Critical Care Transport Exam - Complete Solutions (Answered)

Critical Care Transport Exam - Complete Solutions (Answered) 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? Perform an abdominal assessment Define: Kehr's sign Acute pain in the tip of the shoulder due to the presence of blood or irritants in the peritoneal cavity when a person is lying down & legs are elevated Define: Cardiomyopathy Disease of the heart muscle 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 Define: Allen test Evaluates circulation to the wrist What indicates the patient should not take blood for ABG? Failed Allen test What does a pointed T test indicate? Hyperkalemia Define: Extravasation Leakage outside of the intended area What does dopamine cause if extravasation occurs? Soft tissue necrosis 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 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? Infuse 0.9% sodium chloride bolus What is the purpose of an IV fluid bolus? To fill the right ventricle for the heart to pump What do morphine & nitroglycerin cause? Hypotension What does an elevated ST segment indicate? MI 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 Decreased urine output Define: Cauterization Destruction of tissue by burning What is a late sign of hypovolemic shock? Hypotension Decline in consciousness Low urine output What reflects blood loss greater than 1000mL? Systolic 100mmHg HR 120bpm 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 the lower extremities The nurse receives report 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 cannula. 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? Increase IV fluids to 150mL/min What is the initial treatment for hypotension in clients with septic shock? Fluid resuscitation What are signs of sepsis? Elevated HR, temperature, & RR Low BP 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 patient performs spontaneous breathing in between mechanical ventilation The nurse is caring for a client who is diagnosed with diabetic 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 IV bolus of 0.9% sodium chloride 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? Review the client’s medical record for choice of religious preference What do people who believe in Buddha is the best way to deal with suffering? Detachment What do Buddhist believe after life? Dying is natural & we are reincarnated The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no spontaneous respiration's. The cardiac monitor displays a normal sinus rhythm. Which intervention should the nurse implement? Begin chest compressions at 120/min What requires immediate chest compressions? No pulse or RR 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 Define: Cardiogenic shock pump failure, occurs when heart is so inefficient that it cannot sustain adequate circulation How do you verify placement of a PA catheter? Fast-flush square waveform test/dynamic frequency response test