Question 1

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?

Accepted Answer

A) Attaching the cardiac monitor 
B) Covering the client's head 
C) Drawing blood for electrolytes and glucose 
D) Placing an additional large-bore IV catheter

Question 2

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.

Accepted Answer

A) Assess the client for a carotid pulse 
B) Determine the client's Glasgow Coma Scale score 
C) Maintain airway with head-tilt/chin-lift maneuver 
D) Place a hard cervical collar on the client 
E) Remove the client from the car onto a backboard

Question 3

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?

Accepted Answer

A) Attach a filter to the IV tubing 
B) Check baseline fingerstick glucose levels 
C) Check the results of the portable chest x-ray 
D) Program the electronic infusion pump

Question 4

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)?

Accepted Answer

A) Dehydration 
B) Hypokalemia 
C) Hypotension 
D) Increased cardiac output

Question 5

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?

Accepted Answer

A) Orthostatic blood pressure changes 
B) Presence or absence of knee reflexes 
C) Pupil size and reaction to light 
D) Rate and depth of respirations

Question 6

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 first?

Accepted Answer

A) Assess vital signs 
B) Increase the IV rate to 125 mL/hr 
C) Notify the health care provider 
D) Perform a bladder scan

Question 7

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?

Accepted Answer

A) Administer epinephrine 1 mg IV push 
B) Deactivate the ICD with a magnet 
C) Initiate chest compressions 
D) Take no action and let the ICD work

Question 8

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

Accepted Answer

A) Ask the client to bear down as if having a bowel movement 
B) Grab the crash cart and apply hands-free defibrillation pads 
C) Place ECG leads on client to further assess electrical activity 
D) Place IV line distally from the heart for adenosine administration

Question 9

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?

Accepted Answer

A) Assess level of consciousness, skin temperature, and color 
B) Disconnect pulse oximeter device from the client and restart it 
C) Preoxygenate with 100% oxygen and perform endotracheal suction 
D) Reset the high and low alarm parameters on the pulse oximeter device

Question 10

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?

Accepted Answer

A) Assess the insertion site for presence of subcutaneous emphysema 
B) Notify the surgeon of a large air leak 
C) Take no action as the chest tube is functioning appropriately 
D) Turn down the wall suction until the bubbling disappears

Question 11

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.

Accepted Answer

A) Elevating the head of the bed 30-45 degrees 
B) Performing hourly in-line endotracheal suctioning 
C) Practicing strict hand hygiene 
D) Providing frequent oral care with chlorhexidine 
E) Scheduling daily sedation vacations

Question 12

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?

Accepted Answer

A) Apical heart rate 48/min 
B) Blood pressure 186/92 mm Hg 
C) Cool, clammy skin 
D) Temperature 100 F (37.7 
C)  tympanic

Question 13

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?

Accepted Answer

A) Continue CPR without using the automated external defibrillator (AE
D)  until paramedics arrive 
B) Place one AED pad on the chest and the other on the back 
C) Place one AED pad on the upper right chest and the other on the lower left side 
D) Place one AED pad on the upper right chest and dispose of the other

Question 14

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?

Accepted Answer

A) Administers IV epinephrine 
B) Applies oxygen with bag-mask 
C) Initiates chest compressions 
D) Provides defibrillator shock

Question 15

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

Accepted Answer

A) Glasgow coma scale (GCS) score of 9 throughout shift 
B) Heart rate remaining at 58 beats/min for more than 1 hour 
C) Postoperative pain rated at 10 
D) Respiratory rate maintaining an increase to 30 breaths/min 
E) Sustained change in level of consciousness for 10 minutes

Question 16

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?

Accepted Answer

A) Capillary refill of less than 3 seconds 
B) Left hand cooler than right 
C) Mean arterial pressure of 65 mm Hg 
D) Pressure bag at 300 mm Hg

Question 17

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?

Accepted Answer

A) Check for bleeding at tube connection sites 
B) Perform a fast flush of the arterial line system 
C) Re-level the transducer to the phlebostatic axis 
D) Zero and re-balance the monitor and system

Question 18

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.

Accepted Answer

A) Apply occlusive dressings after rewarming 
B) Elevate affected extremities after rewarming 
C) Massage the areas to increase circulation 
D) Provide adequate analgesia 
E) Provide continuous warm water soaks

Question 19

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.

Accepted Answer

A) Covering client with warm blankets 
B) Logrolling the client from side to side frequently 
C) Mechanical ventilation 
D) Warmed blood administration 
E) Warmed IV fluids

Question 20

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?

Accepted Answer

A) Barotrauma 
B) Decreased oxygen saturation 
C) Hypertension 
D) Oxygen toxicity

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 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 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?

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 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 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?

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?