urine output, decreased level of consciousness, crackles and a weak and thready pulse result from hypoperfusion associated with the condition. A frail, elderly pt recovering from an exploratory laparotomy was extubated following a prolonged period of mechanical ventilation and IV sedation. She continues to receive PRN opioids for pain. Today, the nurse notes occasional combativeness, fluctuating lethargy and poor short-term memory. Data are as follows BP 104/60 HR 87 RR 24 O2 sat 95% on 2L via NC The nurse should recognize that A. mobilization should be limited to prevent injury B. the RASS scale should guide medication administration C. the use of Haldol is associated with lethal dysrhythmias D. moving the pt to a room with a window is a useful distraction technique - ANSWER-C. The most current guidelines advise cautious use of antipsychotic meds to manage delirium, as risk versus benefits data remain unclear. Another choice may be a short-term trial of an atypical antipsychotic such as Quetiapine (Seroquel) The physician gave metoprolol (Lopressor) to a patient with rapid afib 5 minutes ago without effect for rate control and is currently administering IV diltiazem (Cardizem); BP is 94/60. Which of the following should the nurse anticipate. A. calcium chloride B. synchronized cardioversion C. digoxin D. transcutaneous pacing - ANSWER-D. A beta-blocker and calcium channel blocker combination should be used with caution. When drugs from these 2 classes are given together, the additive effect is the potent suppression of the AV node. Having transcutaneous pacing nearby can help the pt be treated early if this complication develops. A pt with HF is on a diuretic and fluid restriction. Assessment indicated atrial tachycardia with a rate of 130, presence of crackles in all lung fields, an S3 at the left apex and BP of 90/40 (previously 130/60). The patient reports feeling SOB. The nurse should anticipate administration of A. a fluid bolus to enhace preload B. dopamine to support BP C. dobutamine to augment cardiac output D. adenosine to reverse tachycardia - ANSWER-C. In pt with decompensated heart failure, use of intravenous inotropic agents such as dobutamine may be indicated to support cardiac function and cardiac output. The dysrhythmia most commonly associated with mitral stenosis is A. 2nd degree AB block type II B. idioventricular rhythm C. sinus bradycardia D. afib - ANSWER-D. Mitral stenosis increases the risk of developing atrial fibrillation because of high pressures in the left atrium that will stimulate left atrial remodeling and enlargement. A pt with an elevated BMI