PCCN questions with Correct Answers

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 Correct 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 Correct AnswerB 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 Correct AnswerA. 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 Correct AnswerA. 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 following findings is most indicative of a ruptured aortic aneurysm A. Back pain B. bounding peripheral pulses C. intermittent claudication D. warm, flushed skin Correct AnswerA. 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 Correct AnswerC. 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. Correct AnswerD. 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 Correct AnswerA. 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 Correct AnswerC. 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 Correct AnswerB. 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 Correct AnswerC. 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.