Exam 3: Critical Care

A registered nurse is precepting a new nurse in the intensive care unit.  The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube.  The new nurse performs interventions to prevent aspiration.  The preceptor should intervene if the new nurse performs which of the following actions?

The nurse is caring for a client on a mechanical ventilator.  The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change.  In anticipation of this blood draw, what intervention should the nurse implement?

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV).  The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night.  What should the nurse identify as the priority nursing diagnosis (ND)?

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest.  The client does not follow commands and remains comatose.  What intervention does the nurse anticipate being added to the client's plan of care?

The nurse is caring for a client who had a near-drowning accident in cold weather.  Which assessment finding indicates the most severe injury?

The client is brought to the emergency department after falling off a roof and landing on his back.  A T1 spinal fracture is diagnosed.  The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry.  What nursing action is a priority?

The emergency department nurse receives a client with extensive injuries to the head and upper back.  The nurse will perform what action to allow the best visualization of the airway?

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm.  The nurse would assess for which conditions that can trigger the high-pressure alarm?  Select all that apply.

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation?  Select all that apply.

A client is admitted to the intensive care unit with diabetic ketoacidosis.  The client is most likely to exhibit which of the following arterial blood gas results?

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock.  Which action taken by the new RN indicates a need for further education?

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose.  Which action would be appropriate?

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP).  Which nursing interventions help reduce ICP?  Select all that apply.

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen.  Which assessment finding is most important for the nurse to report to the health care provider?

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia.  Which assessment finding prompts the nurse to notify the health care provider immediately?

A nurse is caring for a client on a mechanical ventilator.  The ventilator is sounding an alarm and displaying an alert about low tidal volumes.  The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping.  What should the nurse do next?

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client.  Which of the following actions by a resuscitation team member would cause the charge nurse to intervene?  Select all that apply.

The intensive care nurse is caring for a client who has just been extubated.  Which interventions are appropriate at this time?  Select all that apply.

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury.  Which statement by the student nurse indicates a need for further education?

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury.  After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine.  The client now develops hypotension, tachycardia, oliguria, and severe nausea.  What is the client's priority nursing diagnosis (ND) at this time?