Pain is best described as

a. a creation of a person's imagination.
b. an unpleasant, subjective experience.
c. a maladaptive response to a stimulus.
d. a neurologic event resulting from activation of nociceptors.

B

A patient is receiving a PCA infusion after surgery to repair a hip fracture. She is sleeping soundly but awakens when the nurse speaks to her in a normal tone of voice. Her respirations are 8 breaths/minute. The most appropriate nursing action in this situation is to

a. stop the PCA infusion.
b. obtain an oxygen saturation level.
c. continue to closely monitor the patient.
d. administer naloxone and contact the physician.

C

Unrelieved pain is

a. expected after major surgery.
b. expected in a person with cancer.
c. dangerous and can lead to many physical and psychologic complications.
d. an annoying sensation, but it is not as important as other physical care needs.

C

A cancer patient who reports ongoing, constant moderate pain with short periods of severe pain during dressing changes is

a. probably exaggerating his pain.
b. best treated by referral for surgical treatment of his pain.
c. best treated by receiving a long-acting and a short-acting opioid.
d. best treated by regularly scheduled short-acting opioids plus acetaminophen.

C

An example of distraction to provide pain relief is

a. TENS.
b. music.
c. exercise.
d. biofeedback.

B

An important nursing responsibility related to pain is to

a. leave the patient alone to rest.
b. help the patient appear to not be in pain.
c. believe what the patient says about the pain.
d. assume responsibility for eliminating the patient's pain.

C

Providing opioids to a dying patient who is experiencing moderate to severe pain

a. may cause addiction.
b. will probably be ineffective.
c. is an appropriate nursing action.
d. will likely hasten the person's death.

C

A nurse believes that patients with the same type of tissue injury should have the same amount of pain. This statement reflects

a. a belief that will contribute to appropriate pain manage​ment.
b. an accurate statement about pain mechanisms and an expected goal of pain therapy.
c. a belief that will have no effect on the type of care provided to people in pain.
d. a lack of knowledge about pain mechanisms, which is likely to contribute to poor pain management.

D

Transmission of HIV from an infected individual to another most commonly occurs as a result of

a. unprotected anal or vaginal sexual intercourse.
b. low levels of virus in the blood and high levels of CD4+ T cells.
c. transmission from mother to infant during labor and delivery and breastfeeding.
d. sharing of drug-using equipment, including needles, syringes, pipes, and straws.

A

During HIV infection

a. reverse transcriptase helps HIV fuse with the CD4+ T cell.
b. HIV RNA uses the CD4+ T cell's mitochondria to replicate.
c. the immune system is impaired predominantly by the eventual widespread destruction of CD4+ T cells.
d. a long period of dormancy develops during which HIV cannot be found in the blood and there is little viral replication.

C

A diagnosis of AIDS is made when an HIV-infected patient has

a. a CD4+ T cell count below 200/μL.
b. a high level of HIV in the blood and saliva.
c. lipodystrophy with metabolic abnormalities.
d. oral hairy leukoplakia, an infection caused by Epstein-Barr virus.

A

Screening for HIV infection generally involves

a. detecting CD8+ cytotoxic T cells in saliva.
b. laboratory analysis of saliva to detect CD4+ T cells.
c. analysis of lymph tissues for the presence of HIV RNA.
d. laboratory analysis of blood to detect HIV antigen or antibody.

D

HIV antiretroviral drugs are used to

a. cure acute HIV infection.
b. decrease viral RNA levels.
c. treat opportunistic diseases.
d. decrease pain and symptoms in terminal disease.

B

Opportunistic diseases in HIV infection

a. are usually benign.
b. are generally slow to develop and progress.
c. occur in the presence of immunosuppression.
d. are curable with appropriate drug interventions.

C

Which strategy can the nurse teach the patient to eliminate the risk of HIV transmission?

a. Using sterile equipment to inject drugs
b. Cleaning equipment used to inject drugs
c. Taking lamivudine (Epivir) during pregnancy
d. Using latex or polyurethane barriers to cover genitalia during sexual contact

A

What is the most appropriate nursing intervention to help an HIV-infected patient adhere to a treatment regimen?

a. “Set up” a drug pillbox for the patient every week.
b. Give the patient a video and a brochure to view and read at home.
c. Tell the patient that the side effects of the drugs are bad but that they go away after a while.
d. Assess the patient's routines and find adherence cues that fit into the patient's life circumstances.

D

Trends in the incidence and death rates of cancer include the fact that

a. lung cancer is the most common type of cancer in men.
b. a higher percentage of women than men have lung cancer.
c. breast cancer is the leading cause of cancer deaths in women.
d. African Americans have a higher death rate from cancer than whites.

D

A characteristic of the stage of progression in the development of cancer is

a. oncogenic viral transformation of target cells.
b. a reversible steady growth facilitated by carcinogens.
c. a period of latency before clinical detection of cancer.
d. proliferation of cancer cells despite host control mechanisms.

D

The primary protective role of the immune system related to malignant cells is

a. surveillance for cells with tumor-associated antigens.
b. binding with free antigen released by malignant cells.
c. production of blocking factors that immobilize cancer cells.
d. reacting to a new set of antigenic determinants on cancer cells.

A

The nurse is caring for a 59-year-old woman who had surgery 1 day ago for removal of a malignant abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The most effective nursing intervention at this point is to use this opportunity to

a. motivate change in an unhealthy lifestyle.
b. teach her about the seven warning signs of cancer.
c. instruct her about healthy stress relief and coping practices.
d. let her communicate about the meaning of this experience.

D

The goals of cancer treatment are based on the principle that

a. surgery is the single most effective treatment for cancer.
b. initial treatment is always directed toward cure of the cancer.
c. a combination of treatment modalities is effective for controlling many cancers.
d. although cancer cure is rare, quality of life can be increased with treatment modalities.

C

The most effective method of administering a chemotherapy agent that is a vesicant is to

a. give it orally.
b. give it intraarterially.
c. use an Ommaya reservoir.
d. use a central venous access device.

D

The nurse explains to a patient undergoing brachytherapy of the cervix that she

a. must undergo simulation to locate the treatment area.
b. requires the use of radioactive precautions during nursing care.
c. may experience desquamation of the skin on the abdomen and upper legs.
d. requires shielding of the ovaries during treatment to prevent ovarian damage.

B

A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 × 103/μL, hemoglobin of 10.8 g/dL, and a platelet count of 99 × 103/ μL. Based on the CBC results, what is the most serious clinical finding?

a. Cough, rhinitis, and sore throat
b. Fatigue, nausea, and skin redness at site of radiation
c. Temperature of 101.9° F, fatigue, and shortness of breath
d. Skin redness at site of radiation, headache, and constipation

C

To prevent fever and shivering during an infusion of rituximab (Rituxan), the nurse should premedicate the patient with

a. aspirin.
b. acetaminophen.
c. sodium bicarbonate.
d. meperidine (Demerol).

B

The nurse counsels the patient receiving radiation therapy or chemotherapy that

a. effective birth control methods should be used for the rest of the patient's life.
b. if nausea and vomiting occur during treatment, the treatment plan will be modified.
c. after successful treatment, a return to the person's previous functional level can be expected.
d. the cycle of fatigue-depression-fatigue that may occur during treatment may be reduced by restricting activity.

C

A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense of taste. Which nursing intervention would be a priority?

a. Advise the patient to eat foods that are fatty, fried, or high in calories.
b. Discuss with the physician the need for parenteral or enteral feedings.
c. Advise the patient to drink a nutritional supplement beverage at least three times a day.
d. Advise the patient to experiment with spices and seasonings to enhance the flavor of food.

D

A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is confused when awake, and complains of nausea and constipation. Which complication of cancer is this most likely caused by?

a. Hypercalcemia
b. Tumor lysis syndrome
c. Spinal cord compression
d. Superior vena cava syndrome

A

A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the nurse to focus on?

a. Maintaining the patient's hope
b. Preparing a will and advance directives
c. Discussing replacement child care for the patient's children
d. Discussing the patient's past experiences with her grandmother's cancer

A

In a severely anemic patient, the nurse would expect to find

a. dyspnea and tachycardia.
b. cyanosis and pulmonary edema.
c. cardiomegaly and pulmonary fibrosis.
d. ventricular dysrhythmias and wheezing.

A

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about

a. folic acid intake.
b. dietary intake of iron.
c. a history of gastric surgery.
d. a history of sickle cell anemia.

B

A complication of the hyperviscosity of polycythemia is

a. thrombosis.
b. cardiomyopathy.
c. pulmonary edema.
d. disseminated intravascular coagulation (DIC).

A

When caring for a patient with thrombocytopenia, the nurse instructs the patient to

a. dab his or her nose instead of blowing.
b. be careful when shaving with a safety razor.
c. continue with physical activities to stimulate thrombopoiesis.
d. avoid aspirin because it may mask the fever that occurs with thrombocytopenia.

A

The nurse would anticipate that a patient with von Willebrand disease undergoing surgery would be treated with administration of vWF and

a. thrombin.
b. factor VI.
c. factor VII.
d. factor VIII.

D

DIC is a disorder in which

a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels.
b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts.
c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage.
d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature.

C

Because myelodysplastic syndrome arises from the pluripotent hematopoietic stem cell in the bone marrow, laboratory results the nurse would expect to find
include a(n)

a. excess of T cells.
b. excess of platelets.
c. deficiency of granulocytes.
d. deficiency of all cellular blood components.

D

The most common type of leukemia in older adults is

a. acute myelocytic leukemia.
b. acute lymphocytic leukemia.
c. chronic myelocytic leukemia.
d. chronic lymphocytic leukemia.

D

Multiple drugs are often used in combinations to treat leukemia and lymphoma because

a. there are fewer toxic and side effects.
b. the chance that one drug will be effective is increased.
c. the drugs are more effective without causing side effects.
d. the drugs work by different mechanisms to maximize killing of malignant cells.

D

The nurse is aware that a major difference between Hodgkin's lymphoma and non-Hodgkin's lymphoma is that

a. Hodgkin's lymphoma occurs only in young adults.
b. Hodgkin's lymphoma is considered potentially curable.
c. non-Hodgkin's lymphoma can manifest in multiple organs.
d. non-Hodgkin's lymphoma is treated only with radiation therapy.

C

A patient with multiple myeloma becomes confused and lethargic. The nurse would expect that these clinical manifestations may be explained by diagnostic results that indicate

a. hyperkalemia.
b. hyperuricemia.
c. hypercalcemia.
d. CNS myeloma.

C

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find

a. leukopenia.
b. RBC abnormalities.
c. decreased hemoglobin.
d. increased platelet count.

D

Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion are

a. chills and hemolysis.
b. leukostasis and neutrophilia.
c. fluid overload and pulmonary edema.
d. transmission of cytomegalovirus and fever.

D

In teaching a patient who wants to perform BSE, you inform her that the technique involves both the palpation of the breast tissue and

a. palpation of cervical lymph nodes.
b. hard squeezing of the breast tissue.
c. a mammogram to evaluate breast tissue.
d. inspection of the breasts for any changes.

D

You are caring for a young woman who has painful fibrocystic breast changes. Management of this patient would include

a. scheduling a biopsy to rule out malignant changes.
b. teaching that symptoms will probably subside if she stops using oral contraceptives.
c. preparing her for surgical removal of the lumps, since they will become larger and more painful.
d. explaining that restrictions of coffee and chocolate and supplements of vitamin E may relieve some discomfort.

D

When discussing risk factors for breast cancer with a group of women, you emphasize that the greatest known risk factor for breast cancer is

a. being a woman over age 60.
b. experiencing menstruation for 30 years or more.
c. using hormone therapy for 5 years for menopausal symptoms.
d. having a paternal grandmother with postmenopausal breast cancer.

A

A simple mastectomy has been scheduled for your patient with breast cancer. Postoperatively, to restore arm function on the affected side, you would

a. apply heating pads or blankets to increase circulation.
b. place daily ice packs to minimize the risk of lymphedema.
c. teach passive exercises with the affected arm in a dependent position.
d. emphasize regular exercises for the affected shoulder to increase range of motion.

D

Preoperatively, to meet the psychologic needs of a woman scheduled for a simple mastectomy, you would

a. discuss the limitations of breast reconstruction.
b. include her significant other in all conversations.
c. promote an environment for expression of feelings.
d. explain the importance of regular follow-up screening.

C

To prevent capsular formation after breast reconstruction with implants, teach the patient to

a. gently massage the area around the implant.
b. bind the breasts tightly with elastic bandages.
c. exercise the arm on the affected side to promote drainage.
d. avoid strenuous exercise until the implant has healed.

A

The individual with the lowest risk for sexually transmitted pelvic inflammatory disease is a woman who uses

a. oral contraceptives.
b. barrier methods of contraception.
c. an intrauterine device for contraception.
d. Norplant implant or injectable Depo-Provera for contraception.

B

The nurse is obtaining a subjective data assessment from a woman reported as a sexual contact of a man with chlamydial infection. The nurse understands that symptoms of chlamydial infection in women

a. are frequently absent.
b. are similar to those of genital herpes.
c. include a macular palmar rash in the later stages.
d. may involve chancres inside the vagina that are not visible.

A

Explain to the patient with gonorrhea that treatment will include both ceftriaxone and azithromycin because

a. azithromycin helps prevent recurrent infections.
b. some patients do not respond to oral drugs alone.
c. coverage with more than one antibiotic will prevent reinfection.
d. the increasing rates of drug resistance requires the use of at least two drugs.

D

To prevent the infection and transmission of STIs, the nurse's teaching plan would include an explanation of

a. the appropriate use of oral contraceptives.
b. sexual positions that can be used to avoid infection.
c. the necessity of annual Pap tests for patients with HPV.
d. sexual practices that are considered high-risk behaviors.

D

Provide emotional support to a patient with an STI by

a. offering information on how safer sexual practices can prevent STIs.
b. showing concern when listening to the patient who expresses negative feelings.
c. reassuring the patient that the disease is highly curable with appropriate treatment.
d. helping the patient who received an STI from his or her sexual partner in forgiving the partner.

B

In telling a patient with infertility what she and her partner can expect, the nurse explains that

a. ovulatory studies can help determine tube patency.
b. a hysterosalpingogram is a common diagnostic study.
c. the cause will remain unexplained for 40% of couples.
d. if postcoital studies are normal, infection tests will be done.

B

An appropriate question to ask the patient with painful menstruation to differentiate primary from secondary dysmenorrhea is

a. “Does your pain become worse with activity or overexertion?”
b. “Have you had a recent personal crisis or change in your lifestyle?”
c. “Is your pain relieved by nonsteroidal antiinflammatory medications?”
d. “When in your menstrual history did the pain with your period begin?”

D

The nurse should advise the woman recovering from surgical treatment of an ectopic pregnancy that

a. she has an increased risk for salpingitis.
b. bed rest must be maintained for 12 hours to assist in healing.
c. having one ectopic pregnancy increases her risk for another one.
d. intrauterine devices and infertility treatments should be avoided.

C

To prevent or decrease age-related changes that occur after menopause in a patient who chooses not to take hormone therapy, the most important self-care measure to teach is

a. maintaining usual sexual activity.
b. increasing the intake of dairy products.
c. performing regular aerobic, weight-bearing exercise.
d. taking vitamin E and B-complex vitamin supplements.

C

Nursing responsibilities related to the patient with endometrial cancer who has a total abdominal hysterectomy and salpingectomy and oophorectomy include

a. maintaining absolute bed rest.
b. keeping the patient in high Fowler's position.
c. need for supplemental estrogen after removal of ovaries.
d. encouraging movement and walking as much as tolerated.

D

The first nursing intervention for the patient who has been sexually assaulted is to

a. treat urgent medical problems.
b. contact support person for the patient.
c. provide supplies for the patient to cleanse self.
d. document bruises and lacerations of the perineum and the cervix.

A

Symptoms of BPH are primarily caused by

a. obstruction of the urethra.
b. untreated chronic prostatitis.
c. decreased bladder compliance.
d. excessive secretion of testosterone.

A

Postoperatively, a patient who has had a laser prostatectomy has continuous bladder irrigation with a three-way urinary catheter with a 30-mL balloon. When he complains of bladder spasms with the catheter in place, the nurse should

a. deflate the balloon to 10 mL to decrease bulk in the bladder.
b. deflate the balloon and then reinflate to ensure that it is patent.
c. encourage the patient to try to have a bowel movement to relieve colon pressure.
d. explain that this feeling is normal and that he should not try to urinate around the catheter.

D

A patient scheduled for a prostatectomy for prostate cancer expresses the fear that he will have erectile dysfunction. In responding to this patient, the nurse should keep in mind that

a. erectile dysfunction can occur even with a nerve-sparing procedure.
b. the most common complication of this surgery is postoperative bowel incontinence.
c. retrograde ejaculation affects sexual function more frequently than erectile dysfunction.
d. preoperative sexual function is the most important factor in determining
postoperative erectile dysfunction.

A

In assessing a patient for testicular cancer, the nurse understands that the manifestations of this disease often include

a. acute back spasms and testicular pain.
b. rapid onset of scrotal swelling and fever.
c. fertility problems and bilateral scrotal tenderness.
d. painless mass and heaviness sensation in the scrotal area.

D

To decrease the patient's discomfort related to discussing his reproductive organs, the nurse should

a. relate his sexual concerns to his sexual partner.
b. arrange to have male nurses care for the patient.
c. maintain a nonjudgmental attitude toward his sexual practices.
d. use technical terminology when discussing reproductive function.

C

The nurse suspects an ankle sprain when a patient at the urgent care center describes

a. being hit by another soccer player during a game.
b. having ankle pain after sprinting around the track.
c. dropping a 10-lb weight on his lower leg at the health club.
d. twisting his ankle while running bases during a baseball game.

D

A patient with a humeral fracture is returning for a 4-week checkup. The nurse explains that initial evidence of healing on x-ray is indicated by

a. formation of callus.
b. complete bony union.
c. hematoma at the fracture site.
d. presence of granulation tissue.

A

A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when

a. the patient is unable to tolerate prolonged immobilization.
b. the patient cannot tolerate the surgery for a closed reduction.
c. a temporary cast would be too unstable to provide normal mobility.
d. adequate alignment cannot be obtained by other nonsurgical methods.

D

The nurse suspects a neurovascular problem based on assessment of

a. exaggerated strength with movement.
b. increased redness and heat below the injury.
c. decreased sensation distal to the fracture site.
d. purulent drainage at the site of an open fracture.

C

A patient with a stable, closed humeral fracture has a temporary splint with bulky padding applied with an elastic bandage. The nurse notifies the surgeon of possible early compartment syndrome when the patient experiences

a. increasing edema of the limb.
b. muscle spasms of the lower arm.
c. bounding pulse at the fracture site.
d. pain when passively extending the fingers.

D

A patient with a pelvic fracture should be monitored for

a. changes in urine output.
b. petechiae on the abdomen.
c. a palpable lump in the buttock.
d. sudden increase in blood pressure.

A

The nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes

a. hip flexion contracture.
b. clot formation at the incision.
c. skin irritation and breakdown.
d. increased risk of wound dehiscence.

A

A patient is scheduled for total ankle replacement. The nurse should tell the patient that after surgery he should avoid

a. lifting heavy objects.
b. sleeping on the back.
c. abduction exercises of the affected ankle.
d. bearing weight on the affected leg for 6 weeks

D

A patient diagnosed with osteosarcoma of the humerus demonstrates understanding of his treatment options when he states

a. “I accept that I have to lose my arm with surgery.”
b. “The chemotherapy before surgery will shrink the tumor.”
c. “This tumor is related to the melanoma I had 3 years ago.”
d. “I'm glad they can take out the cancer with such a small scar.”

B

A patient with suspected disc herniation is experiencing acute pain and muscle spasms. The nurse's responsibility is to

a. encourage total bed rest for several days.
b. teach principles of back strengthening exercises.
c. stress the importance of straight-leg raises to decrease pain.
d. promote use of cold and hot compresses and pain medication.

D

In caring for a patient after a spinal fusion, the nurse would immediately report which of the following to the surgeon?

a. The patient experiences a single episode of emesis.
b. The patient is unable to move the lower extremities.
c. The patient is nauseated and has not voided in 4 hours.
d. The patient complains of pain at the bone graft donor site.

B

A patient who has had surgical correction of bilateral hallux valgus is being discharged from the same-day surgery unit. The nurse will instruct the patient to

a. expect continued pain in the feet.
b. rest frequently with the feet elevated.
c. soak the feet in warm water several times a day.
d. expect the feet to be numb for the next few days.

B

What is important to include in the teaching plan for a patient with osteopenia?

a. Lose weight.
b. Stop smoking.
c. Eat a high-protein diet.
d. Start swimming for exercise.

B

In assessing the joints of a patient with osteoarthritis, the nurse understands that Bouchard's nodes

a. are often red, swollen, and tender.
b. indicate osteophyte formation at the PIP joints.
c. are the result of pannus formation at the DIP joints.
d. occur from deterioration of cartilage by proteolytic enzymes.

B

When administering medications to the patient with chronic gout, the nurse would recognize which drug is used as a treatment for this disease?

a. Colchicine
b. Febuxostat
c. Sulfasalazine
d. Cyclosporine

B

The nurse should teach the patient with ankylosing spondylitis the importance of

a. regularly exercising and maintaining proper posture.
b. avoiding extremes in environmental temperatures.
c. maintaining patient's usual physical activity during flares.
d. applying hot and cool compresses for relief of local symptoms.

A

In teaching a patient with SLE about the disorder, the nurse knows the pathophysiology of SLE includes

a. circulating immune complexes formed from IgG autoantibodies reacting with IgG.
b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer.
c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles.
d. the production of a variety of autoantibodies directed against components of the cell nucleus.

D

In teaching a patient with Sjögren's syndrome about drug therapy for this disorder, the nurse includes instruction on use of which drug?

a. Pregabalin (Lyrica)
b. Etanercept (Enbrel)
c. Cyclosporine (Restasis)
d. Cyclobenzaprine (Flexeril)

C

A patient has a spinal cord injury at T4. Vital signs include falling blood pressure with bradycardia. The nurse recognizes that the patient is experiencing

a. a relative hypervolemia.
b. an absolute hypovolemia.
c. neurogenic shock from low blood flow.
d. neurogenic shock from massive vasodilation.

D

A 78-yr-old man has confusion and temperature of 104° F (40° C). He is a diabetic with purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of

a. sepsis.
b. septic shock.
c. multiple organ dysfunction syndrome.
d. systemic inflammatory response syndrome.

B

The most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the patient with MODS are

a. blood pressure, pulse, and respirations.
b. breath sounds, blood pressure, and body temperature.
c. pulse pressure, level of consciousness, and pupillary response.
d. level of consciousness, urine output, and skin color and temperature.

D

The O2 delivery system chosen for the patient in acute respiratory failure should

a. always be a low-flow device, such as a nasal cannula or face mask.
b. administer continuous positive airway pressure ventilation to prevent CO2 narcosis.
c. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation.
d. maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible.

D

The most common early clinical manifestations of ARDS that the nurse may observe are

a. dyspnea and tachypnea.
b. cyanosis and apprehension.
c. hypotension and tachycardia.
d. respiratory distress and frothy sputum.

A

Maintenance of fluid balance in the patient with ARDS involves

a. hydration using colloids.
b. administration of surfactant.
c. fluid restriction and diuretics as necessary.
d. keeping the hemoglobin at levels above 9 g/dL (90 g/L).

C

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated?

a. Decreasing PEEP
b. Increasing the tidal volume
c. Use of permissive hypercapnia
d. Use of positive pressure ventilation

C

Certification in critical care nursing (CCRN) by the American Association of Critical-Care Nurses indicates that the nurse

a. is an advanced practice nurse who cares for acutely and critically ill patients.
b. may practice independently to provide symptom management for the critically ill.
c. has earned a master's degree in the field of advanced acute and critical care nursing.
d. has practiced in critical care and successfully completed a test of critical care knowledge.

D

The critical care nurse recognizes that an ideal plan for caregiver involvement includes

a. a caregiver at the bedside at all times.
b. allowing caregivers at the bedside at preset, brief intervals.
c. an individually devised plan to involve caregivers with care and comfort measures.
d. restriction of visiting in the ICU because the environment is overwhelming to caregivers.

C

To establish hemodynamic monitoring for a patient, the nurse zeros the

a. cardiac output monitoring system to the level of the left ventricle.
b. pressure monitoring system to the level of the catheter tip located in the patient.
c. pressure monitoring system to the level of the atrium, identified as the phlebostatic axis.
d. pressure monitoring system to the level of the atrium, identified as the midclavicular line.

C

The purpose of adding PEEP to positive pressure ventilation is to

a. increase functional residual capacity and improve oxygenation.
b. increase FIO2 in an attempt to wean the patient and avoid O2 toxicity.
c. determine if the patient is in synchrony with the ventilator or needs to be paralyzed.
d. determine if the patient is able to be weaned and avoid the risk of pneumomediastinum.

A

The nursing management of a patient with an artificial airway includes

a. maintaining ET tube cuff pressure at 30 cm H2O.
b. routine suctioning of the tube at least every 2 hours.
c. observing for cardiac dysrhythmias during suctioning.
d. preventing tube dislodgment by limiting mouth care to lubrication of the lips.

C

The nurse monitors the patient with positive pressure mechanical ventilation for

a. paralytic ileus because pressure on the abdominal contents affects bowel motility.
b. diuresis and sodium depletion because of increased release of atrial natriuretic peptide.
c. signs of cardiovascular insufficiency because pressure in the chest impedes venous return.
d. respiratory acidosis in a patient with COPD because of alveolar hyperventilation and increased PaO2 levels.

C