nsg 233 final

Question 1

Alcoholic- 1st assessment

Answer 1

Vital signs every 4 hours

Question 2

Burns- agitation

Answer 2

Sign of inhalation injury; also a sign of inadequate hydration

Question 3

ET tube-verify:

Answer 3

The nurse should first auscultate all lung fields to
verify safe placement of the endotracheal (ET) tube by assessing for
the presence of breath sounds in all lung lobes. Verifying ET tube
placement should be confirmed by chest x-ray.

Question 4

What things should be done to determine if an ETT tube is in place. This
is the select all that apply. There will be 3 answers.*

Answer 4

Chest Xray, the chest rises and falls bilaterally, and auscultate breath
sounds

CO2 detector changes color, chest rise & fall, auscultation, IF you
don’t hear something on one side, it’s in the right main, pull the tube
back. Check placement with XRAY

Question 5

Burns- electrical

Answer 5

Assessment: burn odor, leathery skin, cardiac arrest
Patient is at risk for acute kidney injury
Electrical burn pt put him in a cardiac telemetry monitor
Electrical burns: cardiac monitor for 24 hr. b/c dysrhythmias are
common

Question 6

The victims of a large-scale near-drowning incident are brought to the
emergency department. What is the minimum length of time all such
victims should be kept under observation in the hospital?

Answer 6

23 hours

Question 7

A nurse must establish and maintain an airway in a client who has
experienced a near-drowning in the ocean. For which potential danger
should the nurse assess the client?

Answer 7

Pulmonary Edema

Question 8

Following an ileal conduit urinary diversion, a male pt voices several
complaints. Which complaint indicates to the nurse that he is
experiencing a complication?

Answer 8

dark purplish colored stoma

Question 9

Auto dysreflexia- S&S
This medical emergency usually occurs after the period of spinal
shock has finished and is usually triggered by a noxious stimulus such
as bowel or bladder distention.

S/S of autonomic dysreflexia

Answer 9

HTN, diaphoresis, bradycardia, flushing; IV
Labetalol

Question 10

Which action should the nurse take when caring for a client with a
spinal injury who suddenly begins showing signs of autonomic
dysreflexia?

Answer 10

Elevate HOB

s/s
●Diaphoretic and headaches
Occurs in lesions @ T6 or higher - the BP increases and diaphoresis
Elevate HOB and look for source of it

Question 11

What assessment findings should the nurse document in the electronic
medical record for a client who is experiencing autonomic dysreflexia
after a T-4 spinal cord injury?

Answer 11

Severe diaphoresis, and flushing above the lesion

Question 12

The nurse is caring for a client who had gastric bypass surgery
yesterday. Which intervention is most important for the nurse to
implement during the first 24 postoperative hours?

Answer 12

Measure hourly urinary output

Question 13

Patient is septic. What do you do first?

Answer 13

● Give fluids first
● Then cultures
● Then broad-spectrum antibiotics

(possible negative question - in septic shock, massive vasodilation
occurs)
Constriction happens

Question 14

A client with acquired immunodeficiency syndrome (AIDS) has impaired
gas exchange from a respiratory infection. Which assessment finding
warrants immediate intervention by the nurse?

Answer 14

Pain when swallowing

Question 15

The nurse assesses a female client following surgery for a gunshot to
the abdomen and determines that the dressing is saturated with blood
and petechiae on the extremities. His current blood pressure is 80/40
and his heart rate is 130 Beats a minute. Which laboratory finding
confirms the presence of DIC?

Answer 15

Answer: positive D dimer

DIC Uses up all of the clotting factors. Pts bleed everywhere besides
fingers and toes.

Question 16

DIC

Answer 16

first sign is often gums bleeding (PT/INR)

Question 17

TX of DIC

Answer 17

Give heparin (even though they are bleeding); treat symptoms
Those at risk for DIC: trauma patients, pregnancy, those on bleeding
precautions

Question 18

A client develops peritonitis and sepsis after the surgical repair of a
ruptured diverticulum. What signs should the nurse expect when
assessing the client?

Answer 18

a. Fever
b. Tachypnea
d Abdominal rigidity

Question 19

A middle-aged client who was admitted for a multi-traumatic accident is
suspected of developing “Systemic Inflammatory Response” (SIRS).
Which set of vital signs would the nurse anticipate the client to display?

Answer 19

a. RR- 24 breaths/min; HR- 120 beats/minute; and temperature of
100.8???

Question 20

Increased ICP=Space out nursing interventions
s/s =

Answer 20

Decreased pulse and increased BP with changes in LOC

Question 21

In developing a care plan for the patient that has a chest tube and
hemothorax, the nurse should recognize which intervention is essential?

Answer 21

Encourage the client to breathe deeply and cough at frequent intervals

Question 22

Chest tubes- transport

Answer 22

Keep chest tube below level of insertion point when transporting

Question 23

If a PT has a chest tube and they want to walk, how do you carry the
chest tube container?

Answer 23

Keep it below the incision point
If the chest tube is inadvertently dislodged from the client, the nurse
should cover with a dry sterile dressing taped on three sides.

Question 24

A client reports left-sided chest pain after playing racquetball. The
client is hospitalized and diagnosed with left pneumothorax. When
assessing the client’s left chest area, the nurse expects to identify
which finding?

Answer 24

Absence of breath sounds on auscultation

Question 25

Client has a pneumothorax and has a chest tube with NO fluctuation in the water seal. What should the nurse do?

Answer 25

Assess lung sounds

Question 26

On admission to the intensive care for sepsis due to a ruptured appendix, a female client's temperature is 39.8°C and her blood pressure is 68/42. Other hemodynamic findings include cardiac output of 10.71 L/minute, systemic vascular resistance (SVR) of 480 dynes/sec/cm3, and white blood cell count (WBC) of 28000 mm3. Which classification of medications is likely to stabilize this client?

Answer 26

Vasoconstrictor

Question 27

On admission, the client is septic due to a ruptured appendix; vitals of temp 39.8 , WBC 18,000, BP 68/42. What class of meds is needed?

Answer 27

vasoconstrictor

Question 28

MODS- hypotension

Answer 28

Can result from sepsis or trauma. VS change (tachypnea, high HR, low BP) if MAP is consistently low, it is indicative of MODS.

Question 29

A client who had a craniotomy yesterday develops an oral temperature of 103°F. The nurse gives the client a tepid sponge bath. With instituting measures to reduce the clients fever what additional action should be taken to prevent an increase in intracranial pressure?

Answer 29

Limit exposure to prevent shivering

Question 30

SCI- immediate intervention

Answer 30

Spinal cord shock cause hypotension from decreased reflexes not fluid depletion Give IV fluids; check for pul edema Check gag reflex bc inc risk aspiration Hesi Hint: Physical assessment should concentrate on respiratory status, especially in clients with injury at C3 to C5, because the cervical plexus innervates the diaphragm. Maintain client in extended position with cervical collar on during transfer. You might need traction to stabilize or align your spine. Options include soft neck collars and various braces

Question 31

Dissection aneurysm Symptoms of rupture:

Answer 31

hypovolemic or cardiogenic shock with sudden, severe abdominal pain The most common symptom is abdominal pain or low back pain, with the complaint that the client can feel his or her heart beating.

Question 32

Cardiogenic shock- S&S

Answer 32

Decreased cardiac output is a primary cause of cardiogenic shock. The majority of cases of cardiogenic shock are caused by: acute myocardial infarction.

Question 33

Mechanical ventilation- shock

Answer 33

HESI Hint #2: Interventions to prevent complications on mechanical ventilation with ARDS Elevate HOB to at least 30 degrees. Assist with daily awakening ("sedation vacation"). Implement a comprehensive oral hygiene program. Implement a comprehensive mobilization program

Question 34

Cardiac tamponade- PEA

Answer 34

Tamponade is the MCC of PEA prepare the client for pericardiocentesis

Question 35

What is the therapeutic effect of head-of-the-bed elevation and neutral head and neck alignment on increased intracranial pressure (ICP)?

Answer 35

Lowering ICP by facilitating venous drainage and decreasing venous obstruction Look for sx of increased ICP. Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate increased ICP.

Question 36

A patient is receiving CPR. After asystole is confirmed in 2 leads and sending the transcutaneous pacemaker, which IV mediation should be administered?

Answer 36

epinephrine

Question 37

A female client has been in asystole for 20 minutes. She is intubated and epinephrine 1 mg and atropine sulfate 1 mg were administered with no change in rhythm or client status. What should the nurse implement?

Answer 37

Bring members of the family to a private area to discuss the desire to continue life support efforts

Question 38

The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. What parameter should the nurse use to evaluate a therapeutic response to dopamine?

Answer 38

monitor urinary output septic shock and dopamine do not give dopamine until fluids are replaced

Question 39

A client arrives in the emergency department via ambulance with injuries that resulted from being hit by a bus. Vitals signs on admission are: BP 126/78 mmHg, heart rate 100/minute, respirations 28 breast/minute, temperature 99°F. Bloody drainage is noted at the clients left ear canal. What should the nurse do to assess for possible basilar skull fracture and cerebral spinal fluid (CSF) leak?

Answer 39

Dab blood from ear with sterile gauze and observe for halo

Question 40

Auto dysreflexia- document

Answer 40

T6 or higher - the BP increases and diaphoresis; Elevate HOB and look for source of it

Question 41

Change in level of responsiveness is the most important indicator of increased ICP. A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA). The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first?

Answer 41

a. Place the head and neck in alignment. Tx: osmotic diuretics

Question 42

The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care?

Answer 42

The client will remain free of infection.

Question 43

A client with a long history of alcohol abuse develops cirrhosis of the liver. The client exhibits the presence of ascites. What does the nurse conclude is the most likely cause of this client's ascites?

Answer 43

Impaired portal venous return

Question 44

HIV- candidiasis

Answer 44

Thick white exudate in the mouth * Unusual taste to food * Retrosternal burning * Oral ulcers

Question 45

Esophageal varices- rep

Answer 45

Results from liver failure, HTN in esophagus, or lower & upper GI bleeds. May rupture and bleed

Question 46

TX of esophageal varices

Answer 46

Place NG tube; monitor the amount of blood loss. Replace with blood (PRN) and fluids. Portal HTN, in turn causes esophageal varices to occur, what med will be prescribed to prevent further bleeding from esophageal varices: propranolol….and vasopressin stop bleeding

Question 47

Blakemore tube

Answer 47

blow up sections of it so it applies pressure (pt. can aspirate) when they can't breathe, pull the tube- they have aspirated . Blackmore tube = tamponade tube Consists of Gastric balloon and esophageal balloon Gastric balloon gets dislodged = patient will aspirate Complains of dyspnea or SOB – tube come out

Question 48

Medication for esophageal varices

Answer 48

Use sandostatin (octreotide)- decreases pressure in the splenic blood supply

Question 49

The nurse is assessing a group of older adults. What factor in a male pt's hx puts him at greatest risk for developing colon cancer?

Answer 49

Polyps. Intestinal polyps are precancerous lesions and are a major risk for colon cancer

Question 50

prevent rupture of the AAA, the client's must be maintained normotensive, so the elevated blood pressure (D) should be reported to the healthcare provider.

Answer 50

Assess all peripheral pulses and vital signs regularly

Question 51

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon. Which assessment found by the nurse is the most important and should be reported to the HCP immediately?

Answer 51

Hematemesis

Question 52

client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care?

Answer 52

B) Leukopenia

Question 53

Pneumonectomy- chest tube

Answer 53

Chest tubes are not usually used.

Question 54

Thoracotomy- water seal functionality

Answer 54

1. bubbling in water-seal chamber should be gentle and indicate air drainage from the client 2. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation 3. Gentle (not vigorous) bubbling should be noted in the suction-control chamber

Question 55

The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Answer 55

Clear fluid leaking from the nose

Question 56

Dysrhythmias and calcium

Answer 56

One of the most frequent electrolyte abnormalities in critical care, hypocalcemia accounts for 55% to 77% of all electrolyte imbalance

Question 57

If someone has a AAA, what would you be looking for post-op on them?

Answer 57

Pulses in lower extremities (Aware of bending extremities) ■ keep them lying low and not in high fowlers ○ Guarding in abdomen ○ Urinary output might be decreased

Question 58

A Snake skin bite leads to anaphylactic shock. What should we do?

Answer 58

- leave a tourniquet on if they have one on - Give them the antivenom - Elevate the extremity - Ice would worsen the bite Obtaining intravenous access by inserting an IV catheter is the priority intervention so that fluids and medications can Downloaded by Nathaline Gn (ngerm000@gmail.com) lOMoARcPSD|20079053 be administered to increase the client's blood pressure, which is lowered because of massive vasodilation

Question 59

A male client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped at this time. What action is most important for the nurse to take?

Answer 59

Pt is at risk for ANS: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect E. Bone fractures

Question 60

Skin lesions- possible kaposi’s sarcoma

Answer 60

Purple-blue lesions on skin, often arms and legs * Invasion of gastrointestinal tract, lymphatic system, lungs, and brain

Question 61

Colon cancer- tumor markers

Answer 61

CEA. Carcinoembryonic antigen (CEA) serum level is used to evaluate effectiveness of chemotherapy.

Question 62

What might be an acute complication of liver failure that may be an emergent situation?

Answer 62

Esophageal varices burst

Question 63

The patient has been in the progressive care unit for the past 7 days with the diagnosis of liver failure. The nurse notes that the patient has developed a flapping tremor of the hand. The nurse should:

Answer 63

notify the provider because this is a sign that the disease is progressing.

Question 64

The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess?

Answer 64

Upper chest subcutaneous emphysema. Rationale: Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube