1. The critical care nurse is caring for a patient who is in cardiogenic shock. What health status indicator must the nurse assess on this
patient? Select all that apply.
a) Platelet level
*b) Fluid status
*c) Cardiac rhythm
*d) Cardiac ejection fraction
e) Sputum culture
~ The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, ejection fraction, monitor
hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels
and sputum production/culture are not major assessment parameters in a patient who is experiencing cardiogenic shock.
2. The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the
nurse implement to greatly decrease the patient's risk of developing pulmonary emboli (PE)?
*a) Early ambulation
b) Increased dietary intake of protein
c) Maintaining the patient in a supine position
d) Administering aspirin with warfarin
~ For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to
avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not
require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the
postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the
surgical procedure. Aspirin should never be administered with warfarin because it will increase the patient's risk for bleeding.
3. The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this
disease to differentiate the patient's symptoms from those of a cardiac etiology?
a) Carboxyhemoglobin level
*b) Brain natriuretic peptide (BNP) level
c) C-reactive protein (CRP) level
d) Complete blood count
~ Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels,
echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary
edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS.
CRP and CBC levels do not help differentiate from a cardiac problem.
4. The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use
of accessory muscles and is complaining of chest pain and shortness of breath with pulse oximetry reading of 89%. The nurse should
recognize the possibility of what condition?
*a) Pneumothorax
b) Hypovolemic shock
c) Subcutaneous emphysema
d) Septic Shock
~ If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and
air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms
are not definitive of pneumothorax, but because of the patient's recent trauma they are inconsistent with subcutaneous emohysema,
hypovolemic shock,
5. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should
the nurse include in the patient's plan of care?
*a) Suctioning secretions to clear patient's airway.
b) Promote usage of high-dose opioids for sedation.
c) Aggressive fluid resuscitation.
d) Immediately sedate and intubate the patient.
~ As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and
controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep
breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to
stabilize the flail segment.
As with rib fracture, treatment of flail chest is usually supportive. Management includes providing ventilatory support, clearing secretions
from the lungs, and controlling pain. Specific management depends on the degree of respiratory dysfunction. If only a small segment of
the chest is involved, the objectives are to clear the airway through positioning, coughing, deep breathing, and suctioning to aid in the
expansion of the lung, and to relieve pain by intercostal nerve blocks, high thoracic epidural blocks, or cautious use of IV opioids.
6. A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor
most closely on a patient who is postoperative following an embolectomy?
a) Pupillary response
b) Pressure in the vena cava
c) White blood cell differential
*d) Pulmonary arterial pressure
, ~ If the patient has undergone surgical embolectomy, the nurse measures the patient's pulmonary arterial pressure and urinary output.
Pressure is not monitored in a patient's vena cava. White cell levels and pupillary responses would be monitored, but not to the extent
of the patient's pulmonary arterial pressure.
If the patient has undergone surgical embolectomy, the nurse measures the patient’s pulmonary arterial pressure and urinary output.
The nurse also assesses the insertion site of the arterial catheter for hematoma formation and infection. Maintaining the blood pressure
at a level that supports perfusion of vital organs is crucial. p. 618
7.The nurse is caring for a patient with an endotracheal tube with mechanical ventilation. What should be the nurse's first step before
implementing suctioning process?
a) Explain the suctioning procedure to the patient and reposition the patient.
b) Turn on suction source at a pressure not exceeding 120 mm Hg.
*c) Assess the patient's lung sounds and SAO2 via pulse oximeter.
d) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
~ Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of
oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction
source is the fourth step.
8. The intensive care unit nurse is preparing to wean a patient from the ventilator. What parameter is most important for the nurse to
assess?
a) Fluid and electrolyte balance for the last 24 hours.
*b) Arterial blood gas (ABG) levels PaO2 greater than 60 mm Hg with FiO2 less than 40%.
c) Protein intake is 1.5g/kg/day for nutritional support.
d) Determine the size of the endotracheal tube with closed suction system.
~ Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process,
ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less
critical. Measuring fluid volume intake and output, nutrition needs and size of endotracheal tube and closed suction system is always
important when a patient is being mechanically ventilated but not as important with the ABG results.
9. A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3– 22 mEq/L.
Which intervention should the nurse implement first?
*a) Assess the airway.
b) Administer prescribed bronchodilators.
c) Provide oxygen.
d) Administer prescribed mucolytics.
~ All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing
and maintaining an airway. Without a patent airway, other interventions will not be helpful.
Question changed to respiratory alkalosisPAO2 of 60% give oxygen via nasal canula
10. A patient has been diagnosed with a massive pulmonary embolism (PE) and developed hypotension and hypoxemia. What
medication should the nurse anticipate the patient will need as the priority.
*a) Tissue plasminogen activator (Activase)
b) Enoxaparin (Lovenox)
c) Dabigatran (Pradaxa)
d) Warfarin sodium (Coumadin)
11. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client’s chest wall does not
appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the
priority?
a) Administer fluids and reassess.
b) Reassess level of consciousness and pulse.
c) Facilitate a portable chest x-ray.
*d) Prepare to assist with intubation.
~ This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately.
The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after
the client is intubated.
12. A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply
*a) hypotension
b) distended neck veins
*c) increasing hypoxemia
*d) absent breath sounds on the affected side
*e) tracheal deviation toward unaffected side
Changed and the answers were JVD, hemodynamic monitoring, and more!!!
13. A critical care patient is on mechanical ventilation with positive end expiratory pressure (PEEP). Which among the following clinical
manifestations noticed by the nurse suggests that a client is developing tension pneumothorax as a complication of mechanical
ventilation?
*a) new onset of absent breath sounds over the right lung
b) ronchi lung sounds on the left lung field
patient? Select all that apply.
a) Platelet level
*b) Fluid status
*c) Cardiac rhythm
*d) Cardiac ejection fraction
e) Sputum culture
~ The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm, ejection fraction, monitor
hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment data. Platelet levels
and sputum production/culture are not major assessment parameters in a patient who is experiencing cardiogenic shock.
2. The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the
nurse implement to greatly decrease the patient's risk of developing pulmonary emboli (PE)?
*a) Early ambulation
b) Increased dietary intake of protein
c) Maintaining the patient in a supine position
d) Administering aspirin with warfarin
~ For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to
avoid venous stasis, early ambulation, and use of elastic compression stocking are general preventive measures. The patient does not
require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the
postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the
surgical procedure. Aspirin should never be administered with warfarin because it will increase the patient's risk for bleeding.
3. The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this
disease to differentiate the patient's symptoms from those of a cardiac etiology?
a) Carboxyhemoglobin level
*b) Brain natriuretic peptide (BNP) level
c) C-reactive protein (CRP) level
d) Complete blood count
~ Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels,
echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary
edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS.
CRP and CBC levels do not help differentiate from a cardiac problem.
4. The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use
of accessory muscles and is complaining of chest pain and shortness of breath with pulse oximetry reading of 89%. The nurse should
recognize the possibility of what condition?
*a) Pneumothorax
b) Hypovolemic shock
c) Subcutaneous emphysema
d) Septic Shock
~ If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and
air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms
are not definitive of pneumothorax, but because of the patient's recent trauma they are inconsistent with subcutaneous emohysema,
hypovolemic shock,
5. An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should
the nurse include in the patient's plan of care?
*a) Suctioning secretions to clear patient's airway.
b) Promote usage of high-dose opioids for sedation.
c) Aggressive fluid resuscitation.
d) Immediately sedate and intubate the patient.
~ As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and
controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep
breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to
stabilize the flail segment.
As with rib fracture, treatment of flail chest is usually supportive. Management includes providing ventilatory support, clearing secretions
from the lungs, and controlling pain. Specific management depends on the degree of respiratory dysfunction. If only a small segment of
the chest is involved, the objectives are to clear the airway through positioning, coughing, deep breathing, and suctioning to aid in the
expansion of the lung, and to relieve pain by intercostal nerve blocks, high thoracic epidural blocks, or cautious use of IV opioids.
6. A patient in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter does the nurse monitor
most closely on a patient who is postoperative following an embolectomy?
a) Pupillary response
b) Pressure in the vena cava
c) White blood cell differential
*d) Pulmonary arterial pressure
, ~ If the patient has undergone surgical embolectomy, the nurse measures the patient's pulmonary arterial pressure and urinary output.
Pressure is not monitored in a patient's vena cava. White cell levels and pupillary responses would be monitored, but not to the extent
of the patient's pulmonary arterial pressure.
If the patient has undergone surgical embolectomy, the nurse measures the patient’s pulmonary arterial pressure and urinary output.
The nurse also assesses the insertion site of the arterial catheter for hematoma formation and infection. Maintaining the blood pressure
at a level that supports perfusion of vital organs is crucial. p. 618
7.The nurse is caring for a patient with an endotracheal tube with mechanical ventilation. What should be the nurse's first step before
implementing suctioning process?
a) Explain the suctioning procedure to the patient and reposition the patient.
b) Turn on suction source at a pressure not exceeding 120 mm Hg.
*c) Assess the patient's lung sounds and SAO2 via pulse oximeter.
d) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.
~ Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of
oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction
source is the fourth step.
8. The intensive care unit nurse is preparing to wean a patient from the ventilator. What parameter is most important for the nurse to
assess?
a) Fluid and electrolyte balance for the last 24 hours.
*b) Arterial blood gas (ABG) levels PaO2 greater than 60 mm Hg with FiO2 less than 40%.
c) Protein intake is 1.5g/kg/day for nutritional support.
d) Determine the size of the endotracheal tube with closed suction system.
~ Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process,
ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less
critical. Measuring fluid volume intake and output, nutrition needs and size of endotracheal tube and closed suction system is always
important when a patient is being mechanically ventilated but not as important with the ABG results.
9. A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3– 22 mEq/L.
Which intervention should the nurse implement first?
*a) Assess the airway.
b) Administer prescribed bronchodilators.
c) Provide oxygen.
d) Administer prescribed mucolytics.
~ All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing
and maintaining an airway. Without a patent airway, other interventions will not be helpful.
Question changed to respiratory alkalosisPAO2 of 60% give oxygen via nasal canula
10. A patient has been diagnosed with a massive pulmonary embolism (PE) and developed hypotension and hypoxemia. What
medication should the nurse anticipate the patient will need as the priority.
*a) Tissue plasminogen activator (Activase)
b) Enoxaparin (Lovenox)
c) Dabigatran (Pradaxa)
d) Warfarin sodium (Coumadin)
11. A client is brought to the emergency department after sustaining injuries in a severe car crash. The client’s chest wall does not
appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the
priority?
a) Administer fluids and reassess.
b) Reassess level of consciousness and pulse.
c) Facilitate a portable chest x-ray.
*d) Prepare to assist with intubation.
~ This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately.
The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after
the client is intubated.
12. A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply
*a) hypotension
b) distended neck veins
*c) increasing hypoxemia
*d) absent breath sounds on the affected side
*e) tracheal deviation toward unaffected side
Changed and the answers were JVD, hemodynamic monitoring, and more!!!
13. A critical care patient is on mechanical ventilation with positive end expiratory pressure (PEEP). Which among the following clinical
manifestations noticed by the nurse suggests that a client is developing tension pneumothorax as a complication of mechanical
ventilation?
*a) new onset of absent breath sounds over the right lung
b) ronchi lung sounds on the left lung field
