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1. The nurse is caring for a client who B.) Prepare to administer desmopressin (DDAVP).
presents with stroke-like symptoms.
The healthcare provider reviews the Neurogenic diabetes insipidus (DI) is a condition
client's computerized axial tomogra- that can occur when there is trauma to the brain
phy (CAT) scan and prescribes recom- such as tumors or injury to the brain in partic-
binant tissue plasminogen activator ular the pituitary or hypothalamus area. DI can
(rtPA) IV. Which information should also occur with cerebral edema present. The an-
the nurse obtain to determine if the tidiuretic hormone deficiency occurs rapidly and
client is a candidate for this treatment results in polyuria, anywhere between 5- 40 liters of
now? urine/24 hours. The client demonstrates signs and
A.) Identify the underlying cause of symptoms of hypovolemia. Electrolyte imbalances
this condition. include hypernatremia, along with hypokalemia
B.) Prepare to administer desmo- and hypercalcemia when it is neurogenic etiology.
pressin (DDAVP). Clients with neurogenic DI are primarily controlled
C.) Decrease the intravenous fluids to through administration of exogenous ADH prepa-
a maintenance rate. rations, of which desmopressin (DDAVP) is most
D.) Replace fluid losses with D5W every commonly used. Fluid output is carefully monitored
shift and fluids are replaced every hour.
2. An intubated client is in the process A.) Oxygen saturation is 91%
of being weaned off ventilator sup- C.) Heart rate is 97 beats/minute.
port. The client's baseline parame- D.) Work of breathing is done by client
ters are temperature 98.2 F (36.8 C),
heart rate 88 beats/minute, respira- Criteria that indicates a client is tolerating weaning
tions 14 breaths/minute, blood pres- off ventilator support are respirations greater than
sure 112/78 mmHg, and oxygen sat- 8 breaths/minute, but less than 35 breaths/minute;
uration 94%. Which assessment find- oxygen saturation above 90%; heart rate that does
ings would indicate to the nurse that not increase more than 20% from baseline heart
the client is tolerating the weaning rate; most of the work of breathing is performed by
procedure? (Select all that apply.) the client; and no signs of accessory muscles are
A.) Oxygen saturation is 91% used for breathing.
B.) Slight nasal flaring is present.
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C.) Heart rate is 97 beats/minute.
D.) Work of breathing is done by client
E.) Respiratory rate is 36
breaths/minute.
3. The nurse is assessing a burn victim B.) Superficial partial-thickness, 18% TBSA
who suffered destruction of the epi-
dermis and some of the dermis of the A "superficial partial-thickness" burn involves de-
entire right arm and half the length struction of the epidermis layer and some of the
of the right leg. How should the nurse dermis layer. The total body surface area (%TBSA)
document the burn assessment find- is easily calculated by using the "rule of nines"
ings? method. In this case, involvement of one arm is
A.) Superficial, 18% TBSA. calculated as 9% TBSA and one-half of a leg is 9%
B.) Superficial partial-thickness, 18% TBSA for a combined total of 18% TBSA. A total leg
TBSA. involvement is calculated as 18% TBSA.
C.) Deep-partial thickness, 27% TBSA.
D.) Full-thickness, 27% TBSA.
4. he critical care nurse is providing care B.) Maintaining a normal blood pressure.
for a client diagnosed clinically brain C.) Ensuring adequate oxygenation and ventila-
dead and identified as an organ donor. tion.
Which are the nurse's priorities in pro- D.) Treating any coagulopathy, thrombocytopenia
viding care? (Select all that apply.) and anemia.
A.) Sustaining a state of hypothermia. E.) Monitoring arterial blood gases and serum
B.) Maintaining a normal blood pres- electrolytes levels.
sure.
C.) Ensuring adequate oxygenation Once an identified organ donor has been de-
and ventilation. clared clinically brain dead, the primary focus of
D.) Treating any coagulopathy, throm- care changes from preserving life to preserving
bocytopenia and anemia. organ functioning. This is done by maintaining nor-
E.) Monitoring arterial blood gases mal blood pressures, fluid levels, electrolytes lev-
and serum electrolytes levels. els, serum glucose levels, and normothermia. Me-
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chanical ventilation is provided to maintain ade-
quate oxygenation and normal acid-base balance.
If needed, pharmaceutical support is provided for
the treatment of anemia, coagulopathy, thrombo-
cytopenia, and diabetes insipidus. Physiological
changes occur to bodily functions as the result of
decreased perfusion within the brain.
5. A client is admitted to the intensive A.) Absent bowel sounds.
care unit with hematemesis related
to esophageal varices. Which assess- Massive blood loss redirects a significant amount of
ment finding should the nurse identify blood flow to vital organs. A client who has lost 30%
that is the result of an estimated blood to 40% of the total blood volume will exhibit ab-
loss at 35% of total blood volume? sent bowel sounds, lethargy, and increased serum
A.) Absent bowel sounds. potassium.
B.) Coma.
C.) Anuria.
D.) Abdominal pain.
6. The nurse is planning care for a client A.) Contrast-enhanced computed tomography
admitted to the intensive care unit (CT)
with acute infected necrotizing pan-
creatitis. Which diagnostic procedure Contrast-enhanced computed tomography (CT) is
should the nurse prepare the client to the imaging modality of choice to evaluate peripan-
expect the healthcare provider to pre- creatic necrosis.
scribe?
A.) Contrast-enhanced computed to-
mography (CT).
B.) Endoscopic retrograde cholan-
giopancreatography (ERCP).
C.) Abdominal radiography.
D.) Abdominal ultrasound.