Saunders NCLEX Critical Care Questions With Complete
Solutions
A 2-year-old child is being transported to the trauma center from
a local community hospital for treatment of a burn injury that is
estimated as covering more than 40% of the body. The burns are
both partial- and full-thickness burns. The nurse is asked to
prepare for the arrival of the child and gathers supplies,
anticipating that which treatment will be prescribed initially?
1.
Insertion of a Foley catheter
2.
Insertion of a nasogastric tube
3.
Administration of an anesthetic agent for sedation
4.
Application of an antimicrobial agent to the burns Correct
Answer Insertion of a Foley catheter
A Foley catheter is inserted into the child's bladder so that urine
output can be accurately measured on an hourly basis. Although
pain medication may be required, the child would not receive an
anesthetic agent and should not be sedated. The burn wounds
would be cleansed after assessment, but this would not be the
initial action. Intravenous fluids are administered at a rate
sufficient to keep the child's urine output at 1 to 2 mL/kg of
body weight per hour for children weighing less than 30 kg, thus
reflecting adequate tissue perfusion. A nasogastric tube may or
may not be required but would not be the priority intervention.
,A 5-year-old boy is brought by his mother to the emergency
department after ingesting a bottle of acetylsalicylic acid. Which
procedure should be initially instituted with this child?
1.
Administer ipecac by mouth and monitor emesis.
2.
Institute a gastric lavage and administer activated charcoal.
3.
Administer a chelating agent such as edetate calcium disodium.
4.
Institute a gastric lavage and administer the antidote
acetylcysteine. Correct Answer Institute a gastric lavage and
administer activated charcoal.
A gastric lavage must be performed after ingestion of
acetylsalicylic acid, and activated charcoal is administered to
prevent further absorption of the substance. N-acetylcysteine is
the antidote for acetaminophen. Administering ipecac or edetate
calcium disodium is not a treatment measure for acetylsalicylic
acid poisoning. Edetate calcium disodium may be prescribed for
the treatment of lead poisoning. Ipecac causes vomiting, and this
substance is used only in specific poisoning conditions; in this
situation, vomiting can cause irritation of the esophagus.
A child is admitted to the hospital after being seen in the
emergency department with complaints of right lower quadrant
abdominal pain, nausea and vomiting, fever, and chills. The
health care provider (HCP) suspects appendicitis. Which
,assessment finding should the nurse immediately report to the
HCP?
1.
Decreasing oral temperature
2.
Increasing complaints of pain
3.
Refusal to take fluids by mouth
4.
Sudden relief of abdominal pain Correct Answer Sudden relief
of abdominal pain
A sudden relief of pain from a suspected appendicitis is
commonly indicative of a ruptured appendix. This places the
individual at risk for peritonitis and shock. The HCP should be
notified immediately because of the need to begin intravenous
antibiotics to prevent further complications. Although increasing
complaints of pain is a concern, the higher priority is sudden
relief of pain because of the risk of peritonitis and shock.
Temperature should be monitored but is not of highest priority.
The child will be placed on NPO (nothing by mouth) status in
anticipation of surgery; therefore, option 4 is incorrect.
A child is receiving succimer for the treatment of lead
poisoning. The nurse should monitor which most important
laboratory result?
1.
, Iron level
2.
Calcium level
3.
Red blood cell count
4.
Blood urea nitrogen level Correct Answer Blood urea nitrogen
level
Succimer is a medication that is used to treat lead poisoning.
Renal function (blood urea nitrogen and creatinine) is monitored
closely during the administration of chelation therapy because
the medication is excreted via the kidneys. Although it is
important to monitor the iron level, calcium level, and red blood
cell count, these results are not specific to chelation therapy, so
they are not the most important lab values to monitor.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the
pulse rate is elevated, and the blood pressure has decreased
significantly from the baseline value. The nurse suspects that the
child is in shock. Which is the most appropriate nursing action?
1.
Place the child in a supine position.
2.
Notify the health care provider (HCP).
3.
Place the child in Trendelenburg's position.
4.
Solutions
A 2-year-old child is being transported to the trauma center from
a local community hospital for treatment of a burn injury that is
estimated as covering more than 40% of the body. The burns are
both partial- and full-thickness burns. The nurse is asked to
prepare for the arrival of the child and gathers supplies,
anticipating that which treatment will be prescribed initially?
1.
Insertion of a Foley catheter
2.
Insertion of a nasogastric tube
3.
Administration of an anesthetic agent for sedation
4.
Application of an antimicrobial agent to the burns Correct
Answer Insertion of a Foley catheter
A Foley catheter is inserted into the child's bladder so that urine
output can be accurately measured on an hourly basis. Although
pain medication may be required, the child would not receive an
anesthetic agent and should not be sedated. The burn wounds
would be cleansed after assessment, but this would not be the
initial action. Intravenous fluids are administered at a rate
sufficient to keep the child's urine output at 1 to 2 mL/kg of
body weight per hour for children weighing less than 30 kg, thus
reflecting adequate tissue perfusion. A nasogastric tube may or
may not be required but would not be the priority intervention.
,A 5-year-old boy is brought by his mother to the emergency
department after ingesting a bottle of acetylsalicylic acid. Which
procedure should be initially instituted with this child?
1.
Administer ipecac by mouth and monitor emesis.
2.
Institute a gastric lavage and administer activated charcoal.
3.
Administer a chelating agent such as edetate calcium disodium.
4.
Institute a gastric lavage and administer the antidote
acetylcysteine. Correct Answer Institute a gastric lavage and
administer activated charcoal.
A gastric lavage must be performed after ingestion of
acetylsalicylic acid, and activated charcoal is administered to
prevent further absorption of the substance. N-acetylcysteine is
the antidote for acetaminophen. Administering ipecac or edetate
calcium disodium is not a treatment measure for acetylsalicylic
acid poisoning. Edetate calcium disodium may be prescribed for
the treatment of lead poisoning. Ipecac causes vomiting, and this
substance is used only in specific poisoning conditions; in this
situation, vomiting can cause irritation of the esophagus.
A child is admitted to the hospital after being seen in the
emergency department with complaints of right lower quadrant
abdominal pain, nausea and vomiting, fever, and chills. The
health care provider (HCP) suspects appendicitis. Which
,assessment finding should the nurse immediately report to the
HCP?
1.
Decreasing oral temperature
2.
Increasing complaints of pain
3.
Refusal to take fluids by mouth
4.
Sudden relief of abdominal pain Correct Answer Sudden relief
of abdominal pain
A sudden relief of pain from a suspected appendicitis is
commonly indicative of a ruptured appendix. This places the
individual at risk for peritonitis and shock. The HCP should be
notified immediately because of the need to begin intravenous
antibiotics to prevent further complications. Although increasing
complaints of pain is a concern, the higher priority is sudden
relief of pain because of the risk of peritonitis and shock.
Temperature should be monitored but is not of highest priority.
The child will be placed on NPO (nothing by mouth) status in
anticipation of surgery; therefore, option 4 is incorrect.
A child is receiving succimer for the treatment of lead
poisoning. The nurse should monitor which most important
laboratory result?
1.
, Iron level
2.
Calcium level
3.
Red blood cell count
4.
Blood urea nitrogen level Correct Answer Blood urea nitrogen
level
Succimer is a medication that is used to treat lead poisoning.
Renal function (blood urea nitrogen and creatinine) is monitored
closely during the administration of chelation therapy because
the medication is excreted via the kidneys. Although it is
important to monitor the iron level, calcium level, and red blood
cell count, these results are not specific to chelation therapy, so
they are not the most important lab values to monitor.
A child undergoes surgical removal of a brain tumor. During the
postoperative period, the nurse notes that the child is restless, the
pulse rate is elevated, and the blood pressure has decreased
significantly from the baseline value. The nurse suspects that the
child is in shock. Which is the most appropriate nursing action?
1.
Place the child in a supine position.
2.
Notify the health care provider (HCP).
3.
Place the child in Trendelenburg's position.
4.
