Exam 3: Critical Care

A client with hypothermia has just arrived in the emergency department via ambulance.  The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids.  What additional intervention is a priority?

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department.  The client's head has hit the windshield, and the client is unconscious.  What nurse actions are appropriate?  Select all that apply.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN).  The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device.  What is the nurse's priority action before initiating the TPN infusion?

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago.  The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome.  When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items?

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer.  The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control.  The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours.  The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 g/dL (120 g/L).  Which action should the nurse carry out first?

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD).  The client goes into ventricular tachycardia and is pulseless.  The ICD has fired twice.  What action should the nurse take?

A client with palpitations is admitted with supraventricular tachycardia.  The client's heart rate is 210/min.  Which is the most appropriate initial intervention?

The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below.  What is the nurse's immediate action?

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery.  The client has a mediastinal chest tube.  During assessment, the nurse notes bubbling in the suction control chamber.  Which nursing action is appropriate?

A nurse is caring for an intubated client receiving a continuous sedative infusion.  Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia?  Select all that apply.

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident.  Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock?

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse.  CPR is initiated.  When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads.  What is the appropriate action at this time?

The nurse is supervising a graduate nurse (GN) on a telemetry unit.  An assigned client develops asystole with no pulse, and emergency care interventions are initiated.  Which action by the GN would cause the supervising nurse to intervene?

Which would be the appropriate client criteria for activating a rapid response team at the hospital?  Select all that apply.

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU).  The low pressure alarm for the client's radial arterial line sounds.  Which action should the nurse take first?

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes.  The client is experiencing numbness, and assessment shows mottled skin.  Which interventions should be included in the client's plan of care?  Select all that apply.

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic.  Based on anticipated vital signs, the nurse needs to prepare for which interventions?  Select all that apply.

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H₂O (11 mm Hg) positive end-expiratory pressure (PEEP).  The nurse should assess for which complication associated with PEEP?