NUR 02 CRITICAL CARE 01

NUR 02 CRITICAL CARE 01 01 A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed, profusely diaphoretic, and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. 1. IM epinephrine 2. IV atropine 3. IV dantrolene 4. IV glucagon Explanation: Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by general anesthetics (eg, succinylcholine). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. (Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe asthma attacks; it is not appropriate for MH. (Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen tachycardia in this client. (Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously, or intravenously for severe hypoglycemia. IV glucose is preferred for its immediate effect; however, if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood glucose. Educational objective: Malignant hyperthermia (MH) is a life-threatening hypermetabolic condition triggered by general anesthetics. Administration of IV dantrolene slows metabolism and is the priority nursing action for a client with MH. Other interventions include cooling the client and treating high potassium levels. 02 The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome. When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items? 1. Orthostatic blood pressure changes 2. Presence or absence of knee reflexes 3. Pupil size and reaction to light 4. Rate and depth of respirations Explanation: Guillain-Barré syndrome (GBS) is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs). Neuromuscular respiratory failure is the most life-threatening complication. The rate and depth of the respirations should be monitored (Option 4). Measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure. (Option 1) Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not a priority. (Option 2) Absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease. Absence of gag reflex indicates GBS progression. (Option 3) PERRLA (pupils equal, round, reactive to light, accommodation) evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS. Educational objective: The most serious complication to monitor for in new-onset Guillain-Barré syndrome is respiratory compromise from the paralysis ascending into the thoracic region. Monitoring for rate/depth of respirations and measuring serial bedside vital capacity (spirometry) help to detect this early in the disease course. 03 The nurse performs admission assessments on 4 clients. Which client assessment information is most concerning and needs priority care? 17-year-old with suspected meningococcal meningitis who has a fever of 103 F (39.4 1. C), headache with photophobia, and stiff neck 36-year-old who is an IV drug user with cellulitis of the arm, a fever of 103.2 F (39.6 C), and 2. foul-smelling drainage from self-injection sites 45-year-old with diabetes mellitus and osteomyelitis of the foot who has a fever of 100.9 F 3. (38.3 C) and a serum glucose of 295 mg/dL (16.4 mmol/L) 76-year-old with chronic bronchitis who has a fever of 101 F (38.3 C) and a productive 4. cough of thick green mucus Explanation: Meningococcal meningitis is a highly contagious condition that involves inflammation and bacterial infection in the tissues covering the brain and spinal cord (meninges). It is transmitted through direct contact or by inhaling droplets from infected individuals (ie, upper respiratory tract infections) and is prevalent among those living in close proximity (eg, prisons, dormitories). Characteristic signs include fever, headache, nuchal rigidity (stiff neck), photophobia, nausea, vomiting, and changes in mental status. If any of these are present, prompt testing (eg, lumbar puncture [LP], cultures) and initiation of antibiotic therapy immediately following the LP are critical as this is a life-threatening medical emergency. (Option 2) Although this client has an infection, is at increased risk for septicemia, and needs to be treated with antibiotics and antipyretics, this situation is not immediately life-threatening. (Option 3) Fever and hyperglycemia are expected responses to infection, and this client needs to be treated with antibiotics and insulin. However, this situation is not immediately life-threatening. (Option 4) This client is at increased risk for pneumonia and needs to be treated with antibiotics, antipyretics, bronchodilators, and expectorants. This situation is not immediately life-threatening. Educational objective: Meningococcal meningitis is a highly contagious bacterial infection. Classic signs include fever, nuchal rigidity, headache, photophobia, nausea, vomiting, and changes in mental status. If meningococcal meningitis is suspected, diagnostic testing and immediate treatment with antibiotics are critical as it is a life-threatening medical emergency. 04 A client with a bowel obstruction has been treated with gastric suctioning for 4 days. The nurse notices an increase in nasogastric drainage. Which acid-base imbalance does the nurse correctly identify? Click the exhibit button for more information. 1. Metabolic alkalosis, compensated 2. Metabolic alkalosis, uncompensated 3. Respiratory alkalosis, compensated 4. Respiratory alkalosis, uncompensated Explanation: This client's ABG analysis shows uncompensated metabolic alkalosis. The most likely cause of this alkalosis is the loss of acidic gastric contents from prolonged gastric suctioning. Metabolic imbalances affect the bicarbonate level. This client's ABG is high in pH (alkalosis) and bicarbonate. Bicarbonate (HCO3-) is basic; therefore, an elevated bicarbonate level indicates a more basic (alkalotic) state due to a metabolic cause. The nurse recognizes that this is uncompensated alkalosis. The lungs compensate for metabolic imbalance by either blowing off acidic carbon dioxide (hyperventilating) or retaining it (hypoventilating). Hypoventilation raises the carbon dioxide level, making the blood more acidic. Compensation is complete once the pH returns to normal limits (Option 1). (Options 3 and 4) Respiratory alkalosis (pH >7.45) results from a decreased PaCO2 (<35 mm Hg [4.66 kPa]). The kidneys compensate for respiratory alkalosis by excreting HCO3-. Therefore, a decrease in HCO - (<22 mEq/L [22 mmol/L]) and normalized pH (7.35-7.45) would indicate compensated respiratory alkalosis. Educational objective: Loss of acid through suctioning of gastric contents creates a state of metabolic alkalosis. Compensatory hypoventilation may regulate the pH by retaining carbon dioxide (acid). 05 The emergency department nurse receives a client with extensive injuries to the head and upper back. The nurse will perform what action to allow the best visualization of the airway? 1. Head-tilt chin-lift in the supine position on a backboard 2. Head-tilt chin-lift in the Trendelenburg position 3. Jaw-thrust maneuver in semi-Fowler's position 4. Jaw-thrust maneuver in the supine position on a backboard Explanation: Clinical situations involving trauma should follow ABC: Airway, Breathing, and Circulation. Airway assessment is particularly critical in clients with injuries to the head, neck, and upper back. Injury to the upper back should be treated as spinal trauma until the client has been cleared by an Advanced Trauma Life Support-qualified health care provider. Until the spine is appropriately assessed, the client should be placed on a backboard and stabilized. The nurse should use the jaw-thrust maneuver to avoid movement of an unstable spine. One provider should stabilize the cervical vertebra allowing the second provider to articulate the jaw independently of the spinal column. (Option 1) Although use of the backboard is appropriate, the head–tilt chin-lift should not be used as it involves manipulation of the neck without proper stabilization. If the cervical vertebrae are fractured, the spinal cord could be badly damaged. (Option 2) The head-tilt chin-lift does not stabilize the alignment of the head and neck and can cause spinal cord damage. In addition, the Trendelenburg position causes the abdominal organs to shift toward the diaphragm, which increases the work of breathing. (Option 3) The jaw-thrust maneuver is appropriate, but stabilization of the spine is best performed in the supine position, such as on the flat, hard surface of a backboard. Educational objective: If there is any suspicion of spinal injury, the jaw-thrust maneuver should be used for airway assessment to avoid any shifting of unstable vertebrae and subsequent spinal cord damage. 06 A client's wife is panic-stricken at the thought of withdrawing all life support from her husband, who is dying from end-stage chronic obstructive pulmonary disease and sepsis. She asks the nurse what he will experience when mechanical ventilation is stopped. Which statement made by the nurse is most appropriate at this time? "The healthcare provider will prescribe a continuous intravenous infusion of 1. morphine to make him more comfortable." "To maintain blood flow to his heart and lungs, we will continue norepinephrine, the 2. vasopressor, but discontinue all other medications." "To prevent aspiration, we will discontinue his feeding tube and begin total parenteral 3. nutrition to meet his nutritional needs." "We will continue basic care, such as monitoring his vital signs, giving nutrition, and 4. monitoring laboratory tests." Explanation: The nursing goals in end-of-life care are to comfort and support the client and family when death is imminent. Morphine is commonly used to manage the dyspnea, tachycardia, and restlessness associated with withdrawing mechanical ventilator support. Intravenous benzodiazepines, (eg, midazolam, lorazepam) may be administered for additional comfort. (Options 2 and 3) When a client is taken off life support, vasopressors, antibiotics, blood, hemodialysis, and nutritional support are commonly withheld. (Option 4) Vital signs, laboratory testing, and nutritional support are detrimental to client comfort and are usually discontinued after the decision has been made to withdraw life support. Educational objective: When withdrawing life support, the major goal is client comfort. The primary nursing responsibility is to assess and intervene appropriately for symptoms of pain and discomfort. 07 Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report? Select all that apply. Client admitted with white blood cell count of 28,000 mm3 (28.0 × 109/L) and dies from 1. sepsis Client receives 1 mg morphine instead of prescribed 0.5 mg morphine 2. Client refuses pneumonia vaccination and contracts pneumonia 3. Nurse did not report client's new hemoglobin result of 6 g/dL (60 g/L) to oncoming nurse 4. Provider was not notified of client's positive blood culture results 5. Explanation: An adverse event is an injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. The Institute of Medicine (2000) recognizes 4 types of errors. They are: • Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring) • Treatment (error in performance of procedure, treatment, dose; avoidable delay) • Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment) • Other (failure of communication, equipment failure, system failure) Option 2 is a treatment error. Option 4 is a communication error as well as inadequate follow-up. Option 5 is a communication error and a failure to respond to an abnormal test. Timely reporting of critical results of tests and diagnostic procedures is part of the Joint Commission Hospital National Patient Safety Goals. (Option 1) The client was admitted with signs of a severe infection and the death is likely a result of that process rather than a medical error. (Option 3) Under the ethical principle of autonomy, the client has the right to refuse anything even if it is not to the client's ultimate best interest. The pneumonia could be due to lack of vaccination, but there is no direct relationship. Educational objective: Adverse events are injuries caused by medical management rather than a client's underlying condition. Types of errors include diagnostic, treatment, preventive, and failure of communication, equipment, or other systems. 08. The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock. Which action taken by the new RN indicates a need for further education? Administers furosemide to a client with pulmonary artery wedge pressure (PAWP) of 24 mm 1. Hg with cardiogenic shock Increases norepinephrine infusion rate to maintain mean arterial pressure (MAP) ≥65 mm 2. Hg in a client with anaphylactic shock Moves pulse oximeter sensor from the finger to the forehead of a client with septic shock 3. Places the head of the bed (HOB) for a client with hypovolemic shock in high 4. Fowler's position Explanation: