Critical Care Exam With Complete Solutions 100% d d d d d d d
d Correct Latest Update d d
The triage nurse is assessing a victim of a stab wound. The paramedics state the
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weapon used was by a male assailant. The knife blade was 6 inches or 7.2 cm in
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length and 1 inch or 2.5 cm in width. The "point of entry" of the stab wound is two
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inches above and left of the victim's xiphoid process. Which is/are vital organs(s) at
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increased risk of being in the direct path of injury? - ANS Heart
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Lungs
Diaphragm
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In which direction do females stab? - ANS Downwards
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In which direction do males stab? - ANS Upwards
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A client comes to the nurse complaining of feeling achy and weak, tired and coughing
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all the time, headaches frequently and having night sweats. The client's exam is
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significant for bibasilar crackles throughout the lungs, dependent peripheral edema
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+3/+4, S3 and S4 heart sounds, temp 102.4° F (39.1° C), HR 110 beats/min, RR 20
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breaths/min, BP 105/60 mmHg with MAP of (75). Which diagnostic study should the
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nurse plan to implement first? ANSWER Blood culture
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Define: Infective endocarditis - ANSWER Infection of the endocardial surface of the
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heart, usually the heart valves
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What implies ineffective endocarditis is present? - ANSWER Edema & S1/S3 sounds
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The paramedic reported in stating that the victim was seated in the passenger seat
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on the left side of the vehicle involved in the motor vehicle collision. The vehicle was
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stopped at a traffic light when the vehicle was struck on the left side by another
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vehicle traveling at speeds over 60 mph (97 km/h). Client has slight tenderness and
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achiness on
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, (L) side of thorax and body. The major findings upon assessment include the
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dfollowing: weak and threading pulse; diffuse abdominal pain, tenderness, and
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dguarding present upon palpation; skin is diaphoretic with cool to the touch
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dextremities, capillary refill +4 in extremities, and bruising is present in the (L) flank
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darea and progresses towards the abdomen. Vital tics: temperature- 97.2° F (36.2°
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dC), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46
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dmmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. -
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dANSWER Fractured liver & ruptured spleen d d d d d
The nurse is interpreting an arterial blood gas (ABG) of a client who is
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mechanicalley ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3-
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28 mEq/liter. How does the nurse interpret this blood gas? - ANSWER Respiratory
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alkalosis
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Define: Respiratory alkalosis - ANSWER HCO3 & pH is increased while the CO2 is
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decreased
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What is the effect if blood sugar continues to rise? -ANSWER Change in level of
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consciousness
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What precaution should a patient be on with a high sodium? -ANSWER Seizure
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precautions
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Why do people with diabetes have an increased urinary output? -ANSWER Low ADH
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What is the effect of a low ADH? -ANSWER Dehydration & increased serum Sodium
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The client is admitted to the intensive care unit with a diagnosis of SIADH and a
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serum sodium level of 112 mEq/L or mmol/L. Which of the following orders should
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the nurse institute first? - ANSWER Obtain serum sodium every 4 hours
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The nurse is caring for a client who is demonstrating signs of impending death. The
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family is becoming emotionally distraught as the client's condition deteriorates.
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Which information does the nurse provide to the family to facilitate the process? -
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ANSWER Encourage the family to give the patient permission to die
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d Correct Latest Update d d
The triage nurse is assessing a victim of a stab wound. The paramedics state the
d d d d d d d d d d d d d d
weapon used was by a male assailant. The knife blade was 6 inches or 7.2 cm in
d d d d d d d d d d d d d d d d d
length and 1 inch or 2.5 cm in width. The "point of entry" of the stab wound is two
d d d d d d d d d d d d d d d d d d d
inches above and left of the victim's xiphoid process. Which is/are vital organs(s) at
d d d d d d d d d d d d d d
increased risk of being in the direct path of injury? - ANS Heart
d d d d d d d d d d d d d
Lungs
Diaphragm
d
In which direction do females stab? - ANS Downwards
d d d d d d d d
In which direction do males stab? - ANS Upwards
d d d d d d d d
A client comes to the nurse complaining of feeling achy and weak, tired and coughing
d d d d d d d d d d d d d d
all the time, headaches frequently and having night sweats. The client's exam is
d d d d d d d d d d d d d
significant for bibasilar crackles throughout the lungs, dependent peripheral edema
d d d d d d d d d d
+3/+4, S3 and S4 heart sounds, temp 102.4° F (39.1° C), HR 110 beats/min, RR 20
d d d d d d d d d d d d d d d d
breaths/min, BP 105/60 mmHg with MAP of (75). Which diagnostic study should the
d d d d d d d d d d d d d
nurse plan to implement first? ANSWER Blood culture
d d d d d d d d
Define: Infective endocarditis - ANSWER Infection of the endocardial surface of the
d d d d d d d d d d d
heart, usually the heart valves
d d d d d
What implies ineffective endocarditis is present? - ANSWER Edema & S1/S3 sounds
d d d d d d d d d d d
The paramedic reported in stating that the victim was seated in the passenger seat
d d d d d d d d d d d d d
on the left side of the vehicle involved in the motor vehicle collision. The vehicle was
d d d d d d d d d d d d d d d d
stopped at a traffic light when the vehicle was struck on the left side by another
d d d d d d d d d d d d d d d d
vehicle traveling at speeds over 60 mph (97 km/h). Client has slight tenderness and
d d d d d d d d d d d d d d
achiness on
d d
, (L) side of thorax and body. The major findings upon assessment include the
d d d d d d d d d d d d
dfollowing: weak and threading pulse; diffuse abdominal pain, tenderness, and
d d d d d d d d d
dguarding present upon palpation; skin is diaphoretic with cool to the touch
d d d d d d d d d d d
dextremities, capillary refill +4 in extremities, and bruising is present in the (L) flank
d d d d d d d d d d d d d
darea and progresses towards the abdomen. Vital tics: temperature- 97.2° F (36.2°
d d d d d d d d d d d
dC), pulse- 110 beats/minute, respirations- 22 breaths/minute, blood pressure 84/46
d d d d d d d d d
dmmHg, MAP- (57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. -
d d d d d d d d d d d d d d
dANSWER Fractured liver & ruptured spleen d d d d d
The nurse is interpreting an arterial blood gas (ABG) of a client who is
d d d d d d d d d d d d d
mechanicalley ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3-
d d d d d d d d d d d d
28 mEq/liter. How does the nurse interpret this blood gas? - ANSWER Respiratory
d d d d d d d d d d d d d
alkalosis
d
Define: Respiratory alkalosis - ANSWER HCO3 & pH is increased while the CO2 is
d d d d d d d d d d d d d
decreased
d
What is the effect if blood sugar continues to rise? -ANSWER Change in level of
d d d d d d d d d d d d d d
consciousness
d
What precaution should a patient be on with a high sodium? -ANSWER Seizure
d d d d d d d d d d d d
precautions
d
Why do people with diabetes have an increased urinary output? -ANSWER Low ADH
d d d d d d d d d d d d
What is the effect of a low ADH? -ANSWER Dehydration & increased serum Sodium
d d d d d d d d d d d d d
The client is admitted to the intensive care unit with a diagnosis of SIADH and a
d d d d d d d d d d d d d d d
serum sodium level of 112 mEq/L or mmol/L. Which of the following orders should
d d d d d d d d d d d d d d
the nurse institute first? - ANSWER Obtain serum sodium every 4 hours
d d d d d d d d d d d d
The nurse is caring for a client who is demonstrating signs of impending death. The
d d d d d d d d d d d d d d
family is becoming emotionally distraught as the client's condition deteriorates.
d d d d d d d d d d
Which information does the nurse provide to the family to facilitate the process? -
d d d d d d d d d d d d d d
ANSWER Encourage the family to give the patient permission to die
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