Critical Care - Exam 2 questions well
answered
A nursing student is helping care for a patient on the ventilator with posttraumatic brain
swelling, which causes him to have an increased ICP. Which action by the student would require
intervention by the nurse?
A. The student positions the head of the patient's bed at 30 degrees.
B. The student suctions the patient for 10 seconds, three times in a row to ensure all secretions
have been cleared from the patient's airway.
C. The student leaves the light on in the room after she is finished giving a medication.
D. The student repositions and turns the patient every two hours. - ANS ✔✔B. The student
suctions the patient for 10 seconds, three times in a row to ensure all secretions have been
cleared from the patient's airway.
Suctioning increases ICP, must do very small amounts
The nurse provides care for a patient admitted for anaphylactic shock after eating shellfish.
Which family member statement indicates the need for addition teaching regarding this
condition?
A. "We will inform our doctor that contrast dye should be avoided in the future."
B. "We will have an EpiPen on hand wherever we go."
C. "A scratchy throat indicates the need for prompt intervention."
D. "My spouse requires a prescription for diphenhydramine prior to discharge." - ANS ✔✔D.
"My spouse requires a prescription for diphenhydramine prior to discharge."
,Diphenhydramine can be obtained over the counter, prescription is not needed.
A patient in the emergency room has hypovolemic shock. Which assessment finding indicates
that fluid resuscitation has been successful?
A. Hemoglobin of 13.5 g/dL
B. MAP of 50 mmHg
C. Urine output of 55 mL/hr
D. Blood pressure 85/52 - ANS ✔✔C. Urine output of 55 mL/hr
The nurse is caring for a patient with cardiogenic shock. Which intervention is included in the
plan of care?
A. Assess vital signs every 2 hours
B. Assess skin for dryness and pruritus
C. Maintain head of bed <10 degrees
D. Monitor breath sounds every 2-4 hours - ANS ✔✔D. Monitor breath sounds every 2-4 hours
Which assessment finding would indicate to the nurse that a patient is exhibiting early
symptoms of shock? Select All that Apply
A. Restlessness
B. Pallor
C. Increased Bowel Sounds
D. Increased Respiratory Rate
E. Decreased Blood Glucose - ANS ✔✔A. Restlessness
B. Pallor
, D. Increased Respiratory Rate
Bowel motility decreases, and blood glucose typically rises in response to stress
You are caring for a patient admitted for an acute episode of rectal bleeding. The patients vitals
are as follows: BP 112/78, HR 98, RR 22, SPO2 96% on room air, and temperature of 98.9F. If the
patient is suspected to be in a state of hypovolemic shock which of the following stages is he in?
A. Progressive
B. Compensatory
C. Initial
D. Secondary - ANS ✔✔B. Compensatory
You are providing care for a 23-year-old male patient, upon arrival your patient is hypotensive,
and bradycardic. The patient has received 2 liters of NS with no response. The patient was
climbing a tree when he feels to the ground and was unconscious. The patient was mobilized
with a cervical collar and long back board on the scene. The patients only complaint at this time
is tingling and burning sensation in his hands and arms. Which correlates with these findings?
A. Hypovolemic Shock due to suspected internal bleeding
B. Patient is young and may always have a low heart rate and blood pressure
C. Neurogenic shock due to a suspected spinal cord injury
D. The patient is at risk for fluid volume overload and pulmonary edema secondary to the 2
liters he received - ANS ✔✔C. Neurogenic shock due to a suspected spinal cord injury
You are working in the ICU and are caring for a patient who has just arrived from the inpatient
floor with new onset changes in their ECG and difficulty breathing. There is no evidence of an
MI, but upon assessment there are audible crackles bilaterally in the lower lobes of the lungs.
You also obtain a set of vital signs which are as follows: BP 96/54, HR 118, RR 24 SPO2 93% on 2
litters nasal cannula. Which of the following is the primary concern?
answered
A nursing student is helping care for a patient on the ventilator with posttraumatic brain
swelling, which causes him to have an increased ICP. Which action by the student would require
intervention by the nurse?
A. The student positions the head of the patient's bed at 30 degrees.
B. The student suctions the patient for 10 seconds, three times in a row to ensure all secretions
have been cleared from the patient's airway.
C. The student leaves the light on in the room after she is finished giving a medication.
D. The student repositions and turns the patient every two hours. - ANS ✔✔B. The student
suctions the patient for 10 seconds, three times in a row to ensure all secretions have been
cleared from the patient's airway.
Suctioning increases ICP, must do very small amounts
The nurse provides care for a patient admitted for anaphylactic shock after eating shellfish.
Which family member statement indicates the need for addition teaching regarding this
condition?
A. "We will inform our doctor that contrast dye should be avoided in the future."
B. "We will have an EpiPen on hand wherever we go."
C. "A scratchy throat indicates the need for prompt intervention."
D. "My spouse requires a prescription for diphenhydramine prior to discharge." - ANS ✔✔D.
"My spouse requires a prescription for diphenhydramine prior to discharge."
,Diphenhydramine can be obtained over the counter, prescription is not needed.
A patient in the emergency room has hypovolemic shock. Which assessment finding indicates
that fluid resuscitation has been successful?
A. Hemoglobin of 13.5 g/dL
B. MAP of 50 mmHg
C. Urine output of 55 mL/hr
D. Blood pressure 85/52 - ANS ✔✔C. Urine output of 55 mL/hr
The nurse is caring for a patient with cardiogenic shock. Which intervention is included in the
plan of care?
A. Assess vital signs every 2 hours
B. Assess skin for dryness and pruritus
C. Maintain head of bed <10 degrees
D. Monitor breath sounds every 2-4 hours - ANS ✔✔D. Monitor breath sounds every 2-4 hours
Which assessment finding would indicate to the nurse that a patient is exhibiting early
symptoms of shock? Select All that Apply
A. Restlessness
B. Pallor
C. Increased Bowel Sounds
D. Increased Respiratory Rate
E. Decreased Blood Glucose - ANS ✔✔A. Restlessness
B. Pallor
, D. Increased Respiratory Rate
Bowel motility decreases, and blood glucose typically rises in response to stress
You are caring for a patient admitted for an acute episode of rectal bleeding. The patients vitals
are as follows: BP 112/78, HR 98, RR 22, SPO2 96% on room air, and temperature of 98.9F. If the
patient is suspected to be in a state of hypovolemic shock which of the following stages is he in?
A. Progressive
B. Compensatory
C. Initial
D. Secondary - ANS ✔✔B. Compensatory
You are providing care for a 23-year-old male patient, upon arrival your patient is hypotensive,
and bradycardic. The patient has received 2 liters of NS with no response. The patient was
climbing a tree when he feels to the ground and was unconscious. The patient was mobilized
with a cervical collar and long back board on the scene. The patients only complaint at this time
is tingling and burning sensation in his hands and arms. Which correlates with these findings?
A. Hypovolemic Shock due to suspected internal bleeding
B. Patient is young and may always have a low heart rate and blood pressure
C. Neurogenic shock due to a suspected spinal cord injury
D. The patient is at risk for fluid volume overload and pulmonary edema secondary to the 2
liters he received - ANS ✔✔C. Neurogenic shock due to a suspected spinal cord injury
You are working in the ICU and are caring for a patient who has just arrived from the inpatient
floor with new onset changes in their ECG and difficulty breathing. There is no evidence of an
MI, but upon assessment there are audible crackles bilaterally in the lower lobes of the lungs.
You also obtain a set of vital signs which are as follows: BP 96/54, HR 118, RR 24 SPO2 93% on 2
litters nasal cannula. Which of the following is the primary concern?
