1 Answers to Core Review Test 1
1-1. (B) Clinical signs of acute pulmonary edema include tachycardia, tachypnea, inspiratory crackles, and rhonchi with chest x-ray findings of Kerley B lines and peribronchial hilar enlargement. Enlargement of the cardiac silhouette reflects left ventricular enlargement owing to left ventricular failure. Pericardial tamponade (Option A) would be associated with an enlarged cardiac silhouette and widened mediastinum from blood accumulation in the pericardial space, but it is not associated with adventitious breath sounds. Pneumonia would be associated with adventitious breath sounds, but consolidation would be present on the chest x-ray. Right ventricular failure would be associated with clear lung fields and breath sounds.
Ware, L. B., Matthay, M. A. Acute pulmonary edema. New Engl J Med, 353, 2788-2796, 2005.
1-2. (C) The nurse should intervene when informed consent for a research study has not been correctly provided. The nurse recognizes that informed consent in human subjects has not occurred with this patient. Informed consent must include the description and purpose of the research, procedures that are experimental, foreseeable risks, how confidentiality will be maintained, and a clear understanding that the subject can withdraw at any time. Option A is incorrect because it will delay correcting the problem. Option B is incorrect because the investigator may not be readily available and informed consent should be corrected immediately. Option D is incorrect because, regardless of being a volunteer or paid employee, whoever is enrolling a subject in a study must ensure informed consent.
1-3. (C) The administration of oxygen therapy is key to relieving the hypoxia associated with a pulmonary embolism. If there is severe cardiopulmonary compromise, intubation and mechanical ventilation will be necessary. Reassessment in 1 hour would neglect the need to significantly improve this patient’s cardiopulmonary status, particularly with signs of possible cerebral hypoxia, tachypnea, tachycardia, and declining cardiac output. In a pulmonary embolism, early identification and intervention are key. The initiation of sequential compression devices is preventive, and at this stage it is more important to initiate supportive therapy and improve oxygenation. Thrombolytic therapy would represent a secondary line of treatment that would be used only in patients where cardiac failure is profound.
1-4. (C) Since this patient received thrombolytics and subsequently had the groin accessed for PCI, this patient is at great risk for hematoma at the groin insertion site. Hourly inspection of the site to determine if a hematoma is present or expanding is essential to recognize and prevent permanent injury from this complication. The patient was alert and able to give consent to the physician, so an intracranial hemorrhage did not occur from the thrombolytics. Retroperitoneal bleeding would be suspected if signs of hypotension not associated with other obvious sources of bleeding were present. Gray Turner’s sign (flank bruising) is seen in retroperitoneal bleeding, but it is a relatively late sign. Bowel sounds are not anticipated early in the postoperative course and are a nonspecific indicator of GI bleeding. The NG tube aspirate would be a better indicator of GI bleeding.
1-5. (B) The purpose of the primary and secondary trauma survey is to provide a consistent method of caring for individuals with multiple injuries and to keep the team focused on care priorities. The primary survey involves a continuous process of assessment, intervention, and reevaluation. Potentially life-threatening injuries can be identified during the primary survey and appropriate interventions instituted. The components of the primary trauma survey are A—airway, B—breathing, C—circulation, D—disability (neurological deficits), and E—exposure and environmental control. Components of the secondary survey are F—full set of vital signs, facilitation of family presence, and five interventions (cardiac monitoring, nasogastric/orogastric tube, urinary catheter, laboratory tests, and pulse oximetry); G—give comfort measures; H—history and head-to-toe examination; and I—inspect the posterior surfaces.
1-6. (D) Data suggest that leads III and V3 should be used to perform ST segment monitoring in patients with acute coronary artery syndrome. Lead II (Option A) is useful for general cardiac monitoring, but it is not especially helpful for ST segment monitoring. Leads V6 (Option B) and I (Option C) are helpful together for distinguishing ventricular aberration but not for ST segment monitoring.
Reference: AACN Practice Alert. ST Segment Monitoring. Available at www.aacn.org//AACN/practiceAlert.nsf/Files/ECG%20ST%20Segment/ Retrieved on July 1, 2006.
1-7. (B) Phenylephrine (Neosynephrine) is a potent vasoconstrictor which may cause bradycardia because it has no beta 1 or beta 2 activity. Dopamine, epinephrine and norepinephrine (Levophed) have strong beta 1 activity and increase the heart rate.
1-8. (D) Lung protective ventilation decreases pulmonary pressures by decreasing tidal volumes and preventing volutrauma. The patient’s oxygenation is only minimally adequate and needs to be closely followed with the changes in tidal volume. Pressure support is not indicated with the clinical findings described. Although the patient is acidotic, increasing the ventilatory rate will not lessen the pressures, and lung protective strategies may include permissive hypercapnea.
1-9. (C) Common injuries resulting from blunt abdominal trauma can include injury to the liver, spleen, mesenteric vessels, pancreas, or kidneys. In a nonoperative approach to blunt abdominal trauma, observation and monitoring include serial hematocrits to evaluate for intra-abdominal bleeding. The platelet count does not fluctuate unless there is a disease process (cirrhosis, leukemia) or significant blood loss. If there is significant blood loss, the platelet count is reduced along with total blood volume. Platelet levels are not good indicators for acute blood loss as they must be hand-counted and may be influenced by medications and volume resuscitation. Protime (prothrombin time) is a monitor of coagulation status. The level can be prolonged without active bleeding. This is not an accurate measure of intra-abdominal bleeding. Mean corpuscular volume measures the average volume or size of a single RBC and is used in classifying anemias. It is not a good measure of intravascular blood volume in acute bleeding situations.
1-10. (C) The patient may have initially presented with the large nonreactive pupil and ptosis. A little bit of detective work through reviewing the patient’s medical record can help the nurse distinguish whether the examination findings are old or new. Since the examination is otherwise nonfocal and the GCS is 15, no acute change in her condition is apparent, so Option A, notifying the neurosurgeon is not indicated at this time. The findings are likely relatively old and do not warrant Option B, rushing the patient to the OR or CT scanner. The patient’s level of consciousness has not diminished, so Option D, intubation, is not indicated.
1-11. (D) The patient should be immediately disconnected from the circuit and machine because these findings suggest that the patient is experiencing a diaylzer or hemofilter reaction. Signs of this reaction include hypotension, pruritis, back pain, angioedema, and/or anaphylaxis. Once removed from the treatment, the patient is reassessed, and the symptoms are managed. At this time, administration of a fluid bolus may be used to manage hypotension. Assessment for bleeding at the access site is done routinely and with episodes of hypotension. The administration of diphenhydramine may occur if the patient continues to have pruritis, provided the patient is not hypotensive.
1-12. (A) The 12-lead ECG represents a narrow complex tachycardia. Immediate interventions for this stable tachycardia with an acceptable blood pressure include having the patient perform vagal maneuvers to slow conduction from the SA node to the AV node. If this is ineffective in slowing or terminating the tachycardia, the next intervention would be to administer adenosine. Adenosine causes transient block in AV node conduction, which may cause asystole. If the patient is stable, administration of a medication that may cause asystole is contraindicated. Diltiazem is indicated for rate control in atrial fibrillation with a rapid ventricular rate. Synchronized cardioversion is indicated for unstable supraventricular tachycardias.
1-13. (D) Two large-bore IV lines should be immediately inserted to enable fluid administration and vasopressor support. Laboratory studies for type and crossmatch should be obtained for anticipated blood replacement. Surgery should not be delayed to complete a pericardiocentesis. Labetolol administration is contraindicated in hypotension. Norepinephrine administration is contraindicated in hypovolemia and will increase the force of contraction, which may cause the dissection to rupture.
1-14. (A) Individuals with ICDs often fear that the device will shock them. These patients do not report concerns about being awakend by the device or about the device being triggered by exertion, nor do they experience depression owing to dependence on the ICD.
1-15. (D) The patient has likely suffered an aspiration. Cultures will need to be completed to determine the causative organism(s), and pulmonary hygiene will assist in clearing the lobar pneumonia. Administration of broad-spectrum antibiotics should await completion of the cultures. Bronchoalveolar lavage does not reach the distal airways, so it is not likely to help this patient. Steroid therapy is not indicated for this condition.
1-16. (C) At this point, the nurse should focus on educating the patient and family regarding the benefits of treatment options available with early intervention. This patient delayed hospitalization and therefore missed an opportunity to received needed therapy that might have averted the acute MI. Unless the patient will be taking thrombolytics, additional instruction related to their use is not indicated. There is no indication that the patient’s delay was owing to any inability to reach a telephone, so Option B is not warranted. Admonishing the patient may resemble scolding, blaming, or scare tactics, and it does not represent an appropriate means of enabling an adult to improve his or her self-care.
1-17. (D) MODS is characterized by the presence of progressive physiologic dysfunction of two or more organ systems after an acute threat to systemic homeostasis. SIRS is characterized by a generalized systemic inflammation in organs remote from an initial insult. Septic shock is sepsis-induced shock with hypotension despite adequate fluid resuscitation, along with the presence of perfusion abnormalities. Bacteremia is the presence of viable bacteria in the blood.
1-18. (A) The persistent air leak could suggest a bronchopleural fistula or other pulmonary parenchymal pathology. If the leak worsens, the patient could start losing tidal volume into the leak, which would be demonstrated by a discrepancy in his inspiratory and expiratory tidal volumes as well as adverse effects on his ABGs (Option A). The scenario does not suggest that this is an acute change, so STAT diagnostic tests are not warranted (Option B). Tracheal deviation is a late sign of a tension pneumothorax, which is unlikely as long as the chest tube drainage system is functioning properly (Option C). Placing the chest tube to water seal could place the patient at risk for accumulating a tension pneumothorax (Option D).
1-19. (A) A patient complaint of shoulder pain during peritoneal dialysis can result from the presence of air in the infusion tubing. To prevent this problem, the critical care nurse should ensure that all air is primed out of the infusion tubing. Once the problem has occurred, the nurse needs to drain the effluent with the patient in the knee-chest position. The knee-chest position facilitates the movement of air to the lower abdomen where it may be expelled. Changing the patient to the right side-lying position will not move the air to the lower abdomen and is usually done to manage fluid obstruction. Failure to warm the infusion will cause severe abdominal cramping and hypothermia. Increasing the dwell time will affect the amount of fluid removed from the peritoneal capillaries; however, the increase is not proportional due to osmotic equilibrium.
1-20. (B) Diabetes insipidus may develop after trauma to the central nervous system. Criteria for this malady include urinary output of more than 500 mL/hr for 2 consecutive hours and low specific gravity. Failure to control diabetes insipidus may result in drastic shifts of fluids and electrolytes, which may evoke seizures, ventricular ectopy, circulatory collapse, and, eventually, death. Increases in abdominal girth measurement would be useful for detection of abdominal bleeding but cannot account for this patient’s increased urine output. An elevated capillary glucose measurement may lead to polyuria; however, this is not as ominous a situation as a decrease in specific gravity, and polyuria will subside with treatment of hyperglycemia. The potassium level will change with polyuria, but discovering the source of the polyuria and treating the cause will limit the potential alteration in electrolyte balance.
1-21. (C) The normal BNP is less than 100 pg/mL. Levels greater than 500 pg/mL are consistent with heart failure. A CPK-MB level of 5% and troponin level of 0.3 ng/mL do not support a diagnosis of acute myocardial infarction. Tricuspid valve insufficiency generally results in peripheral edema. ECG signs of pericarditis include diffuse ST segment elevation rather than depression.
1-22. (A) Heparin-induced thrombocytopenia is the result of an antigen/antibody response to the drug heparin. The ELISA test establishes the presence of the antigen for heparin-induced thrombocytopenia, and a platelet count of 30% to 50% of baseline is the key indicator of this condition. While international normalized ratio and partial thromboplastin time would help in understanding the degree of anticoagulation that has occurred with routine use of coumadin and heparin, respectively, they are not specific to heparin-induced thrombocytopenia. The complete blood count may be decreased for many different reasons, whereas the differential white count would not provide information needed to diagnose this autoimmune situation. Comparison of arterial with mixed venous gases provides information about gas exchange and oxygen use and would not be helpful in making this decision.
1-23. (A) The patient needs to understand the possible causes for development of pancreatitis. If the patient’s history does not include alcoholism, other possible etiologies associated with pancreatitis include gallstones and diet. Options B, C, and D are of a lesser concern for a diagnosis of pancreatitis. Option B does not apply because the patient scenario did not mention weight loss, and in any case that finding is not true for all patients with pancreatitis. Determining food preferences (Option C) will become important if the pancreatitis is related to gallstones. Option D is inappropriate because nothing in the scenario suggests that the patient’s prognosis is poor or terminal.
1-24. (C) Increased pulmonary capillary pressure (as measured by the PCWP) causes fluid to move out of the pulmonary capillaries into the pulmonary extravascular tissues and alveoli. Increased right atrial pressures cause fluid to accumulate in the venous system proximal to the lungs in the extremities. Decreased cardiac output may be a symptom of pulmonary edema related to redistribution of blood volume into lung tissue. Increased systemic blood pressure may precipitate pulmonary edema, but only when lymphatic drainage is insufficient to compensate for fluid accumulation in lung tissue.
1-25. (D) In either pulmonary or fat embolism to the pulmonary vasculature, reduced preload results from obstruction to pulmonary blood flow, increased pulmonary resistance, and reduction in cardiac output (CO). The hypotension associated with a fall in CO then triggers release of catecholamines, prostaglandins, serotonin, and histamine, which attempt to restore CO by raising systemic vascular resistance via peripheral vasoconstriction. Increased afterload, then, occurs as a compensatory response to the development of hypotension. The right heart dysfunction, rather than intravascular volume, elevates CVP. Cardiomyopathy may be due to viral infections, coronary heart disease, congenital heart defects, vitamin deficiency, or alcoholism, but this patient does not show any risk factors for cardiomyopathy.
1-26. (A) During endovascular repair of AAA, fluoroscopy is used to determine that the position of the endograft is appropriate and does not occlude the renal artery. Blood losses are generally minimal with the endovascular approach unless retroperitoneal or endoleak bleeding is present. Fluoroscopic evidence of renal artery patency negates occlusion as a cause of diminished urine output. Absence of signs of bleeding such as tachycardia, hypotension, and delayed capillary refill indicate that hypovolemia and bleeding are not the cause of the decreased urinary output.
Reference: Hall, S. W. Endovascular repair of abdominal aortic aneurysm. AORN J, 77, 630-642, 2003.
1-27. (D) Dumping syndrome is a set of postprandial vasomotor and GI symptoms that occurs in some patients who have had gastric surgery or vagotomy that alters upper GI anatomy and neurologic innervation. When a volume of simple carbohydrates is consumed, accelerated gastric emptying causes hyperosmolar contents to be rapidly moved into the upper small intestine, causing bowel distention, abdominal fullness, and intestinal hypermotility that lead to osmotic fluid shifts from the intravascular compartment into the gut lumen, creating relative intravascular volume contraction and hemoconcentration. Compensatory changes lead to release of vasoactive GI hormones, which produce peripheral and splanchnic vasodilation and vasomotor symptoms such as tachycardia, weakness, fainting, dizziness, palpitations, diaphoresis, cramping, diarrhea, and reactive hypoglycemia. An acute MI may cause diaphoresis, nausea, and vomiting, but would usually produce chest pain and ECG changes, which this patient does not exhibit. Pulmonary embolism can occur suddenly in a postsurgical patient, but this patient lacks common risk factors such as prolonged immobility and has experienced no chest pain or hemoptysis. Symptoms of hyperglycemia are polyuria, polydypsia, and blurred vision. This patient does not exhibit any of these symptoms.
Ukleja, A. Dumping syndrome. Practical Gastroenterology, 29(2), 32, 34-46, 2006.
1-28. (A) Advocating for the patient in this scenario means contacting the appropriate agency for filing a report to start an investigation into the care of this older woman. The nurse recognized a finding that clearly constitutes evidence of neglect and failure by a caregiver to adequately meet the physical, social, or emotional needs of a dependent older person. Option B is an action that a nurse would take with any notable assessment finding and would not advocate for this patient’s protection. Options C and D will delay getting an investigation of this incident started.
Hoban, S., Kearney, K. Elder abuse and neglect. Am J Nurs, 100(11), 49-50, 2000.
1-29. (B) Nitroglycerin is not harmful to the fetus and reduces blood pressure by vasodilation and afterload reduction. Sodium nitroprussode (Nipride) is rarely used in the treatment of pre-eclampsia due to the risk of thiocyanate toxicity in the fetus. ACE inhibitors such as captopril should not be administered in the antepartum period as they have been shown to potentiate fetal abnormalities. Phentolamine (Regitine) is an alpha adrenergic blocker indicated in the treatment of acute hypertension related to cocaine or catecholamine stimulating conditions such as pheochromocytoma.
1-30. (A) The peak inspiratory pressure reflects airway resistance and compliance of lung tissue. The decrease in peak inspiratory pressure indicates that less pressure is necessary to deliver tidal volume and signifies improvement in compliance or distensibility of lung tissue. The decrease in PaCO2 is not specific and may be related to the patient’s respiratory rate rather than to any improvement. The increase in PaO2 is minimal and may be related to factors such as suctioning, position change, or other laboratory factors. An increase in respiratory rate may be related to patient agitation, activity, or decrease in sedation.
1-31. (A) One of the most common sites of origin for bacteremia and sepsis is the respiratory tract. For patients who are intubated for an extended period of time (greater than 24 hr), the incidence of VAP increases significantly. Aspiration of oral and/or gastric fluids and colonization of the mouth are presumed to be precursors to the development of VAP. Patients in the supine position have an increased incidence of aspiration. Elevating the HOB to an angle of 30 to 45 degrees decreases that incidence. Oral care should be given every 2 to 4 hr for optimal outcomes; if care is delayed more than 4 hr, these benefits are lost. Research has shown that there is no increase in the incidence of VAP associated with prolonged use of ventilator circuits; as a result, frequent changes of the circuit are not warranted. Saliva serves a protective function for the oral mucosa. Mechanical ventilation causes drying of the oral mucosa, affecting salivary flow and contributing to mucositis and gram-negative colonization. Mouth moisturizer should be applied with each cleansing.
1-32. (B) Hypertension after coronary artery bypass graft surgery should be treated promptly to prevent stress on graft sites and decrease bleeding. The nitroglycerin infusion should be increased to enhance vasodilation and decrease the blood pressure. Although the PAD and RAP are borderline low, the urine output indicates that the patient is not hypovolemic at this point, so a fluid bolus is not yet indicated. Increasing the pacing rate will increase the cardiac output, but CO of 3.5 L/min is acceptable immediately after surgery and does not require treatment. Beta-blocking medications are generally avoided in the early postoperative cardiac surgery period because of their negative inotropic effects during the period when myocardial stunning may be present.
1-33. (D) In a patient with longstanding asthma, respiratory acidosis and hypercarbia are signs of worsening gas exchange and a diminishing respiratory effort. These are generally considered ominous signs, so expeditious intubation is the best answer (Option D). Anti-inflammatory agents such as steroids and leukotriene inhibitors (Options A and B) are administered in concert with the bronchodilator therapy but should be added prior to the development of hypercarbia. Inhaled nitric oxide (Option C) via an endotracheal tube is used for the treatment of ARDS and pulmonary hypertension.
1-34. (C) This question illustrates the nurse’s competency for System Thinking. Options A and B would diminish VAP incidence within the hospital, but not to the extent afforded by Option C, which, by implementing a vaccination program for all patients age 65 years and older who come to the facility, clearly has the farthest-reaching impact. DVT prophylaxis has not been associated with decreasing VAP. When choosing an intervention to improve outcomes, wide-reaching solutions should be considered over those with more limited impact.
References: Houghton, D. HAI prevention: the power is in your hands. Nurs Manage, 37, S1-S7, 2006.
1-35. (C) Before administering interventions such as medications or food, the nurse should assess the patient. In this case, the capillary glucose level should be assessed, as restlessness and irritability are classic signs of hypoglycemia, and this patient has an insulin drip. Except as part of the nurse’s admission appraisal, there is no indication apparent for auscultating breath sounds. Administration of an anxiolytic medication without first determining whether that medication is warranted could potentially be detrimental to a patient who needed glucose. Because irritability may also indicate hypoxemia, this would be an appropriate second area in which to assess this patient. While providing milk and crackers for this patient will help to alleviate hypoglycemia over a long period of time, a person experiencing hypoglycemia initially needs a rapidly absorbed source of glucose after the assessment is completed.
1-36. (A) Allowing the patient to have things that make him or her feel more at home helps to reduce anxiety. Cats tend to carry many pathogens, owing to their bathing habits and litter box use, that could become opportunistic for this patient. School-aged children spend a large part of their days in a confined area with 20 to 30 other people, sharing many communicable diseases, and they may not be well-served by adult-sized masks, gowns, and gloves (used as barrier devices), so they pose potential sources of pathogens to the patient. Fresh foods may improve a patient’s appetite and enhance a sense of well-being, but they carry the risk of transmitting bacteria and viruses from the fields in which they were grown, so commercially canned foods are preferable.
1-37. (C) Unstable tachycardia should be treated with immediate synchronized cardioversion. Stable ventricular tachycardia, stable tachycardias of uncertain etiology and atrial fibrillation with Wolff-Parkinson-White syndrome may be treated with amiodarone. Stable supraventricular tachycardia may be treated with adenosine. Defibrillation is indicated for unstable ventricular tachycardia or ventricular fibrillation.
1-38. (A) Using evidence-based protocols, policies, standards, and guidelines to improve patient care reflects the use of clinical inquiry. Option A indicates that the nurse needs to conduct a literature search for evidence-based practice for patients at high risk for SRMD and that the nurse’s practice should be protocol-driven. Although Option B (use of proton pump inhibitors) would be useful as an intervention for SRMD, not every patient needs to be placed on a PPI, and prevention of SRMD is preferred over allowing the condition to develop. Option C turns the problem over to a medical committee, where nurse input may not be included in development of the protocol. Option D adds needless delay to address the issue.
1-39. (A) Paradoxical pulse, a variation in pulse or blood pressure with respiration, is a sign of pericardial tamponade or hypovolemia. Pericardial tamponade may occur after PCI owing to coronary artery dissection or perforation of the myocardium. Coronary artery spasm causes signs of myocardial ischemia such as chest pain and ECG changes but does not affect blood pressure. Dysrhythmias such as atrial fibrillation and premature ventricular contractions may cause irregularities in pulse pressure, but do not cause paradoxical pulse. Vasovagal reactions cause decreased blood pressure and bradycardia.
1-40. (B) Morbid obesity contributes to immobility, one of the risk factors for deep vein thrombosis (DVT) and pulmonary embolism. Sudden onset of dyspnea and chest pain indicate an acute condition such as pneumothorax, aspiration or pulmonary embolus. The chest x-ray findings of an enlarged, or prominent pulmonary artery suggest that pulmonary obstruction is due to pulmonary embolism. There is no radiologic evidence of pneumothorax. Acute MI would be indicated by ST segment elevation. Aspiration pneumonia would not likely have acute onset unless the aspirate was large in volume (which would be demonstrated on x-ray) or acid in pH.
1-41. (C) The patient is experiencing hyperphosphatemia and requires the administration of aluminum hydroxide. Calcium and phosphorus are regulated at the renal level by parathyroid hormone (PTH). PTH facilitates calcium reabsorption and phosphorus excretion in people with normal renal function. Patients with chronic renal failure require medications that bind with phosphorus (e.g., aluminum hydroxide) so that phosphorus can be excreted via the stool. As the serum phosphorus level decreases, blood calcium levels increase. Administration of a potassium supplement will not correct the patient’s hyperphosphatemia. Supplementing the patient with oral phosphates will worsen the problem. Sodium bicarbonate administration will not address the hyperphosphatemia.
1-42. (B) Inferior wall MI is caused by occlusion of the right coronary artery, which also supplies the right ventricle. ST segment elevation is present in II, III, and aVF indicating inferior wall MI. In right ventricular MI, the right ventricle fails and requires higher volume to produce adequate cardiac filling and output, causing hypotension after administration of nitroglycerin. Although some drop in BP is expected after nitroglycerin administration, hypotension to this extent would not be anticipated in the supine position and, if hypersensitivity to nitroglycerin was the source, hypotension would likely have been accompanied by other findings such as nausea and vomiting. Papillary muscle rupture causes signs of left ventricular failure; symptoms would diminish after administration of nitroglycerin due to decreased afterload. Rupture of the ventricular free wall would cause symptoms of pericardial tamponade and shock.
1-43. (B) The best reply is to provide the patient with an instructional rationale for holding fluids until it is safe for them to drink again. Option A is incorrect because the patient may be able to swallow and still not have a gag reflex. Option C ignores the patient’s request and lacks any instructional value. Option D is incorrect because lunch cannot be given without verification that the patient has intact and fully functioning reflexes (gag, cough, etc.) and can safely ingest fluids and the assigned diet.
1-44. (C) Studies have found that routine ventilator circuit changes do little to prevent the development of VAP. As a result, the Centers for Disease Control and Prevention (CDC) no longer calls for routine changes of the ventilator circuit (tubing, exhalation valve, and attached humidifier) but instead recommends changing these components only when the equipment is visibly soiled or malfunctioning. In a related recommendation, the CDC recommends draining and discarding condensate that collects in the ventilator tubing and not allowing it to drain back toward the patient.
Reference: Chulay, M. VAP prevention: the latest guidelines. RNweb. Posted March 1, 2005. Accessed at http://rnweb.com/rnweb/article/articleDetail.jsp?id=149672 (November 7, 2006).
1-45. (B) A pacemaker magnet placed over the ICD generator will disable the ICD and prevent further inappropriate discharge. Trancutaneous pacing is indicated for symptomatic bradycardia. Medication administration will not prevent inappropriate shock delivery. Diltiazem will control the rate and amiodarone might convert the atrial fibrillation to sinus rhythm.
1-46. (C) Exogenous corticosteroid administration frequently results in a hyperglycemic state related to inhibition of gluconeogenesis and increased insulin resistance. Untreated, the serum glucose gradually climbs, but the presence of exogenous insulin prevents the development of diabetic ketoacidosis. In response to polyuria, the patient becomes hyperosmolar. Diabetes insipidus would cause hyperosmolarity but would not result in a serum glucose of 624 mg/dL. In Type 1 diabetes with such a high serum glucose, ketoacidosis would have been evidenced in the laboratory work. While the patient may develop polycythemia vera after years of poor oxygenation, that condition would not produce this serum glucose value.
1-47. (A) The normal ejection fraction is 50-75%. Patients with diastolic dysfunction often have decreased early diastolic filling time and preserved ejection fraction. The left ventricular ejection time is reduced due to diminished left ventricular end-diastolic volume. Beta-blocking agents prolong the diastolic filling time, resulting in improved left ventricular contraction and decreased diastolic pressure.
1-48. (B) Researching the current ICD registries in use, the typical complications monitored, and the type of reporting required by the FDA should be the nurse’s initial step in designing a program to monitor ICDs in the facility. When asked to develop a new program, current strategies should be researched to identify best practices. Option A would most likely provide information on that vendor’s ICD but not other vendors’ devices, and any vendor information would need to be considered for potential bias. Option C overlooks considering the complexity of the device and may therefore neglect appraisal of important features. Option D fails to demonstrate any competency in clinical inquiry.
1-49. (B) Large-bore IV insertion is a priority in this patient so that initiation of fluid resuscitation can begin to ensure maintenance of a MAP of 60 mm Hg. The monitoring of coagulation studies will be of importance if there is prolonged bleeding or after the administration of blood products. These values adjust to reflect the patient’s condition over time. An upright KUB will assist in the determination if there is free air in the abdomen; however, stabilization of the patient’s circulatory status is the initial focus for the nurse. Monitoring fluid balance and renal function is an ongoing intervention for this patient. It will be important to replace fluid losses and maintain intravascular volume, but this aspect of care is not the most immediate need of the patient.
1-50. (C) The most appropriate action for the nurse to take would be to inform the patient of the spouse’s concerns and determine what his current wishes are. A trial period, or a trial period with time limitations, may be an option that the patient is willing to consider. An open atmosphere for both the patient and his spouse to express their desires and concerns should be encouraged. Although it is correct that the DPA is not in effect until the patient is no longer able to make decisions, informing the spouse of this fact may make the spouse feel that the nurse is not willing to listen to the spouse’s concerns. A dyspneic patient is not likely to be able to carry on a discussion of this nature, and expectations that the patient would be physically able to discuss an emotional topic such as end-of-life decisions with his spouse are unrealistic under these circumstances.
1-51. (A) Coronary artery spasm is common after coronary atherectomy. Treatment with intravenous nitroglycerin and fluids maintains coronary artery dilation and prevents spasm. Calcium channel blockers lower blood pressure through vasodilation, but do not prevent coronary artery spasm. Heparin and glycoprotein IIb/IIIa inhibitors prevent new clot formation and aid in promoting thrombus dissolution but do not affect coronary spasm.
1-52. (A) After surviving aneurysmal subarachnoid hemorrhage, patients are primarily at risk for developing any or all of the following three problems: (1) rebleed of the aneurysm if unsecured, (2) hydrocephalus owing to problems with reabsorption of CSF, or (3) vasospasm. Blood in the subarachnoid space can block reabsorption of CSF by the arachnoid villi. This is a type of communicating hydrocephalus. A thrombus (Option B) could potentially cause an obstruction of CSF flow; however, hydrocephalus after SAH is generally communicating rather than obstructive in nature. Mass effect (Option C) can block CSF flow but would more likely be associated with a brain tumor than with SAH. This patient population is at risk of developing vasospasm (Option D), which can result in further stroke, but vasospasm directly affects blood flow, not CSF flow.
Greenberg, M. S. (ed.). Handbook of Neurosurgery, 6th ed. New York, Thieme Medical Publishers, 2006.
1-53. (C) Decreased urine output may be the first indication that early compensatory mechanisms to prevent shock are occurring. Activation of the sympathetic nervous system causes vasoconstriction, which decreases renal blood flow. When renal blood flow decreases, renin and angiotensin are released and produce vasoconstriction, which increases capillary refill time. Hypotension and tachycardia are later signs seen in a more advanced stage of shock.
1-54. (B) Administration of oxygen is the first priority in this emergent situation. Although this patient likely has a pneumothorax, the physician will confirm that finding with a chest x-ray unless the patient is acutely decompensating. The patient may have pain, but administration of narcotics may decrease his respiratory drive and worsen hypoxia. Older patients with rib fractures often require 24 to 48 hours of observation in the ICU, but treatment of hypoxia takes priority at this time.
1-55. (A) Clinical inquiry is demonstrated when the nurse uses evidence-based information to make changes in nursing practice. Implementing a change in practice requires first identifying the key stakeholders for the change in order to introduce the proposed change. Research utilization and experiential knowledge can be applied to improve patient outcomes when others are part of the change process. Numerous studies have demonstrated the safety and accuracy of drawing blood from peripheral venous access devices (VADs) for aPTTs. The intended change has already been identified. Option C is incorrect because one does not implement a change without getting input from key stakeholders. Option D is incorrect because evaluation would not be performed until after the change had been implemented.
1-56. (C) In pericardial tamponade, the patient becomes hypotensive due to inadequate cardiac filling. Right and left heart pressures equalize and the patient may develop jugular venous distension and tachycardia. Beck’s triad is the classic presentation for cardiac tamponade and includes decreased systolic blood pressure, increased CVP/JVP and muffled heart tones. Tachycardia may not be present in the early postoperative period of the open heart surgery patient due to myocardial stunning. Chest tube output is not a reliable indicator of whether pericardial tamponade is present because chest tube output may be decreased due to clot formation. No evidence of MI was presented in the case described.
1-57. (C) Several recreational drugs and stimulants are associated with development of rhabdomyolysis, particularly agents that either mimic or stimulate the sympathetic nervous system. The appearance of discolored urine is indicative of large amounts of myoglobin in the urine and is often the initial clinical finding in rhabdomyolysis. The goal of treatment for rhabdomyolysis is to prevent renal failure. This is achieved by maintaining a urine output >150 mL/hr with intravascular volume expansion using isotonic crystalloid and diuretics. Myoglobin is a dark red protein responsible for supplying oxygen to the myocytes. The breakdown of myoglobin produces a pigment-induced nephropathy with subsequent sloughing of the tubular epithelium. This exfoliate, together with large myoglobin molecules, results in the formation of brown casts that obstruct renal tubules. Low urinary pH facilitates the formation of casts and also promotes the dissociation of myoglobin molecules into cytotoxic components. The addition of sodium bicarbonate to IV solutions alkalinizes urine to prevent dissociation of myoglobin into its nephrotoxic components. The goal for urinary pH is to maintain >6.0. The purpose of insertion of an indwelling catheter and hemodynamic monitoring is to guide the bedside nurse in management and evaluation of the patients’ response to fluid administration and diuretic therapy, not to prevent renal failure.
1-58. (B) SPECT perfusion imaging is the most helpful in diagnosing myocardial ischemia in a patient with left bundle branch block. LBBB may mask ST and T wave abnormalities, making it difficult to determine if ischemia is present. Perfusion defects are demonstrated during SPECT studies. Those which appear during exercise and disappear during rest indicate ischemia. MRI is useful in demonstrating structural defects of the heart, aorta, and pericardium, but not the coronary arteries. MR angiography (MRA) may be useful to determine if coronary grafts are patent.
1-59. (D) The nurse in this situation should promote patient-centered decision making that honors the rights and interests of the patient even when the patient’s choice is not what the nurse would chose. The patient has the right to have his reports of pain believed. Options A, B, and C do not involve the patient in the decision-making process. Giving the NTG before giving the morphine may be viewed by the patient as the nurse’s not listening to his needs. Option B is incorrect because administering the morphine assumes that this is the drug the patient wants. Making the patient wait 30 minutes may imply to the patient that the nurse does not believe he is having pain and that his pain needs are not being met.
1-60. (A) The optimal ventilation strategy for this patient includes use of low tidal volumes, minimizing potential barotrauma, and carefully monitoring respiratory rates. Patients in status asthmaticus are at great risk for air trapping and developing auto-PEEP due to airway constriction. As a result, high tidal volumes and high PEEP place the patient at risk for barotrauma (Options B, C, D).
1-61. (A) Revasularization may result in the release of products of anaerobic metabolism, lactic acid and potassium, into circulation. Acidosis and potassium imbalance place the patient at increased risk of dysrhythmias. Elevated CPK levels are expected after revascularization due to skeletal muscle ischemia. Graft occlusion may occur if hypotension or coagulopathy occur. Pulmonary embolus is a risk of surgery, but is usually associated with venous thrombus. Heart failure is a complication of fluids administered during surgery and the effects of anesthetics, but is not indicated by an elevated potassium and metabolic acidosis.
Reference: Fahey, V. A. Vascular Nursing, 4th ed. St. Louis, Elsevier, 2004.
1-62. (D) The first three questions provide important information related to this patient’s medical history, but only Option D poses a question that may solicit a belief or value rather than a fact.
1-63. (A) COPD is an umbrella term for a variety of pathologies such as emphysema and chronic bronchitis. Patients typically have components of both diseases, so they often benefit from carefully monitored increases in FiO2. While ABGs should be drawn to guide care of this patient, they should not be the sole determinant for clinical interventions. Manipulations of oxygen should be done with careful monitoring of the patient’s clinical response; however, hypoxia is a greater concern for this patient than respiratory drive. Hypoxemic vasoconstriction is a compensatory process that maximizes V/Q matching in this patient population. It does not create a diffusion defect.
1-64. (D) The initial therapy would be calcium chloride 1000 mg in 1000 mL NS (calcium gluconate might also be considered) because the patient is manifesting signs of hypocalcemia. In acute pancreatitis, calcium precipitates in the pancreas. Signs of hypocalcemia include positive Chvostek’s and Trousseau’s signs, tetany, seizures, respiratory arrest, bronchospasm, stridor, wheezing, paralytic ileus, and diarrhea. Magnesium sulfate would be used to manage hypomagnesemia. Plicamycin is used to treat hypercalcemia and vasopressin is used for hyperosmolar disorders.
1-65. (B) The causes of erosive gastritis include drugs (especially NSAIDs), alcohol, and acute stress. When viewed with an endoscope, superficial erosions are seen that do not penetrate into the deeper layers of the stomach. They are frequently accompanied by some degree of hemorrhage. When gastritis is diffuse, the amount of blood loss can be extensive. A pulmonary embolism usually occurs in the setting of deep vein thrombosis. This patient has not been immobilized for a significant period of time. The signs and symptoms of a pulmonary embolism include acute chest pain, cough, and hemoptysis, which this patient is not exhibiting. Intracranial hypertension presents with widening pulse pressure and bradycardia, findings inconsistent with this patient’s presentation. Dehydration owing to alcohol abuse may contribute to this patient’s overall hydration status. Dehydration does not usually result in gastrointestinal bleeding.
1-66. (C) Thiocyanate toxicity generally occurs when sodium nitroprusside is used for longer than 48 hours. Thiocyanate is a metabolite of sodium nitroprusside and causes oxygen to bind to hemoglobin, preventing its release to tissues; as a result, SpO2 is not a reliable indicator of tissue oxygenation. Early symptoms include mental status changes and delirium. Stroke may present as altered mental status, but it is unlikely if the patient is receiving appropriate blood pressure reduction therapy. Myocardial infarction is also unlikely owing to the vasodilatory effects of sodium nitroprusside and lack of chest pain complaints. Encephalopathy would have been evident earlier in the treatment of hypertensive crisis if blood pressure reduction was too rapid for cerebral autoregulation to be maintained.
1-67. (C) In septic shock, HR increases in response to stimulation of the sympathetic nervous system baroreceptors and release of epinephrine and norepinephrine by the adrenal gland. Mixed venous oxygen saturation (SVO2) reflects the balance between O2 delivery and O2 consumption. A normal SVO2 is 60% to 80%. Several factors can increase the SVO2—increase in oxygen saturation and/or increase in cardiac output. In the patient with septic shock, a decrease in oxygen consumption occurs at the cellular level owing to a reduced ability of the cells to use the oxygen and inadequate tissue perfusion related to vasoconstriction. The oxygen is not extracted from the blood at the tissue level, resulting in an abnormally elevated SVO2. The patient’s temperature is elevated in response to pyrogens released from invading microorganisms, immune mediator activation, and increased metabolic activity. Urine output declines because of decreased perfusion to the kidneys. Dilation of the arterial system causes SVR to fall, thereby reducing left ventricular afterload. If the patient is euvolemic, these compensatory changes help to produce a normal to high CO. Dilation of the venous system leads to a decrease in venous return to the heart, which results in decreased preload as evidenced by a decreased RAP. Ventilation and perfusion mismatching occurs in the lungs as a result of pulmonary vasoconstriction and the presence of pulmonary microemboli. Hypoxemia occurs, and the RR increases to compensate for the lack of oxygen.
1-68. (B) The best approach to establishing a comprehensive program of oral care should begin with forming a multidisciplinary team that can review supporting scientific literature and develop a policy or protocol, provide hospital wide education, and measure outcomes of the intervention. Option A is incorrect because placing kits at the bedside does not ensure their use. Merely obtaining staff input does not designate any accountability for the project as Option B does. Option D is of very limited help because the nature of those oral care orders needs to coincide with a best-practices approach to care before outcomes could be expected to improve.
1-69. (B) The patient’s blood pressure is adequate to give the beta blocker, but because of worsening symptoms of heart failure, a reduced dose is warranted. Abrupt discontinuation of beta blocker therapy can cause rebound hypertension and tachycardia. Tachycardia will worsen heart failure, as it increases oxygen consumption and reduces ventricular filling time. Additional doses of beta blockers may worsen symptoms. ACE inhibitor therapy reduces afterload and decreases sodium retention. ACE inhibitors have a mild diuretic effect and may be added to current therapy, but additional doses are not warranted to treat worsening symptoms.
1-70. (B) Noninvasive ventilatory techniques (CPAP, BiPAP) are routinely used for COPD patients with moderate respiratory failure. NIV therapies improve respiratory mechanics by allowing the patient to take larger tidal volumes and preventing fatigue of respiratory muscles, which often precipitates a need for intubation. NIV is not an option for every patient, however, including those with significant cardiovascular compromise, arrhythmias with hypotension, or impaired consciousness (except O2 induced) and those with significant risk of aspiration. Heavy sedation is contraindicated with NIV as this therapy requires that the patient be able to spontaneously ventilate and be sufficiently conscious to protect their airway. NIV reduces work of breathing in patients with COPD. Use of masks versus nasal pillows is a matter of patient preference and is not required for COPD patients.
1-71. (B) Breakdown of fat cells produces ketone bodies, which are acids. An increase in metabolic acids results in an increase of urinary output in an attempt to decrease serum glucose, diminish the concentration of acids, and rebalance electrolyte levels. The patient may have faithfully adhered to his routine of managing his type 1 diabetes, yet developed ketoacidosis when emotional or physical stress, such as a viral illness led to increased release of cortisol. The next most likely cause of ketoacidosis would be inadequate insulin in relation to caloric intake. Type 2 diabetes, not type 1, has been found to have a genetic predisposition. Type 1 is currently believed to be autoimmune in origin. Increased levels of activity would result in hypoglycemia rather than hyperglycemia and ketoacidosis.
1-72. (C) This patient needs continued fluid resuscitation with crystalloids such as Ringer’s lactate or normal saline. Continued administration of crystalloid will enable renal excretion of excess hydrogen ions and resolve acidosis. Administration of sodium bicarbonate may induce alkalosis and prevent oxygen release to tissues. The hematocrit is greater than 28% so transfusion is not indicated. Endotracheal intubation is not indicated with a PaO2 of 80 mm Hg.
Reference: Kelly, D. Hypovolemic shock. Crit Care Nurs Q, 28, 2-19, 2005.
1-73. (C) Stabilization of the airway with endotracheal intubation is warranted given the patient’s increasing respiratory distress. In patients with severe respiratory distress, increasing the FIO2 is appropriate; however, it would be increased to 100% at least until airway intubation is completed. There is no radiologic evidence of a pneumothorax, so placement of a chest tube would not be appropriate, and there is no indication that a repeat chest x-ray is warranted at this time. Once intubation has been completed, the chest x-ray can be repeated to confirm correct placement of the endotracheal tube.
1-74. (D) Controlling a dying patient’s pain minimizes any suffering, a common fear related to end-of-life concerns. Option A is incorrect because there is no evidence that any particular staffing pattern will assure a “good death.” Option B is incorrect because unrestricted visiting may be exhausting and undesired for the patient. Encouraging hope when there is none represents a barrier to providing a good death.
1-75. (A) Aortic regurgitation may be caused by congenital or degenerative cardiac disease or by endocarditis. Symptoms of aortic regurgitation include systolic ejection murmur, bounding or water-hammer peripheral pulses, head bobbing with each heart beat, dyspnea, syncope, and signs of left ventricular failure. Mitral valve stenosis may cause symptoms of right heart failure, atrial fibrillation, jugular venous distention (JVD), and a diastolic murmur. Tricuspid regurgitation causes a high-pitched holosystolic murmur and symptoms of right heart failure. Signs of pericardial effusion include jugular venous distention (JVD), tachycardia, and symptoms of decreased cardiac output. The ECG in pericardial effusion would typically demonstrate low voltage and tachycardia.
Reference: Bekeredjian, R., Grayburn, P. A. Valvular heart disease, aortic regurgitation. Circulation, 11, 125-134, 2005.
1-76. (C) All of the options are possible reasons for seizures, but substance withdrawal is the most likely choice among these possibilities. Hypoxia (Option A) is less likely because the patient just started this activity of clenching on his endotracheal tube. Delirium tremens (Option B) is another possibility, but DTs usually occur 48 to 72 hours after cessation of alcohol intake. The patient received seizure prophylaxis for post-traumatic seizures (Option D), so while this is possible, it is a less likely cause.
1-77. (B) Absorption describes the extent and rate of substance removal from outside the body to the bloodstream. Factors affecting absorption include the route and the bioavailability of the particular substance. Clearance is the measurement of the body’s ability to eliminate a substance from blood or plasma over time. Distribution is the way in which a substance disseminates throughout the body. Chelation describes one means by which toxic minerals, metals, or chemical substances may be removed from the body via chemical bonding with a chelating agent for elimination in urine and feces.
1-78. (A) Since the medications and transcutaneous pacemaker are equally accessible, the initial intervention should be to initiate transcutaneous pacing. Atropine IV, dopamine or epinephrine infusions may be administered for symptomatic bradycardia if there would be a delay in initiating pacing.
1-79. (B) Among the groups listed, only Anglo-American families are typically organized around the nuclear family. All of the other listed options (Asians, African Americans, and Native Americans) reflect cultures where the common family unit is an extended family.
1-80. (C) Classic symptoms of cardiac tamponade include Beck’s triad: hypotension, jugular venous distension and distant heart tones. Breath sounds are equal bilaterally, so pneumothorax requiring chest tube insertion or needle thoracostomy is not suspected. The SpO2 is adequate so intubation is not indicated.
1-81. (D) The absence of breath sounds over all of the right lung fields strongly suggests a pneumothorax. If there is no penetrating trauma creating a sucking chest wound, these findings are significant for a tension pneumothorax. If the tension pneumothorax enlarges without relief, the patient can go into cardiopulmonary collapse within minutes. Inspiratory wheezing is indicative of narrowed airways; when wheezing clears with coughing, it indicates an intermittent and reversible concern. If the patient were receiving large volumes of IV fluids, frequent auscultation would be warranted. Decreased breath sounds in the bases or over the right lung fields may indicate areas of atelectasis, a collapsed lobe, or a hemothorax. Although these may be significant complications, they are not immediately life-threatening.
1-82. (D) Fifty percent of patients with cirrhosis develop esophageal varicies. Variceal hemorrhage accounts for one third of deaths in patients with cirrhosis. The veins of the esophagus represent a high-flow but low-pressure system. When there is increased resistance to blood flow within the liver, the pressure within this system increases, resulting in portal hypertension and the development of esophageal varicies. The varicies are prone to rupture if they are not eliminated by endoscopy or if the pressure is not reduced by a beta blocker. While portal hypertension can increase the risk of right-sided heart failure, heart failure does not cause gastrointestinal bleeding. In cirrhosis, shunting and vasodilatation occur with elevated pressure in the venous portal system, but circulating blood volume does not increase. Normal liver tissues are not fibrotic. Damage to the liver causes hepatocyte necrosis, collapse of the healthy tissue, and replacement with fibrotic tissue. It is not until the liver becomes cirrhotic that portal hypertension leads to a risk of hemorrhage.
Krumberger, J. M. How to manage an acute upper GI bleed. RN, 68(3), pp 34-39, 2005.
1-83. (A) Right bundle branch block is demonstrated by an rSR′ pattern in leads V1 or V2 (the right chest leads), a slurred S wave in V5 and V6 and a QRS duration of greater than 0.12 seconds. LBBB would be demonstrated by a deep S wave in the right chest leads and a QRS greater than 0.12 seconds in leads V5 and V6. The heart rate is 100 BPM in this ECG so it does not qualify as tachycardia. There is ST segment depression in the anterior leads (V2-V5), which does not signify acute MI. Acute anterior wall MI would be demonstrated by ST segment elevation or Q waves in the anterior leads.
1-84. (A) Postoperative care basics are universal and include optimizing airway, breathing, circulation, pain management, wound care, and intake and output. In the neurosurgical patient, those universals also need to incorporate monitoring and optimizing cerebral perfusion and blood flow. Brain, blood, and CSF are the contents of the cranium. If blood flow—either arterial inflow or venous outflow—is altered, cerebral perfusion may be compromised. If jugular venous outflow is obstructed, cerebral blood volume increases. That volume directly corresponds to pressure, particularly since the cranium is fixed in size and cannot accommodate varying volumes or pressures. Not only would this affect intracranial pressure, but it may also influence postoperative bleeding. Generally, the nurse would not try to decrease CPP (Option B). The usual goal CPP in monitored patients with intracranial processes is 60–70 mm Hg. Positioning of a postoperative patient does not affect CSF flow (Option C) within the central nervous system. No physiologic benefits derive from immobilizing the surgical site or the head (Option D).
1-85. (C) Sudden onset of back pain and neurological changes such as syncope are classic findings in aortic dissection. BP differences and facial edema may be the initial indicators that a thoracic aortic aneurysm is present. Pressure differences greater than 20 mm Hg between the left and right arm may indicate the presence of an aortic aneurysm, but do not signal that dissection is occurring unless they are accompanied by other findings. A pulsatile abdominal mass associated with a bruit is a sign that an abdominal aortic aneurysm is present, and may be found on routine abdominal examination. These findings may be difficult to appreciate in the obese patient. Hypertension and renal insufficiency are frequently found in patients with abdominal aortic aneurysm owing to decreased renal blood flow.
1-86. (C) Bronchodilators, oxygen, mucolytic agents, antibiotics, and glucocortocoids are all commonly employed to treat acute exacerbations of COPD. Although viral infections are a frequent cause of these exacerbations, antiviral therapy is not routinely administered to COPD patients. Inhaled prostacycline is an option for maximizing V/Q matching in patients with ARDS, and its intravenous administration is a common treatment for pulmonary hypertension, but it is not used in COPD. A recent review of evidence related to the efficacy of antibiotics in this patient population supports use of antibiotics for patients with COPD exacerbations who are moderately or severely ill with increased cough and colored sputum. Cholinergic agents would not be used in patients with COPD since they would intensify airway bronchoconstriction; COPD patients receive anticholinergic agents, which antagonize acetylcholine, thereby leading to bronchodilation.
1-87. (A) Percutaneous coronary intervention would eliminate the cause of the dysrhythmia, which is right coronary artery (RCA) occlusion. The RCA supplies the sinus node in most people, and patients with RCA occlusion and IWMI typically have bradycardia. ECG changes associated with RCA occlusion are ST segment elevation in leads II, III, and aVF. Temporary pacing and atropine will only temporarily treat the bradycardia associated with IWMI.
1-88. (C) This question illustrates the nurse’s competency for systems thinking. Systems thinking is displayed as the nurse makes a connection between insertion of an ICD, its malfunction, regulatory requirements related to the incident, and impact on the facility. FDA regulations require manufacturers and hospitals to report all pacemaker and ICD malfunctions, especially those that result in death or surgery. Failure to communicate this device problem may lead to underreporting of their potential defects. Between 1990 and 2002, the average rate of ICD device malfunction was 20.7 per 1000 new implants. Option A reflects an expanded concern that includes effects on the facility but does not approach the still wider repercussions of this scenario on the safety of numerous patients with ICDs. Providing emotional support to the family is an obvious and immediate concern but neglects recognition of the system effects of this incident. There is no evidence that indicates staff need instruction regarding ICD malfunctions, so that option is inappropriate at this time.
1-89. (B) Administration of fluid (crystalloid) would be the most appropriate and immediate treatment at this time. The patient is hemodynamically compromised with hypotension and tachycardia. With the patient’s history of nausea, vomiting, and diarrhea, intravascular volume deficit is the rationale for the patient’s hemodynamic status. Inotropic support would be detrimental to this patient until volume resuscitation is provided. The patient is anemic and will need a blood transfusion, but it will require time to prepare the packed RBCs; therefore, this is not considered an immediate treatment. β-blocker therapy to decrease the heart rate is not indicated for this patient in the presence of hypotension, since the tachycardia is likely a compensatory change for hypovolemia.
1-90. (A) Therapeutic goals for the patient in cardiogenic shock include achieving a mean arterial pressure (MAP) sufficient to ensure central and peripheral perfusion. A MAP of 60 mm Hg will provide cerebral perfusion. Elevated systemic vascular resistance increases left ventricular work and the potential for decreased end organ perfusion. A heart rate nearing normal further indicates that myocardial work has decreased and oxygenation potentially improved.
Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St. Louis, Elsevier, 2005.
1-91. (A) The patient should have autonomy in deciding how the information will be shared and with whom. Option B completely avoids providing the patient with the information. Suggesting the chaplain’s presence shrouds the reply in an undue, ominous tone that is inappropriate. Option D is inappropriate as it reflects a biased reply related to how the information should be conveyed.
1-92. (B) More than 50% of COPD exacerbations are related to bacterial or viral infections. Patients with COPD typically experience considerable sputum production, but these secretions do not become inspissated in this disorder. Airway inflammation and sputum production typically occur as a result of the exacerbation, rather than as its cause.
1-93. (B) Hypotension and a low PCWP require volume replacement. Surgical blood loss that causes such a dramatic decrease in PCWP requires blood replacement. Packed cells would replenish intravascular blood volume. Normal saline bolus would be a temporary volume replacement and may enter the extravascular space in several hours. Vasoconstricting agents such as dopamine and vasopressin should be withheld until volume status is corrected.
1-94. (C) The patient is in acute renal failure. Given that the patient is fluid overloaded and hemodynamically unstable, continuous renal replacement therapy is the treatment modality of choice. Administering fluid boluses to a patient who is in the oliguric phase of ATN will worsen the fluid overload. Hemodialysis requires the patient to be hemodynamically stable. Peritoneal dialysis is not an option owing to the patient’s having recently undergone abdominal surgery.
1-95. (A) Weight gain is an early and reliable sign of fluid retention and potentially worsening heart failure, so these patients require instruction regarding daily weights and reinforcement that an increase in weight should be reported to health care providers to prevent a hospital readmission. Option B is incorrect in that not all heart failure patients have anemia. The literature reports that approximately 30% will experience fatigue and/or anemia. Option C is incorrect even though compliance with appointments might help to ensure early identification of problems by the health care provider. Fluid restriction is important and may eventually prevent a readmission; however, immediate intervention is needed when the patient identifies a weight gain.
1-96. (B) Symptoms of pericardial tamponade include hypotension, narrowed pulse pressure, JVD, and pulsus paradoxus. Tamponade may also cause pulsus paradoxus owing to cardiac compression and decreased stroke volume. Hypovolemia may cause tachycardia, hypotension, and decreased stroke volume, but it is not associated with JVD or a friction rub. Tension pneumothorax may cause hypotension and tachycardia but would be associated with severe dyspnea. Superior vena cava syndrome would cause enlargement of neck veins, edema of the face, shortness of breath, and altered mental status.
1-97. (A) The protracted vomiting and abdominal fluid sequestration associated with acute pancreatitis may result in significant electrolyte imbalances, especially those of calcium, magnesium, and potassium. If severe hypocalcemia occurs, the QT intervals lengthen on the ECG, and seizures may occur. Cullen’s sign, a bluish discoloration of the periumbilical skin typically assocated with subcutaneous intraperitoneal hemorrhage, may or may not be observed in patients with acute pancreatitis, and measurements of abdominal girth are not typically warranted. Although pain control is essential for patients with acute pancreatitis, fluids would not be restricted in patients with vomiting and diarrhea. These patients would be expected to have diminished bowel sounds owing to fluid sequestration. Although vascular stasis and coagulopathies may eventually arise, peripheral pulses are not typically compromised.
Reference: Whitcomb, D. C. Acute pancreatitis. N Engl J Med, 354, 2142-2150, 2006.
1-98. (A) The first nursing action is discontinuation of the tube feeding to remove the threat of aspiration and its associated complications such as aspiration pneumonia. Metoclopramide should be given after the tube feeding is stopped in order to promote gastrointestinal motility and stomach emptying, further diminishing the chance of aspiration of tube feedings. Checking feeding tube or endotracheal tube placement may be helpful to determine whether dislodgment of either tube is causing the aspiration rather than a reopening of the fistula, though auscultation of air through a feed tube is often unreliable for assessing such dislodgment. Other diagnostic studies such as bronchoscopy or endoscopy are indicated prior to continuing or resuming feedings.
1-99. (C) Sinus rhythm at a rate of less than 100 beats/min indicates that the workload on the left ventricle has decreased effectively, and oxygenation has improved. The heart rate would be elevated if hypoxia was present. Because respiratory effort may cause exhaustion, a slow respiratory rate may indicate fatigue and impending respiratory failure. The amount of diuresis is not a specific indicator that pulmonary fluid overload has resolved. Systolic blood pressure is influenced by multiple factors, including catecholamine release, blood volume, and vasodilation, making it a nonspecific indicator for resolution of pulmonary edema.
1-100. (C) The response to cytokine release during sepsis results in (1) systemic vasodilation with decreased afterload (↓ SVR) and hypotension; (2) increased capillary permeability with decreased preload (↓ CVP), third-spacing, and interstitial edema; (3) relative hypovolemia; and (4) decreased tissue oxygen extraction (↑ SVO2). The hemodynamic values in Option A are consistent with a patient in cardiogenic shock. The elevated SVR reflects the sympathetic nervous system response of vasoconstriction. The CVP is elevated owing to pump dysfunction. The SVO2 is decreased owing to low cardiac output. Option B illustrates a patient with loss of vascular tone as seen in spinal cord injury. The patient has adequate preload and normal oxygen extraction at the tissue level. Option D describes a patient with hypovolemic shock. Again, the SVR is elevated as a compensatory response to low pressure with vasoconstriction. The low preload (↓ CVP) is consistent with decreased circulating volume. The SVO2 is decreased in relation to the low preload with resultant low cardiac output.
1-101. (A) Chest tube output greater than 200 mL for 2 consecutive hours indicates a need to return to the operating room to determine if there is a correctable source of bleeding. Low MAP requires pharmacologic support and increasing the rate of dopamine infusion, changing therapy to norepinephrine (Levophed), and fluid bolus to increase blood pressure. Low cardiac output may indicate a need for vasopressor support, fluid administration, increased pacing rate, or cardiac assist with IABP. Elevated PCWP should be treated with vasodilators or possible IABP support to decrease afterload.
1-102. (C) The patient must be repositioned because effective chest compressions need to be delivered with the patient in a supine position. Instructing the new nurse on use of the 2006 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care from the AHA provides current information on correct patient placement from an authoritative source and clarifies that the Trendelenburg position should not be used. Option A is incorrect because in order for chest compressions to be effective, the patient must first be positioned for optimal compression. Option B is a good response but not the best response. The nurse should begin CPR immediately, and then the preceptor can initiate the unit’s code blue response. Option D is important, but suction should already be available at an ICU patient’s bedside.
1-103. (C) In hypertrophic cardiomyopathy, obstruction is decreased when afterload is increased and when preload is decreased; as a result, treatment aims toward increasing afterload and/or increasing preload. Nitroglycerin decreases both preload and afterload, so when it is administered to patients with hypertrophic cardiomyopathy, both of these effects worsen the obstruction and intensify symptoms. Since hypertrophic cardiomyopathy is associated with diastolic dysfunction, medications (such as beta blockers and calcium channel blockers) that slow the heart rate allow increased diastolic filling, which increases preload and promotes myocardial stretch with more efficient emptying of the ventricle. Amiodarone may be used in the treatment of hypertrophic cardiomyopathy to treat atrial or ventricular dysrhythmias.
Reference: Bruce, J. Getting to the heart of cardiomyopathies. Nursing 2005, 35, 44-47, 2005.
1-104. (C) Regardless of the factors contributing to the development of disseminated intravascular coagulopathy, the definitive treatment is to eliminate the potential causes of this malady. Until this has been accomplished, the patient’s situation will continue to deteriorate. Use of heparin may or may not be useful for the patient experiencing DIC, depending on the factors related to the etiology. Subcutaneous administration of any medication may lead to prolonged bleeding from the injection site and should be avoided, especially because the impairment of circulation would limit absorption. While supportive care is necessary, unless the cause of the DIC is addressed, the patient will not survive.
1-105. (B) Although septic shock is usually associated with vasodilation caused by the release of proinflammatory cytokines and prostaglandins, not all blood vessels dilate. The arterioles in the microcirculation remain vasoconstricted, leading to a maldistribution of blood flow and subsequent inadequate tissue perfusion. Inadequate tissue perfusion is evaluated by tissue oxygen indices, which include oxygen delivery (DO2) and consumption (VO2). Normal oxygen delivery is approximately 1000 mL/min, while normal oxygen consumption is estimated at 250 mL/min. In septic shock, the absolute intravascular volume may be normal, but because of acute vasodilation, a relative hypovolemia occurs. Myocardial depression can occur in patients with septic shock and is characterized by reversible biventricular dilation, decreased ejection fraction, altered myocardial compliance, and decreased contractile response to fluid resuscitation and catecholamines. It is caused primarily by myocardial depressant factors released as a result of sepsis and not by altered coronary perfusion or global ischemia. The patient’s hemodynamic values indicate the patient has not received adequate volume resuscitation.
1-106. (C) An emergent tracheotomy will provide immediate access to and maintenance of a patent airway so the patient can be ventilated and enable management of the pulmonary trauma that has resulted in the subcutaneous emphysema. The rapid onset of airway obstruction suggests that the obstruction is located in the upper airways, so oral intubation will be ineffective to solve the problem. A fiberoptic bronchoscopy can only be used after the airway has been secured. There is no indication that cardiac compressions for initiation of cardiopulmonary resuscitation are warranted, as the patient has not lost pulses.
1-107. (B) Risk factors for intracerebral hemorrhage (ICH) include low weight (<70 kg), hypertension, advanced age (>70 yr), and thrombolytic therapy. Coagulopathies must be reversed as soon as possible. Warfarin should be reversed with vitamin K (three 10 mg IV doses) and fresh frozen plasma to normalize prothrombin time. Factor IX concentrate can be used along with vitamin K. IV bolus dosing of recombinant factor VIIa can be administered within the first 3 to 4 hours after symptom onset or in patients at risk of additional bleeding, such as those with warfarin-related coagulopathies. It may limit hematoma enlargement and reduce morbidity and mortality after ICH. Surgery (Option A) for evacuation of a large deep hemispheric clot has been found ineffective in reducing mortality or disability. CT scan is appropriate for diagnostic evaluation in this case. MRI (Option C) may be considered in cases where the clot morphology, location, or presentation is inconsistent with typical ICH. However, this patient does not present with any atypical findings. Epsilon-aminocaproic acid (EACA) (Option D) is indicated in patients who recently received a thrombolytic and are deteriorating. EACA can enhance hemostasis when fibrinolysis contributes to bleeding, but it can also cause excessive thrombosis and is generally not indicated in this scenario.
1-108. (B) Identifying and locating resources that the patient’s wife could use would help relieve the heavy burden of the husband’s care. There is no basis for involving the ethics committee in this situation. Option C has a somewhat judgmental tone and is at odds with the wife’s stated feelings and perspective on the situation. Option D may be supportive to some extent, but fails to address the issues of greatest concern at the moment.
1-109. (D) Renal insufficiency as demonstrated by elevated creatinine should be reported to the cardiologist as adjustments in the amount or type of contrast used for the catheterization may be necessary. Premedication with fenoldopam or acetylcysteine and hydration may be ordered to prevent nephrotoxicity from the contrast agent. Heparin will be continued during catheterization and will be discontinued prior to sheath removal. A serum troponin level of 0.2 ng/dL is not indicative of myocardial ischemia. The potassium level is within normal limits. Contrast media frequently cause diuresis, which may decrease the serum potassium.
1-110. (B) Administration of insulin will begin to correct the patient’s acid-base imbalances. This initial bolus should be followed up with an IV drip of regular insulin, which is fast acting and will stop the formation of ketone bodies, thereby correcting metabolic acidosis. Administration of antibiotics may not be an appropriate intervention, as there is no indication the patient is febrile or producing purulent sputum or urine. The patient is compensating for his metabolic acidosis through an increase in the depth and rate of respirations, and bicarbonate level will likely return to a normal level as the cause of the metabolic acidosis is corrected. Normal saline is important for its hydrating effects; however, this rate of infusion would be inadequate to replace fluids lost over a 4-day period.
1-111. (B) Elevation of the head of the bed 30 to 45 degrees has been shown to decrease the rate and risk of aspiration and hospital-acquired pneumonia. Feeding tube placement does not decrease the risk of aspiration. No matter where the tip of a feeding tube is placed, residuals increase the risk of aspiration. In order to prevent tissue trauma and unwarranted oxygen desaturation, patients should be only suctioned when clinically indicated by the presence of secretions. Enteral feedings appropriately delivered have been shown to decrease mortality and morbidity when compared with hyperalimentation.
1-112. (B) The patient’s rhythm strip indicates first degree AV block with bradycardia and the automated blood pressure is adequate, therefore no immediate interventions are necessary. Bradycardia is common in healthy persons during sleep. If the automated blood pressure was below 90 mm Hg systolic, the nurse may awaken the patient to determine if symptomatic bradycardia is present. If the patient had low blood pressure or symptoms of decreased perfusion such as altered mental status, administration of atropine would be warranted. Administration of oxygen is indicated for symptomatic bradycardia.
1-113. (A) The body uses oxygen to generate high-energy phosphates via cellular metabolism. If oxygen delivery is not sufficient to meet cellular demands—as seen during periods of shock—the body must rely on anaerobic metabolism. The end product of anaerobic metabolism is lactate. Serum lactate can be used as an alternative parameter to measure the adequacy of oxygen delivery. Although initial serum lactate levels do not differ significantly between survivors and nonsurvivors, survival rates are highest in patients whose serum lactate levels return to normal within the first 24 hours. Thereafter, the longer it takes for lactate levels to clear, the higher the incidence of organ failure and mortality.
1-114. (C) The anterior wall is synonymous with the left ventricle. Acute myocardial infarction of the left ventricle is associated with left ventricular failure and signs of heart failure. Occlusion of the right coronary artery is associated with SA and AV block and bradycardia. Hiccoughs and GI upset are also common with inferior wall MI. Right ventricular MI may cause right ventricular failure and related signs such as JVD and peripheral edema.
1-115. (C) Option C is the best because hospitalized patients are often highly motivated to change their lifestyles to improve their health, so hospitals are appropriate sites for prevention. Option A does not facilitate communication. Options B and D avoid discussing an obvious and potentially life-threatening behavior problem.
1-116. (C) Signs of retroperitoneal bleeding after PCI include back and groin pain. This condition may be seen when access is difficult due to obesity and the iliac artery is punctured anteriorly and posteriorly during sheath insertion. The serum hemoglobin and hematocrit would decrease with blood loss into the peritoneal space. The 12-lead ECG would not show changes related to bleeding other than tachycardia, or sometimes bradycardia. Morphine administration would relieve pain, but would not stop bleeding.
1-117. (B) This client requires referral to a social worker or psychiatric clinical nurse specialist who can conduct a comprehensive assessment of this patient’s needs related to child care issues, financial and employment issues, and drug rehabilitation. Option A is not an immediate concern since the children are being cared for. Although the patient’s employment status is a relevant point to document, the patient’s competence to care for her children depends on numerous factors and cannot be assumed without further assessment. Referrals for drug and alcohol rehabilitation can be arranged by the social worker or CNS.
1-118. (A) COPD is primarily a disease of pulmonary mechanics and is best monitored by measuring ease of expiratory flow, which can be done using serial peak flow measurements. Hypoxia is usually a later sign during an exacerbation. Excessive mucous production is a common problem in COPD and exacerbations may be caused by infectious processes, but this will not track respiratory function. Patient reports of dyspnea are multifactorial and are not necessarily associated with an exacerbation.
1-119. (C) The patient is at highest risk of falling due to diuretic use. Concomitant use of anticoagulants places the patient at higher risk of bleeding complications at points of fall contact. Hematomas and cerebral bleeds will prolong this patient’s hospital stay. The risk of stroke is decreased owing to anticoagulants, and if therapeutic levels are maintained, that risk is potentially preventable. While the patient is in the acute phase of care, exercise expectations are restricted to patient abilities and may be restricted to sitting in a chair. It is anticipated that treatment with diuretics will prevent the occurrence of pulmonary edema.
1-120. (C) Following CABG surgery, patient depression is associated with a high incidence of adverse outcomes. Early identification (within the first 48 hours) of a postoperative CABG patient experiencing depression enables prompt intervention to improve the patient’s psychological health. Option A is incorrect because postoperative pain is associated with virtually all types of surgery, is readily identified, and does not, in itself, lead to these complications. Option B is incorrect as a loss of control is not associated with poor outcomes in CABG patients. Option D is incorrect as anemia can be readily identified and corrected with blood products.
References: Doering, L. V., Moser, D. K., Lemankiewicz, W., et al: Depression, healing and recovery from coronary artery bypass surgery. Am J Crit Care, 14(4), 316-324, 2005.
1-121. (D) Beta blocking medications decrease the incidence of myocardial reinfarction as well as the incidence of ventricular and supraventricular dysrhythmias, reduce myocardial remodeling, and prevent sympathetic stress on the myocardium, making beta blockers useful in reducing mortality in acute MI. Calcium channel blocking agents do not prevent ventricular dysrhythmias and have not been shown to reduce mortality in acute MI. Magnesium prophylaxis does not reduce development of ventricular dysrhythmias in the setting of acute MI after thrombolytic therapy. Lidocaine decreases ventricular dysrhythmias, but side effects such as bradycardia, paresthesias, and altered mental status, which persist after the reperfusion dysrhythmias, make it a poor treatment choice.
1-122. (B) Spontaneous bacterial peritonitis is the infection of ascites fluid and is a common complication of decompensated cirrhosis. This should be suspected when a patient with cirrhosis and ascites also develops fever, abdominal pain, or deterioration in mental status. Although these clinical findings may be subtle, spontaneous bacterial peritonitis may precipitate septic shock, renal failure, and liver failure. Acute appendicitis typically manifests as a vague midline abdominal pain accompanied by nausea, vomiting, and lack of appetite that slowly migrates to the right lower quadrant over 24 hours. A small bowel obstruction presents with nausea, vomiting, and severe cramping abdominal pain that often comes in waves at intervals every 5 to 15 minutes but does not include fever. Acute pancreatitis will present with severe upper abdominal pain, nausea, vomiting, and fever.
Yamada, T. Handbook of Gastroenterology, 2nd ed. Philadelphia, Lippincott Williams & Wilkins, 2005.
1-123. (D) Echocardiography best determines the absence of pericardial effusion and tamponade. While the pericardial catheter is in place and functioning properly, the patient should demonstrate absence of symptoms of pericardial effusion and tamponade. A lack of drainage may signal catheter obstruction and does not necessarily indicate that pericardial effusion has resolved. Approximately 250 mL of pericardial fluid is necessary for the effusion to be visualized on chest x-ray as an enlarged cardiac silhouette or water-bottle shape.
1-124. (A) In Haitian culture, the family is matriarchcal. The wife is instrumental in decision making and overseeing major decisions. Kong is not widely used in the Haitian culture and is not a product for young men. Kong is used to increase virility and is not sold at local grocery stores. Haitian culture is matriarchal rather than patriarchal.
References: Colin, J. M., Paperwalla, G. Haitian-Americans, 1998, retrieved April 20, 2006, from http://www-unix.oit.umass.edu/∼efhayes/haitian.htm
1-125. (B) Meningitis is a potential complication of basilar skull fracture, and an elevated temperature is a key examination finding. Deep vein thrombosis (Option A) may present with an elevated white count and/or elevated temperature. Screening would include venous duplex of the extremities. However, infectious sources are a more likely cause of fever. Hypothalamic dysfunction or “storming” (Option C) characteristically presents with hypertension, tachycardia, and fever. The scenario presented does not include all of these key features. While a retained foreign body (Option D) may eventually result in infection, the scenario described suggests a more common and likely source of infection for this patient.
References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6th ed. St. Louis, Elsevier, 2006.
1-126. (B) The nurse would anticipate administration of platelets to decrease bleeding in this patient. The normal platelet count is 250,000 to 500,000/mm3. Packed RBCs are not indicated unless the hematocrit falls below 28%. Fresh frozen plasma would be indicated to replace clotting factors if the INR was greater than 1.5. Salt poor albumin is used to replace volume in patients with low albumin or extravascular fluid overload.
1-127. (B) Patients with pelvic fractures require prompt and effective nutritional support to optimize recovery. A specialist should evaluate nutritional needs and begin feeding within 24 hours of admission. Nutrition is key to ensuring adequate healing. Option A is not warranted unless the patient has an underlying psychiatric problem that needs to be addressed. Neither Option C nor Option D is required at this point in the patient’s care.
Reference: Frakes, M. A., Evans, T. Major pelvic fractures. Crit Care Nurse, 24(2), 18-32, 2004.
1-128. (D) A “silent chest” represented by inaudible breath sounds on auscultation is the most ominous sign of acute respiratory failure in the asthmatic patient because it reflects significantly diminished ventilation or movement of air into and out of the lungs. Poor ventilation may be due to respiratory muscle fatigue or bronchoconstriction. Wheezing indicates bronchoconstriction but also reflects the patient’s ability to move sufficient air to produce the wheezing sounds. Although sentence length is a general indicator of severity of shortness of breath, it is not an indicator of respiratory failure. Tachypnea may lead to respiratory failure if its prolonged duration results in respiratory muscle fatigue.
1-129. (C) When the liver loses its ability to break down and conjugate new proteins, immune globulins are produced in progressively smaller quantities. The pathophysiology of liver failure, not the patient’s medications, is the cause of the patient’s immune compromise. Adhering to the medication regimen will increase the patient’s ability to ward off infection as laboratory values become more normal. Long-term malnutrition and impaired uptake of nutrients are not the primary reason for decreased immunity. While it is true that fewer fat-soluble vitamins and vitamin B-12 are stored, this is not the primary reason for immune compromise.
1-130. (B) The highest Glasgow Coma Scale (GCS) score a patient can receive is 15, and the lowest is 3. For the eye score, the patient receives one point because his eyes do not open (even to noxious stimuli). His verbal score is 1 since he is intubated (although given his motor response, he is unlikely to make any better response). He flexes his right upper extremity (motor score of 3) and extends his left upper extremity (motor score of 2) to noxious stimuli. As the best motor score is used to calculate a patient’s GCS score, his total GCS score is 5 (Eye = 1, Verbal = 1, Motor = 3).
1-131. (A) Research shows that many (over 70%) patients have difficulty following the dietary and fluid restrictions necessary while on hemodialysis, especially younger male patients. The best response is to have a nutritionist determine the need for additional education regarding renal diet and fluid restriction and provide any supplementation warranted. The nutritionist needs to design a dietary plan and work with the patient (and, if patient wishes, with his spouse or other family members who assist with food shopping and cooking) to identify food selection and short-term goals. Option B would be implemented only at the patient’s request. Option C may be a true statement, but attempts to improve compliance based on induced fear are not supported in the literature. Option D is a discussion he should have with his nephrologist and does not afford an immediate solution to his problem of diet and fluid protocol nonadherence.
1-132. (A) Uncontrolled hypertension is an absolute contraindication to the administration of thrombolytics. Blood pressure may be reduced with beta blockers or vasodilators to enable administration of thrombolytics to reduce the risk of intracerebral bleeding. Although TIA may increase the risk of stroke, it does not necessarily indicate that a thrombus is present, and the risk of intracerebral bleed should be weighed against the benefit of thrombolytic administration. History of stroke is a relative contraindication to administration of thrombolytics. Remote stroke should not prevent administration of thrombolytics because intracerebral clots should be absorbed over time through normal processes. Age is also a relative contraindication. If percutaneous intervention (PCI) is available within 90 minutes for an elderly patient with acute myocardial infarction, PCI would be a better alternative. If PCI is not available, the patient should receive thrombolytic therapy.
1-133. (B) The patient is experiencing vascular steal syndrome. This syndrome occurs when blood is shunted away from tissues, causing tissue hypoperfusion. The incidence of vascular steal syndrome is higher in patients with grafts and/or upper arm accesses, in diabetics, and in the elderly; the incidence increases in extremities with previous access procedures. Management of the patient’s symptoms includes comfort measures such as applying warm compresses and administering ordered analgesics that improve vascular supply to the hand. All other options would reduce blood flow and further exacerbate the patient’s symptoms.
1-134. (B) Option B is the correct reply not only because it is factually correct, but also because the easiest way to begin learning about a procedure such as this is by recognizing what constitutes a “normal” finding. Option A is factually incorrect. Both Option C and Option D are incorrect because these activities are not included in the procedures related to measuring bladder pressures.
Reference: Gallagher, J. J. Ask the expert. Crit Care Nurse, 26(1), 67-70, 2006.
1-135. (C) If cardiomyopathy is due to myocardial ischemia, the most definitive treatment is to restore coronary circulation by either percutaneous coronary intervention or coronary bypass surgery. ACE inhibitors can decrease pulmonary congestion and prevent ventricular remodeling, but they do not afford definitive benefit. Likewise, diuretics only temporarily relieve symptoms such as pulmonary congestion. Permanent pacing could be used to treat dysrhythmias or improve cardiac output caused by lack of AV synchrony.
1-136. (A) Enteric leakage from anastomotic sites is a complication of the roux-en-y gastric bypass. In addition to an elevated WBC count, patients may have subtle signs of infection or have signs of sepsis and hemodynamic instability. In most cases of infection, the WBC count is elevated and the platelet count remains unchanged. Potassium levels usually are reduced in patients with increased gastrointestinal drainage. Platelet counts are elevated in patients with hematological disorders or in those who have undergone a splenectomy, neither of which pertain to this patient. Lipase is elevated in pancreatic disorders. This patient does not exhibit clinical evidence of pancreatic dysfunction .
1-137. (C) Gram-negative pneumonia and persistent immunocompromise are both risk factors for developing a lung abscess or parapneumonic effusion. This patient’s clinical and diagnostic test findings are consistent with those associated with these conditions and warrant manual thoracic drainage and antibiotic administration. Results from a BAL would not reflect a process in the pleural space. Option B identifies interventions for hemothorax, a condition not evidenced in this patient’s clinical presentation. Bronchial hygiene interventions will not affect an intrapleural process.
1-138. (D) The patient has most likely developed complete heart block from scar formation subsequent to surgical repair of the atrial septal defect (ASD). Prior to the patient’s surgery, the left to right atrial shunt associated with ASD caused pulmonary hypertension, which resulted in right ventricular and right atrial enlargement; RA and RV enlargement, in turn, may precipitate development of right bundle branch block (complete or incomplete) and delayed conduction from the SA to AV node evidenced by a prolonged PR interval. As a result, first and second degree AV block, Type 1, could have existed preoperatively with progression to complete AV block occurring gradually with scar tissue formation postoperatively.
1-139. (C) Korsakoff syndrome is characterized by retrograde and anterograde amnesia, decreased spontaneity, decreased initiative, and confabulation (filling in memory gaps with distorted facts). Gait disturbances, paralysis of the eye muscles, and nystagmus are clinical manifestations of Wernicke’s encephalopathy. Both conditions are the result of chronic alcohol ingestion and a thiamine deficiency. Thiamine plays a key role in glucose metabolism. The major organ systems that are affected by a thiamine deficiency are those that depend on energy from metabolism of carbohydrates: the peripheral nerves, heart and brain. Other symptoms of thiamine deficiency include peripheral neuropathy with myelin degeneration, hypertension, and cardiomyopathy.
1-140. (D) The immediate need of this patient is to alleviate her frustration by consulting a speech therapist who can assist the patient in regaining and improving her speech expression. Progress in that area will, in turn, help to alleviate the patient’s vexation with her current limitations. Nothing in the scenario described supports this patient’s need for either occupational or physical therapy. Although the patient’s responses of anger and frustration might suggest the need for a psychiatric social worker, these are perfectly normal early behavioral responses to the patient’s current physical challenges.
1-141. (D) Immediate treatment with cardioversion is appropriate to treat atrial fibrillation in this patient. Inferior wall infarction decreases perfusion to the right atrium and may result in SA node ischemia and atrial dysrhythmias. Atrial fibrillation decreases cardiac output and may further compromise coronary perfusion. Although amiodarone, diltiazem, and digoxin are all possible antiarrhythmic agents that may be used to treat atrial fibrillation, the time it takes for these pharmacologic interventions to circulate and take effect may allow detrimental effects of myocardial ischemia to occur.
1-142. (B) A continuous infusion of 10% dextrose is less irritating to the peripheral veins than repeated doses of 50% dextrose and will allow correction of fluid and electrolyte imbalances to occur at a slower and more steady pace, helping to avoid seizure or dysrhythmia activity. Because the patient has a diminished level of consciousness, it would not be safe to administer any form of glucose as an oral fluid. After beginning the 10% dextrose infusion, glucagon may be administered intramuscularly, not intravenously. While glargine insulin produces a steady control of glucose, this patient is in an acute phase and reduction of glucose would not be desirable at this time.
1-143. (A) Acting as an arbitrator between family members is the most helpful behavior for families. Though often used by nurses, Option B is incorrect because all family members should be involved in understanding options at the end of life. Option C is incorrect because the use of terms such as death and dying is realistic and often helps the family understand the patient’s prognosis. Option D should be pursued only when the family requests clergy support.
Thelen, M. End-of-life decision making in intensive care. Crit Care Nurse, 25(6), 28-37, 2005.
1-144. (A) Abdominal discomfort and bladder distention indicate urinary tract obstruction, which could progress to renal transplant graft failure. An increase in urinary output and decreasing serum creatinine indicate improved renal function. Right upper quadrant tenderness and elevation of liver enzymes and bilirubin are indicative of rejection of a transplanted liver. Elevation of serum glucose with symptoms of hyperglycemia are associated with pancreatic rejection and would appear days after signs and symptoms of renal rejection in the case of transplant of multiple organs.
1-145. (D) Dark, tea-colored urine suggests that the patient has myoglobinuria. Once myoglobinuria is diagnosed, treatment is aimed at preventing subsequent renal failure. Aggressive administration of IV fluids increases renal blood flow and decreases the concentration of nephrotoxic pigments. Continuous infusion of mannitol and sodium bicarbonate will alkalinize the urine and prevent myoglobin crystallization in the renal tubules. Nursing management is aimed at achieving fluid and electrolyte balance. The patient needs to be assessed for hypernatremia, hyperosmolality, and volume overload. Patient management goals include maintaining a serum pH less than 7.5, serum Na of 135 to 145 mEq/L, urine output greater than or equal to 200 mL/hr, and urine pH of 6.0 to 7.0.
1-146. (C) Patients with inferior wall MI often complain of abdominal or gastrointestinal symptoms. A 12-lead ECG should be performed prior to administration of nitroglycerin in order to detect changes owing to ischemia. NG decompression should be attempted with caution in a patient on heparin. Troponin studies should be performed after the 12-lead ECG and nitroglycerin are administered.
1-147. (C) A sudden decrease or absence of chest drainage may indicate an obstruction in the chest tube caused by tube kinking or the presence of a blood clot or tissue debris. Tube obstruction can interfere with the re-expansion of the lung following hemothorax or pneumothorax and contribute to hemodynamic compromise. Fluctuation or tidaling in the water-seal chamber indicates a properly functioning chest tube. Discomfort at the chest tube insertion site can be relieved with analgesics. Intermittent bubbling in the water-seal chamber may occur when the system is initially placed to suction and may continue until the patient’s lung is re-expanded.
1-148. (B) Some over-the-counter cough medications contain aspirin. This can cause gastric irritation resulting in a blood loss of 100-200 mL, which presents as melana. Since the patient has not been taking the cough medicine during the hospitalization, the cause of the irritation has been removed. Hemorrhoidal bleeding presents as bright red blood on the outside of the stool, sometimes coloring the toilet water light pink. A ruptured diverticula would present with crampy abdominal pain and bright red bleeding. A healing peptic ulcer would not have any bleeding associated with it.
1-149. (D) In most people, the dominant internal carotid artery is on the left, so a stroke involving that artery would be expected to produce the clinical picture described. A right middle cerebral artery (Option A) stroke would produce left-sided motor or sensory loss (greater in arm than leg), left-sided motor loss in lower face, left-sided visual field loss, and aphasia. A right vertebral artery (Option B) stroke would likely cause right facial weakness and numbness, facial and eye pain, clumsiness, ataxia, vertigo, nystagmus, hiccups, dysphagia, and dysarthria. Left anterior cerebral artery (Option C) stroke would typically result in confusion, personality changes, perseveration, incontinence, and right-sided motor or sensory loss (greater in leg than arm).
1-150. (D) The most appropriate nursing action is to continue to monitor the patient on the current ventilator settings. Permissive hypercapnea is used in ARDS to prevent volutrauma from large tidal volumes and high PEEP levels. The use of tidal volumes from 5-8 mL/kg decreases the risk of volutrauma in noncompliant lung tissue. Increased respiratory rates increase patient energy use and may also increase the risk of alveolar damage owing to air trapping. Therapy goals in ARDS include maintaining the pH greater than 7.20. If the pH decreases below 7.20, sodium bicarbonate may be used to raise the pH.
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