2-1. (A) In patients with ARDS, pneumothorax is frequently related to the use of high PEEP and tidal volumes intended to promote oxygenation and is easily treated by insertion of a chest tube. Immediate treatment of pneumothorax is warranted to prevent further patient compromise. Although decreased urine output is of concern, improvement in oxygenation by relieving pneumothorax takes precedence. Although pneumonia may have contributed to sepsis, causing ARDS, sputum cultures would not be indicated for a patient with pneumothorax (indicated by the radiolucence in the right middle lobe). Administration of norepinephrine to increase blood pressure is not the immediate concern for this patient. Blood pressure may be improved via treatment of the pneumothorax.

Reference: Hemmila, M. R., Napolitano, L. M. Severe respiratory failure: advanced treatment options. Crit Care Med, 34, S278-S290, 2006.

2-2. (D) Signs of brain death include the following: fixed pupils, no motor response to deep central pain, absent corneal reflexes, absent oculocephalic (doll’s eyes) reflex, absent oculovestibular reflex (cold water calorics), positive apnea test (no spontaneous breaths with PaCO₂ >60 mm Hg and despite 100% FiO₂ ventilation 15 minutes prior). Loss of vascular tone (Option A) is not part of the diagnostic criteria for brain death, but hemodynamic instability can occur prior to or following diagnosis. Barbiturate infusion (Option B) is provided for refractory intracranial hypertension as a salvage measure. Lack of response to this treatment is not pathopneumonic for brain death, but many patients have a poor outcome. Barbiturates are metabolized slowly, so it can take days before they are cleared to subtherapeutic values, a prerequisite prior to testing for brain death. All diagnoses should be made in the absence of hypothermia, metabolic, or drug cause, shock or anoxia, or immediately post resuscitation. Responses of the spinal reflex arc (Option C)—elicited with infliction of peripheral noxious stimuli such as nail bed pressure—are commonly present after brain death.

References: Bader, M. K., Littlejohns, L. R. (eds.). AANN Core Curriculum for Neuroscience Nursing, 4^th ed. St. Louis, Elsevier, 2004.

Wijdicks, E. F. M. The Clinical Practice of Critical Care Neurology. New York, Oxford University Press, 2003.

2-3. (C) Hyponatremia and hypokalemia result from prolonged vomiting. Changes in serum sodium concentration usually reflect changes in water balance. The signs and symptoms of hyponatremia are often nonspecific, and most are related to the changes in serum osmolality and consequent fluid shifts in the central nervous system. These can include headache, lethargy, disorientation, seizures, muscle cramps, or weakness. Hypokalemia can develop as a result of intracellular shifts of potassium or as a result of increased loss of or decreased ingestion or administration of potassium. Clinical signs of hypokalemia include weakness, paralysis, respiratory compromise, rhabdomyolysis, ECG changes, cardiac disrhythmias, and sudden death. Hyperglycemia may occur with extreme stress. Signs and symptoms of hyperkalemia (peaked T waves, diarrhea) are not associated with vomiting. These symptoms usually occur with ketoacidosis, tissue destruction, and renal failure and with certain medications such as beta-blockers. Hypoglycemia may occur with dehydration and protracted vomiting. However, symptoms of hyponatremia (headache, tremors, disorientation) occur with overuse of diuretics, certain psychoactive medications, inadequate dietary intake of sodium, water intoxication, or impaired adrenal or kidney function. Jaundice owing to hyperbilirubinemia, water retention and swelling, and muscle cramps owing to hypoalbuminemia, occur in patients with conditions such as cirrhosis.

Reference: Kraft, M. D., Btiache, I. F., Sacks, G. S., et. al. Treatment of electrolyte disorders in adult patients in the intensive care unit. Am J Health-Syst Pharm, 62, 1663-1682, 2005.

2-4. (C) Flail chest, caused by blunt trauma to the thoracic cavity, occurs when two or more adjacent ribs are fractured in two or more places. This flail segment moves independently from the rest of the thoracic cage and results in paradoxical chest wall movement during the respiratory cycle. Paradoxical motion refers to the movement of the flail segment in the direction opposite that of the intact chest wall. Instead of expanding outward with the rest of the thoracic wall during inspiration, the flail segment is drawn inward by the negative inspiratory pressure. Conversely, as this negative pressure falls during exhalation, the flail segment is pushed outward.

References: Newberry, L., Criddle, L. M., (eds.). Sheehy’s Manual of Emergency Care, 6^th ed. St. Louis, Elsevier, 2005, p 655.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing, Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 991-992.

2-5. (A) ST segment depression and T wave inversion indicate myocardial ischemia. Acute transmural infarction would be evidenced on 12-lead ECG as ST segment elevation (STEMI) or Q waves in indicative leads. Lateral wall ischemia or infarct is observed in leads I and aV_L or leads V₅ and V₆ on the 12-lead ECG. Anterior wall changes indicative of ischemia or infarct would be seen in leads V₃ and V₄.

Reference: Achar, S. A., Kundu, S., Norcross, W. A. Diagnosis of acute coronary syndrome. Am Fam Phys, 72, 119-1126, 2005.

2-6. (D) Late complications of renal injury include: hypertension, hydronephrosis, chronic pyelonephritis, calculus formation, and intrarenal calcification. Early complications include ileus, sepsis, shock, impairment or loss of renal function, perinephric or renal abscess, and fistula formation.

References: Adams, K., Johnson, K. Trauma. In Urden, L. D., Stacy, K. M., Lough, M. E. (eds.). Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 969-1008.

Stark, J. L. The renal system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 525-607.

2-7. (C) Gastric irritation is a frequent adverse effect of immunosuppressive agents, so taking this medication with commercial chocolate milk (that contains algae derivatives for thickening) or food will help to prevent development of gastric ulcers. It is not safe to double the dose of immunosuppressive medications if a dose is missed because of the possibility of untoward effects. Resuming the normal dose as soon as possible will limit incidence of graft vs. host disease. Levels of immunosuppressive medications are not monitored using laboratory values, although antibody levels may be used to evaluate the effectiveness of immunosuppressive therapy. Elevated blood pressure represents a serious untoward effect of immunosuppressive agents and, if not monitored or reported to the primary health care provider, may lead to permanent neurological deficits.

References: Deglin, J. H., Vallerand, A. H. Davis’s Drug Guide For Nurses, 10^th ed. Philadelphia, F. A. Davis, 2007, pp 58-59, 336-339, 1100-1101.

Morton, P. G., Fontaine, D. K., Hudak, C. M., Gallo, B. M. Critical Care Nursing: A Holistic Approach, 8^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005, pp 1122-1128.

2-8. (A) Option A is correct because encouraging patients to recall past successes or reflect on the past may support adaptation to life changes. Option B is incorrect because a patient’s views on these issues would not explain their current diagnosis. Option C might be an informative and reflective experience but would not necessarily have health implicatons for the future. Option D is not appropriate because the scenario described does not suggest this patient needs to focus on their mortality at this time.

References: Hardin, S. R. Caring practices. In S. R. Hardin, R. Kaplow (eds.). Synergy for Clinical Excellence. Sudbury, Jones & Bartlett, 2005, pp 69-74.

Rustoen, T., Howie, J., Eidsmo, I., Moum, T. Hope in patients hospitalized with heart failure. Am J Crit Care, 14(5), 417-425, 2005.

2-9. (B) In cases of acute hypoglycemia, treatment should be administered, then its effectiveness assessed through the use of capillary glucose measurement 15 minutes after administration of the glucose source. This timeframe should be adhered to regardless of whether or when circulation is restored or the patient is transferred between units.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 428-432.

Urden, L. D., Stacy, K. M., Lough, M. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, p 926.

2-10. (A) The inferior wall is supplied by the right coronary artery, which also supplies the right ventricle. A right side ECG would demonstrate if RVMI has occurred. Treatment for RVMI requires fluid administration and perfusion and may be compromised by administration of vasodilators such as nitroglycerin. A second ECG in 30 minutes is not warranted and would delay treatment for this patient with acute inferior wall STEMI (ST segment elevation in leads II, III, and aVF). Although the heart rate is less than 50/min., transcutaneous pacing or administration of atropine would increase myocardial demand and potentially worsen ischemia, so it should be withheld unless signs of decreased perfusion are present.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-11. (A) Chlorhexidine gluconate solutions used for vascular catheter site care reduce catheter-related bloodstream infections and catheter colonization more effectively than povidone iodine solutions. Data suggest that IV tubing containing crystalloids can be replaced every 72 to 96 hours, so Option B is not correct. Option C is not accurate because the transducer, tubing, flush device, and flush solution need to be replaced only every 96 hours. If aseptic technique during insertion cannot be ensured, the catheter should be replaced soon as possible, but within 48 hours, not within 72 hours as Option D suggests.

Reference: AACN Practice Alert. Preventing Catheter Related Bloodstream Infections. Available at www.aacn.org//AACN/practiceAlert.nsf/Files/Practice%20AlertCatherter%20Related%20BSI/$file/Practice%20AlertCatherter%20Related%20Blood%20Stream%20Infections.pdf. Retrieved on July 1, 2006.

2-12. (D) Pulse oximetry measures the percent of hemoglobin molecules that are saturated, but does not distinguish whether that saturation is with oxyhemoglobin or carboxyhemoglobin. During the initial management of patients with CO poisoning, arterial blood gas studies need to be used to evaluate a patient’s oxygenation status. Poor tissue perfusion owing to hemodynamic instability leads to loss of pulsatile flow, signal failure, and unreliable readings. The cherry-red skin color is due to the binding of hemoglobin and CO in the blood. SaO₂ readings in the presence of carboxyhemoglobin are falsely elevated. The amount of oxygen a patient receives has no bearing on the accuracy of pulse oximetry.

Reference: Newberry, L., Criddle, L. M. (eds.). Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2005, pp 470-471.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing, Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 616, 1057.

2-13. (C) Administration of agents that dilate the pulmonary arteries such as epoprostenol or calcium channel blocker agents will, in some cases, reduce right ventricular work and improve pulmonary blood flow and oxygenation. Phlebotomy may be considered in polycythemic patients with pulmonary hypertension when the hematocrit is greater than 60%. Fluid bolus may reduce blood viscosity but would not reduce symptoms owing to tricuspid valve incompetence. Increased cardiac contractility would not improve cardiac output in patients with tricuspid regurgitation.

Reference: Holcomb, S. S. Understanding pulmonary arterial hypertension. Nurs Manage, 3, 56A-56G, 2005.

2-14. (A) The body habitus of morbidly obese patients predisposes them to hypoventilation, particularly when in the supine position. Their body habitus does not lead to elevated intra-abdominal pressure (Option B), and their obesity does not alter immune responses (Option D). Option C is untrue.

Reference: Hurst, S., Blanco, K., Boyle, D., et al. Bariatric implications of critical care nursing. Dimensions Crit Care Nurse, 23, 76-83, 2004.

2-15. (B) The majority of postoperative complications in emergency hemicolectomy relate to infection, including sepsis, intra-abdominal abscess and wound infections. These complications are associated with increased morbidity and mortality. Using the sepsis bundle for early resuscitation, the intravascular volume needs to be re-established and the tissue beds need to be perfused to reduce tissue hypoxia. Lactate levels need to be kept less than 4 mmol/L. Normal central venous pressure is 5-8 mm Hg. A central venous pressure less than this indicates continued reduction in preload, which would not be an optimal response to the initiation of rapid fluid resuscitations. Urine output of 25 mL/hr is still below the norm of 30 mL/hr. This would not be an optimal response to rapid fluid administration. Cool, dry skin could indicate that the patient is experiencing peripheral vasoconstriction, suggesting continued hypovolemia and the need for further fluid resuscitation.

References: Dellinger, R. P., Vincent, J. L. The Surviving Sepsis Campaign sepsis change bundles and clinical practice. Crit Care, 9(6), 653-654, 2005.

Wyrzykowski, A. D., Feliciano, D. V., George, T. A., et al. Emergent right hemicolectomy. Am Surg, 71(8), 653-657, 2005.

2-16. (A) Dilated cardiomyopathy may be idiopathic or caused by toxic agents such as chemotherapy, alcohol, or cocaine. In dilated cardiomyopathy, death is usually related to the development of ventricular dysrhythmias, bradycardia, or thrombus formation in the dilated ventricle. Warfarin prevents clot formation and prevents death related to thrombus. Calcium channel blockers prevent supraventricular dysrhythmias, which are not common in dilated cardiomyopathy. Nitrates will improve coronary artery perfusion, but the primary defect in dilated cardiomyopathy is a structural defect in the ventricle that is not improved with administration of vasodilators. Digoxin improves contractility in cardiomyopathy but has no effect on the development of ventricular dysrhythmias, which may cause sudden death in this population. In addition, digoxin may contribute to the development of bradycardia, which could be detrimental.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-17. (A) Treprostinil sodium (Remodulin) is administered on a continuous subcutaneous basis, using a programmable pump. As a result, patients and caregivers must receive training in how to operate the pump. Treprostinil does not result in potential for pelvic bleeding. The drug is administered subcutaneously and does not interfere with digestion or cause indigestion. The pump does not use wireless technology.

Reference: Eells, P. L. Advances in prostacyclin therapy for pulmonary arterial hypertension. Crit Care Nurse, 24(2), 42-54, 2004.

2-18. (C) Transfusion of two units of packed red blood cells should increase the hemoglobin by 2 g/dL and the hematocrit by 4-6% in this patient with anemia. Patients with end-stage renal disease (ESRD) experience anemia secondary to a decrease in production of erythropoietin; as a result, there is diminished stimulation of the bone marrow to produce red blood cells. Transfusion of one unit of packed red blood cells will not sufficiently increase the patient’s hemoglobin and hematocrit. Administration of Epoetin Alfa takes weeks to increase the hemoglobin and hematocrit and is contraindicated in patients with uncontrolled hypertension. Decreasing the dose of Epoetin Alpha will not address the problems of low hemoglobin and hematocrit.

References: Dressler, D. K. Hematology and immunology systems. In M. Chulay, S. M. Burns (eds.). AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, pp 305-316.

Mayer, B. Hematologic disorders and oncologic emergencies. In L. D. Urden, K. M. Stacy, M. E. Lough (eds.). Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 1128-1144.

Stark, J. L. The renal system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 525-607.

2-19. (D) An invasive strategy is preferred if the onset of symptoms and signs of acute MI have persisted for more than 3 hours from the time of presentation. Since the availability of open heart surgery as an intervention would cause further delay in treatment, percutaneous coronary intervention is the preferred therapy for this patient. Administration of thrombolytic therapy is contraindicated in a patient who has exhibited symptoms for longer than 3 hours. The patient has evidence of STEMI. Heparin and G IIb/IIIa inhibitors are indicated for patients with acute coronary syndrome.

Reference: Field, J. M., Hazinski, M. F., Gilmore, D. (eds.). Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, American Heart Association, 2006.

2-20. (C) Maintaining glucose levels <150 mg/dL has been shown to reduce morbidity in critically ill medical patients with sepsis. In a large double-blind study, human recombinant activated protein C decreased mortality by 6% in patients with severe sepsis and decreased mortality by 13% for patients at high risk for death (i.e., patients having an APACHE II score of 25 or greater), but there is no indication that this patient had severe sepsis, so Option A is not correct. When a patient is hypotensive, fluid replacement should be optimized before vasopressors are started. Option B is incorrect because aggressive volume resuscitation is an essential early intervention for sepsis so that the hemodynamics altered by the inflammatory response are corrected prior to use of vasopressors. Option D is incorrect as two meta-analyses have concluded that high-dose corticosteroids are of no benefit or may be detrimental to patients with septic shock.

Reference: AACN Practice Alert. Severe Sepsis. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/ss/$file/Severe%20Sepsis.pdf Retrieved July 1, 2006.

2-21. (D) Linear fracture of the temporal bone leading to laceration of the middle meningeal artery is the most common cause of epidural hematoma. Classically, these patients present with a history of a brief loss of consciousness immediately after the injury with a subsequent period of lucidity. Subsequently, these patients often deteriorate owing to the expanding arterial bleed. Epidural hematoma is a neurosurgical emergency. Urgent non-contrast head CT scan may be considered, but this patient’s history would most likely result in immediate operative intervention for this surgical emergency. Option A, cerebral angiography and coil embolization, would be indicated for a cerebral aneurysm, not a traumatic brain injury (TBI). This patient was noted to have a linear left temporal skull fracture. Once the likely underlying epidural hematoma is evacuated, the patient should significantly improve and is unlikely to need (Option B) ventriculostomy and CSF drainage. If there were additional intracranial findings, these actions may be indicated. Option C, osmotic diuretic, may be given to patients with known head injury and focal neurologic deficits. However, corticosteroids are not indicated in traumatic brain injury.

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 475.

Bader, M. K., Littlejohns, L. R. (eds.). AANN Core Curriculum for Neuroscience Nursing, 4^th ed. St. Louis, Elsevier, 2004.

Greenberg, M. S. (ed.). Handbook of Neurosurgery, 6^th ed. New York, Thieme Medical Publishers, 2006.

2-22. (D) Sore throats, aching joints, and painful urination all signal activity of opportunistic bacteria and fungal growth associated with taking immunosuppressive medications to protect donor organs. Rapid recognition and intervention will help to avoid damage and potentially lethal infections. Neither restricted physical activity nor dietary restrictions will help avoid future infections. Drinking plenty of liquids will help avoid dehydration and infection, but this is not the best reply for avoiding delays in treatment.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 681-682.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 1105.

2-23. (C) The chest-x-ray demonstrates atelectasis, which may be due to obesity hypoventilation syndrome. Another common finding related to this syndrome is loss of hypoxic drive. Addition of CPAP will assist in opening the alveoli and decreasing atelectasis. Decreasing the FiO₂ may help to increase this patient’s respiratory drive and reduce ventilator dependence. It should be anticipated that the patient may have sleep apnea after extubation and would benefit from BiPAP, but due to the difficulty in intubating the patient, immediate extubation prior to correcting atelectasis should occur. T-piece would not be an effective weaning strategy for this patient because inspiratory volumes would not be predictable owing to the restrictive effects of obesity, and positioning of bariatric patients may present challenges to effective ventilation owing to abdominal size and pressure on the diaphragm. Pressure support may not be an effective weaning mode for morbidly obese patients because of the increase in weight on the thorax preventing delivery of adequate tidal volumes.

Reference: Blouw, E. L., Rudolph, A. D., Narr, B. J., Sarr, M. G. The frequency of respiratory failure in patients with morbid obesity undergoing gastric bypass. AANA J, 71, 45-50, 2003.

2-24. (D) Data suggest that both low dose unfractionated heparin (UFH) and low molecular weight heparin (LMWH) are effective in preventing DVT in moderate-risk critical care patients. For patients at higher risk, such as those who have experienced major trauma or orthopedic surgery, LMWH has been shown to provide better protection than low dose UFH (Option B). Direct thrombin inhibitors may be used in place of LMWH or UFH for patients with documented or suspected heparin induced thrombocytopenia. In general, mechanical prophylaxis (Options A and C) is less effective when compared with anticoagulation-based therapy. Data suggest that there is a high risk of noncompliance with pneumatic compression devices. In one study involving below-the-knee graded stockings (Option C), 98% of commercially available stockings failed to produce an ideal pressure gradient, and 54% were found to produce a dangerous reverse pressure gradient.

Reference: AACN Practice Alert. Deep Vein Thrombosis Prevention. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/dvt/$file/DVT.pdf Retrieved on July 1, 2006.

2-25. (D) Enterocutaneous fistulas can result in major fluid losses. The low serum albumin contributes to the development of edema and further increases intravascular fluid loss. Replacement of albumin is the most appropriate method to increase intravascular volume and blood pressure. The hematocrit is 30%, and blood replacement is not indicated until the hematocrit is decreased to 28% or less. The patient is on hyperalimentation, which contains glucose, and the serum glucose is low normal, so D50% is not indicated. Since the serum sodium is already elevated, fluid replacement with normal saline would be controversial. ½ normal saline may be preferred for fluid replacement in the hypernatremic patient.

Reference: Baird, M. S., Keen, J. H., Swearingen, P. L. Manual of Critical Care Nursing. St. Louis, Elsevier, 2005.

2-26. (C) The patient is exhibiting findings characteristic of an arthropod-borne encephalitis. CSF cultures would be most beneficial in identifying the causative organism. While (Option A) serologic tests may be of help, the nurse would not obtain a specimen while the patient is experiencing a grand mal seizure. Nor would the nurse (Option B) wait to intervene until the seizure is completed, as prolonged seizure activity is life-threatening. If a standing order for a benzodiazepine is available for the patient, then the nurse would be able to quickly provide treatment to stop the seizure activity. If no order is available, the nurse should notify the physician to inform of the situation and obtain further orders. While it is important to protect the patient from injury, restraints (Option D) are not appropriate in this circumstance. Padded side rails would be most appropriate.

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

Bader, M. K., Littlejohns, L. R. (eds.). AANN Core Curriculum for Neuroscience Nursing, 4^th ed. St. Louis, Elsevier, 2004.

2-27. (C) Compared with Caucasians, all ethnic groups are more sensitive to the effects of central nervous system drugs and require lower doses. Asians metabolize CNS drugs more slowly than other groups and therefore require lower doses of antidepressants. Chinese in particular require lower doses of haloperidol. There are no data in the case to suggest the patient’s symptoms are related to hypovolemia, as described in Option A. Option A also will not protect the patient from potentially getting too high a dose of medication. Option B is incorrect because it suggests the patient will receive a larger loading dose of this medication, which may cause harm. Option D is not the best choice because this test is not readily available in hospital laboratories and will not address the underlying issue of the patient requiring a lower dose of medication; in addition, this deficiency is not associated with metabolism of haloperidol.

Reference: Burroughs, V., Maxey, R., Crawley, L., et al. Cultural and Genetic Diversity in America: The Need for Individualized Pharmaceutical Treatment. Available at www.npcnow.org. Retrieved on July 1, 2006.

2-28. (D) Morphine sulfate is the most appropriate medication to relieve chest pain due to myocarditis. In myocarditis, pain is due to inflammation of the myocardium and is often related to autoimmune infiltration. Nitroglycerin is not effective in relieving the pain of myocarditis because the pain is not related to coronary blood flow. Diuretics may be effective to relieve symptoms of heart failure associated with myocarditis, but they would not relieve pain. Non-steroidal anti-inflammatory medications are contraindicated in chest pain associated with myocarditis because they may induce complications such as bleeding and tamponade.

References: Deason, J., Hope, B. A 23 year old man with chest pressure, pallor, tachypnea and tonsillitis. J Emerg Nurs, 31, 199-202, 2005.

Magnani, J. W., William, D. Myocarditis current trends in diagnosis and treatment. Circulation, 113, 876-890, 2006.

2-29. (D) In patients with liver dysfunction, an altered level of consciousness occurs due to the development of hepatic encephalopathy, which occurs when the detoxification functions of the liver are lost, resulting in impairment of the central nervous system. Hepatic encephalopathy is a neuropsychiatric disorder associated with portal hypertension. In the patient with acute liver failure, the development of encephalopathy follows the development of jaundice. An additional concern is that when patients develops encephalopathy, their ability to maintain a patent airway may become compromised. Hypotension is not a clinical feature of patients with hepatic dysfunction; hyperdynamic circulation is more likely with liver disorders. While esophageal bleeding is a potential complication with liver failure, this patient evidences no indications of that problem. Although the patient has elevated liver enzymes, there are no findings that specifically reflect the presence of systemic infection.

References: Hays, P. C., Simpson K. J. Approach to the patient with fulminant (acute) liver failure. In T. Yamada (ed.).Textbook of Gastroenterology, 4^th ed. Philadelphia, Lippincott Williams & Wilkins, 2003.

Stewart, C. A., Cerhan, J. Hepatic encephalopathy: a dynamic or static condition. Metab Brain Dis, 20, 193-204, 2005.

2-30. (C) On the 12-lead ECG, posterior wall MI presents as tall, broad R waves and ST depression in leads V₁ and V₂. When reversed and rotated 180 degrees, these findings appear as deep Q waves and ST segment elevation. Unstable angina presents on the 12-lead ECG as transient ST depression and T wave inversion. Anterior septal MI presents with ST segment elevation in leads V₁-V₃. Pericarditis would present on the 12-lead ECG as ST segment elevation in the anterior leads V₁– V₆.

Reference: Sole, M. L., Klein, D. G., Moseley, M. J. Introduction to Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2005.

2-31. (A) Social support can be emotional or instrumental in facilitating a need. Emotional support consists of receiving comforting gestures and knowing that someone is available. The patient does not appear to be experiencing anxiety (Option B). Patient needs related to Options C and D can be met through other activities, such as watching TV or reading.

References: Finfgeld-Connett, D. Clarification of social support. J Nurs Scholarship, 37(1), 4-9, 2005.

Hardin, S. R. Caring practices. In Hardin, S. R., Kaplow, R. (eds.). Synergy for Clinical Excellence. Sudbury, Jones & Bartlett, 2005, pp 69-74.

2-32. (B) Cautious use of antihypertensives (such as labetolol and hydralazine) and diuretics (such as furosemide) to decrease blood pressure without causing hypotension will help to maintain blood flow to the fetus and represent the goals of therapy in peripartum cardiomyopathy. Immediate C-section is not indicated unless the fetus demonstrates distress such as deceleration of fetal heart rate. ACE inhibitors are contraindicated in the antepartum period because they may cause birth defects, spontaneous abortions, stillbirth, and low birth weight due to fetal hypotension. Chronic use of beta blockers in pregnancy is associated with low birth weight, but beta blockers such as labetolol are frequently used to treat hypertensive emergencies in pregnancy.

Reference: Tidswell, M. Peripartum cardiomyopathy. Crit Care Clin, 20, 777-786, 2004.

2-33. (B) Patients with longstanding COPD have difficulty maintaining adequate nutritional intake owing to the caloric demands inflicted by increased work of breathing and by the great effort required to breathe and eat simultaneously. Cor pulmonale demonstrates as right heart failure and causes edema with weight gain. The weight loss may be associated with weaker thoracic excursion and diminished ventilation and is not usually related to dehydration.

Reference: Nici, L., Donner, C., Wouters, E., et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med, 173, 1390-1413, 2006.

2-34. (D) Data support that pulmonary embolus, anastomotic leaks, and respiratory failure account for 80% of all deaths within 30 days after bariatric surgery. These data need to be incorporated in the assessment and plan of care of these patients. Appropriate prophylaxis for venous thrombotic events usually includes low-molecular-weight heparin. Option A reflects some of the common short-term complications of bariatric surgery, which include wound infection, stomal stenosis, marginal ulceration, and constipation. Options B and C relate to some long-term complications of this surgery, including symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and nutritional deficiencies.

Reference: Virji, A., Murr, M. M. Caring for patients after bariatric surgery. Am Fam Physician, 73(8), 1403-1408, 2006.

2-35. (B) Vasovagal reaction may occur during sheath removal and resolve rapidly after administration of atropine. If decreased blood pressure occurs without bradycardia, a normal saline bolus may be administered. Nausea occurs due to decreased blood pressure. Prochlorperazine (Compazine) is associated with vasodilation and would cause a further decrease in blood pressure. Retroperitoneal bleeding generally becomes evident after sheath removal when the puncture site is no longer protected by the sheath.

Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St. Louis, Elsevier, 2005.

2-36. (B) Use of garlic may increase bleeding time. This can pose problems in patients undergoing invasive procedures. Not respecting a patient’s desire to use complementary therapies, if not contraindicated, demonstrates a low level of caring practices. Option A is incorrect because the patient should not be taking garlic on the day of the procedure. Option C does not respect the patient’s choice to use complementary therapies. Option D is not correct because patients are usually instructed to take their cardiac medications on the day of the procedure, and beta blocker therapy should continue unless contraindicated.

References: Agency for Healthcare Research and Quality: Garlic: Effects on cardiovascular risks and disease, protective effects against cancer, and clinical adverse effects. Evidence Report/Technology Assessment: Number 20. Rockville, MD, Author. Available at http://www.ahrq.gov/clinic/epcsums/garlicsum.htm. Retrieved on July 1, 2006.

Eschiti, V. S. A closing word: critically ill patients’ use of complementary and alternative modalities. Dimens Crit Care Nurs, 25(1): 52-53, 2006.

2-37. (B) In right ventricular myocardial infarction, the right ventricle is unable to maintain forward flow to the lungs without adequate preload. Intravenous fluid administration increases right ventricular volume and promotes forward flow to the lungs. Diuretics would diminish circulating volume and preload, and so would aggravate the problem. Nitroglycerin and morphine cause vasodilation which decreases preload and would diminish right ventricular filling and output, thus worsening myocardial ischemia.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-38. (A) Anterior cord syndrome is commonly caused by flexion injuries as seen in head-on collisions or by acute herniation of an intervertebral disk. It is associated with injury to the anterior gray horn (motor) cells, the spinothalamic tracts (pain), the anterior spinothalamic tract (light touch), and the corticospinal tracts (temperature). This type of injury results in a loss of motor function and the ability to sense pain and temperature with intact position sense and sensation to pressure and vibration below the level of the injury. Central cord syndrome produces a motor and sensory deficit more pronounced in the upper extremities than in the lower extremities. Brown-Sequard syndrome presents as loss of voluntary motor movement on the same side as the injury with loss of pain, temperature, and sensation on the opposite side. Posterior cord syndrome results in loss of position sense, pressure, and vibration below the level of injury with intact motor function and sensation of pain and temperature.

Reference: Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing, Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 981-984.

2-39. (C) Delivery of a succession of shocks by the AICD is termed implantable cardioverter defibrillator storm. After interrogation, if no mechanical error is found, the patient should be assessed for electrolyte imbalance, medication compliance and activities that may have induced the dysrhythmia. Since the device functioned appropriately, lead fracture is not suspected. EP testing would be indicated prior to device implant if the dysrhythmia required ablation.

Reference: O’Brien, M. C., Langberg, J., Valderrama, A. L., et al. Implantable cardioverter defibrillator storm: nursing care issues for patients and families. Crit Care Nurs Clin North Am, 17, 9-16, 2005.

2-40. (C) The earliest indication that aspiration may have occurred would be the development of tachypnea and tachycardia. The PaCO₂ may decrease with tachypnea associated with aspiration, and the tachypnea associated with aspiration is generally the reason an arterial blood gas is obtained. Chest x-ray findings are later signs and may be seen in the right middle lobe owing to the angle of the right mainstem bronchus, although infiltrates associated with aspiration may be located in any dependent lung field. This patient’s cough reflex may be suppressed, and positive sputum cultures associated with bacterial infections may take up to 3 days to develop.

Reference: Myrianthefs, P. M., Kalafati, M., Samara, I., Baltopoulos, G. J. Nosocomial pneumonia. Crit Care Nurs Q, 27, 241-257, 2004.

2-41. (C) The patient failed to respond to the initial insulin infusion dose, which should have caused the serum glucose to drop by 50 mg/dL after each hour of therapy. Doubling the hourly infusion rate and continuing to monitor is the appropriate intervention under such a circumstance. Simply documenting and monitoring the patient will not achieve desirable results, as the patient will continue to produce ketone bodies. Increasing by 2 units/hr is inadequate because the client is failing to respond to a rate of 4 units/hr, and doubling the dose is the acceptable intervention. In this acute phase, it is too early to move to subcutaneous insulin, which has a slower rate of absorption than the intravenous route.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 426-431.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 934-937.

2-42. (C) The 12-lead ECG does not demonstrate evidence of ischemia or infarction, and the troponin level is within normal limits. This patient would benefit from serial ECGs and serum markers to determine if evolving myocardial ischemia is present. Immediate PCI or thrombolytic therapy is indicated if the patient has evidence of myocardial ischemia. Administration of aspirin should occur as soon as possible after the onset of chest pain. Administration of heparin and ACE inhibitors is indicated for patients at high or intermediate risk of cardiac ischemia.

Reference: Field, J. M., Hazinski, M. F., Gilmore, D. (eds.). Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, American Heart Association, 2006.

2-43. (B) The most appropriate action is Option B, because the most reliable source of information would be a chart audit to objectively quantify the number of cases and the specific outcome indicators for each. This option could also be accomplished quickly. Option A will delay securing data to determine the nature and extent of any problem for 6 months; if a problem were identified, its solution would be even further delayed, possibly compromising patient outcomes. Options C and D afford purely subjective discussions rather than the facts needed for future decision making at the organizational level.

Reference: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

2-44. (C) The primary goals of emergency management of intracerebral hemorrhage (ICH) are to prevent subsequent damage from rebleeding, edema, or hypoxia and to identify the cause, site and extent of the hemorrhage. If coagulopathies are present, these must be corrected in order to prevent further bleeding. In patients with ICH, BP reduction (Option A) should be gradual and controlled because acute BP normalization may reduce local cerebral perfusion pressure and cerebral blood flow to ischemic levels; in chronically hypertensive patients, it may shift the autoregulatory curve to higher pressures. BP treatment must be tailored to the needs of the individual patient. As a guide, for patients with a history of significant hypertension, the MAP should initially be maintained in the range of 120 mm Hg. In formerly nonhypertensive patients, lowering SBP to less than 160 mm Hg in the first hours after ICH may prevent additional bleeding. CT scan of the head is the primary imaging modality used for these patients, whereas cerebral angiography (Option B) is not commonly performed in this patient population. Size and location of an ICH are used to judge the usefulness of surgical interventions (Option D). While surgical intervention may be beneficial for noncomatose patients with large or enlarging superficial clots, traditional craniotomy with evacuation of spontaneous supratentorial hematomas has been shown to be ineffective in reducing mortality or disability in this patient population as a whole. Infratentorial hematomas, which often present with signs of brain stem compression, are often treated with surgical evacuation and have significantly decreased mortality in this subgroup.

References: Adams, H., Adams, R., Del Zoppo, G., Goldstein L. B. Guidelines for the early management of patients with ischemic stroke: 2005 guidelines update. A scientific statement from the Stroke Council of the American Heart Association/American Stroke Association. Stroke, 36: 916-923, 2005.

Grotta, J. C. Management of primary hypertensive hemorrhage of the brain. Curr Treat Options Neurol, 6(6), 435-442, 2004.

2-45. (A) There should be bubbling in the water seal chamber when the patient exhales to indicate that air is escaping from the pleural space. A large amount of bubbling that does not coincide with the patient’s phase of ventilation suggests a large air leak in the system. Bubbling in the water seal chamber will disappear slowly as the lung re-expands to fill the pleural space and air stops leaking. There should not be any dependent loops in the chest drainage tubing system, as these may inhibit drainage. If suction is ordered, it will be a negative pressure. Positive pressure is not applied to a closed drainage system. A chest tube is not to be clamped unless specifically ordered by the physician or unless unit procedure calls for clamping as part of replacing or changing the system.

References: Ellstrom, K. Pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 151.

Roman, M., Mercado, D. Review of chest tube use. Med-Surg Nurs, 15(1), 41-43, 2006.

2-46. (C) Norepinephrine would be the vasopressor of choice in this particular patient. Norepinephrine is a positive inotrope and increases mean arterial pressure due to its vasoconstrictive effects, with little change in heart rate and less increase in stroke volume compared with dopamine. Because the patient is experiencing tachycardia with a heart rate of 110, dopamine would not be the initial choice. Epinephrine also has strong positive chronotropic effects, so would not be the preferred agent. Vasopressin is a direct vasoconstrictor and a negative inotrope. Use of vasopressin can lead to coronary artery and splanchnic ischemia, resulting in further compromise of a critically ill patient.

Reference: Dellinger, R. P., Carlet, J. M., Masur, H., et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32(3), 858-873, 2004.

2-47. (A) Patients receiving a large volume of fluids and blood components are at high risk for dilutional coagulopathy, which is accentuated with hypothermia (temperature less than 36.5° C or 97.7° F); therefore, warming blood components and fluids will help control factors altering coagulopathy. Monitoring laboratory values alone will not prevent the development of complications. Antihistamine and anti-inflammatory medication will help to decrease immune responses to blood transfusions, including febrile incidents and pruritis, but these are not life-threatening complications. In times of trauma and shock, intramuscular injections are poorly absorbed.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 117-122.

Schell, H., Puntillo, K. A. Critical Care Nursing Secrets, 2^nd ed. St. Louis, Elsevier, 2006, p 433.

2-48. (A) Mediastinal bleeding is very common in the early postoperative period after VAD implantation. The extracorporeal circuits and anticoagulation for the procedure increase coagulopathy. VADs may be pulsatile or continuous flow. Flow rates are generally maintained high enough to prevent thrombus formation, so anticoagulants may not be necessary, but blood contact with the circuits increases the risk of thrombus formation. Ventricular assist devices are now portable so patients are not restricted from contact with others (except those with infections). Neutropenia does not occur with VAD implantation unless the patient receives immunosuppression in the immediate pretransplant period. Although the patient may become immunologically sensitized, this does not prevent future transplant.

Reference: Bojar, R. M. Manual of Perioperative Care in Adult Cardiac Surgery, 4^th ed. Berlin, VT, Blackwell, 2005.

2-49. (D) Blood pressure reductions that occur after bariatric surgery and substantial weight loss depend on the blood pressure status of patients before surgery: normotensive patients and hypertensive patients taking antihypertensive medications show small postsurgical pressure reductions, while patients with elevated blood pressure before surgery show notable postsurgical pressure drops. Option A does not answer the patient’s question directly even though it illustrates the nurse’s ability to collaborate with other members of the multidisciplinary team. Option B describes gastric banding, which is not the procedure the patient had. Gastric leakage does not necessarily cause a change in a patient’s blood pressure.

Reference: Fernstrom, J. D., Courcoulas, A. P., Houck, P. R., Fernstrom, M. H. Long-term changes in blood pressure in extremely obese patients who have undergone bariatric surgery. Arch Surg, 141(3), 276-283, 2006.

2-50. (D) After turning a postoperative coronary artery bypass patient, it is common to have an increase in chest tube drainage, from blood which has pooled. The nurse should continue to monitor drainage, and if drainage continues at 200 mL/hr after the patient is turned, the physician should be notified. Autotransfusion is generally performed when there is greater than 400 mL of blood in the autotransfusion apparatus. Stripping of chest tubes is controversial. Aggressive stripping may damage the myocardial or pleural tissue. Coagulation studies are not indicated unless the patient exhibits continued bleeding.

Reference: Bojar, R. M. Manual of Perioperative Care in Adult Cardiac Surgery, 4^th ed. Berlin, VT, Blackwell, 2005.

2-51. (C) The resuscitation of a patient in severe sepsis or sepsis-induced tissue hypoperfusion (hypotension or lactic acidosis) should begin as soon as the syndrome is recognized. An elevated serum lactate concentration identifies tissue hypoperfusion in patients at risk who are not hypotensive. Early goal-directed therapy has been shown to improve survival for patients presenting with septic shock. Resuscitation directed toward the following four goals for the initial 6-hour period of the resuscitation reduced 28-day mortality: (1) CVP 8-12 mm Hg (in ventilated patients: 12-15 mm Hg); (2) mean arterial pressure ≥65 mm Hg; (3) urine output ≥ 0.5 mL/kg/hr; (4) continuous central venous oxygen saturation (ScVO₂) ≥70% (normal 70% to 80%).

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 768.

Dellinger, R. P., Carlet, J. M., Masur, H., et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32(3), 858-873, 2004.

2-52. (A) Nesiritide (Natrecor) is a potent vasodilator used in the treatment of heart failure that may cause profound hypotension. It should be withheld if the patient’s blood pressure is below 90 mm Hg. Although placing the patient flat in bed would improve blood pressure, it would likely increase respiratory distress and lower the SpO_2. A fluid bolus is inappropriate in this instance as it would likely worsen the patient’s heart failure. The diuresis resulting from furosemide (Lasix) administration may further decrease blood pressure.

Reference: Smith, A. L., Brown, C. S. New advances and novel treatments in heart failure. Crit Care Nurs, 23, S11-S20, 2003.

2-53. (B) Alleviation of postoperative pain will allow the patient to perform breathing exercises focused on prevention of atelectasis. Although the patient may require increased oxygen, the breathing exercises will likely restore his oxygen saturation to acceptable levels. There is no clinical evidence of hemothorax; breath sounds are diminished owing to lobe removal on the right and atelectasis on the left. Anxiety management alone would be insufficient to improve this patient’s pulmonary status.

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

Brunner, Suddarth (eds.). Textbook of Medical-Surgical Nursing, 10th ed. Philadelphia, Lippincott Williams & Wilkins, 2004.

2-54. (C) Pleural effusion and pain are complications of pancreatitis that can negatively affect management of ARDS. Pancreatic enzymes released into the circulation damage pulmonary vasculature and stimulate inflammation, leading to intrapulmonary shunt and hypoxemia. Exudates may then cross the diaphragm and enter the pleural space via lymphatic channels, causing pleural effusions. Pleural effusions can reduce pulmonary compliance and limit lung expansion. The hypovolemia experienced by patients with acute peritonitis is typically a relative form owing to third-spacing of fluids within the abdomen and can be managed with fluids to optimize preload and circulating volume. Autodigestion of body tissues by pancreatic enzymes can lead to fistula formation and impaired skin integrity, but these problems do not significantly affect pulmonary function. The pain associated with acute pancreatitis is often characterized as “the worst ever” and could compromise pulmonary function via limited lung expansion and guarding. Effective, aggressive, and continual pain management should enable avoidance of additional pulmonary compromise owing to pain.

Reference: Pastor, C. M., Matthay, M. A., Frossard, J. L. Pancreatitis associated acute lung injury: new insights. Chest, 124, 2341-2351, 2003.

2-55. (C) Pericardial tamponade from lead perforation would result in symptoms of JVD and hypotension with narrowed pulse pressure. Hemothorax or pneumothorax may cause diminished breath sounds on the affected side. Pacemaker syndrome results from loss of atrial kick during pacing and may cause altered mental status and hypotension, but not narrowed pulse pressure or JVD.

Reference: Howell, C., Bergin, J. D. A case report of pacemaker lead perforation causing late pericardial effusion and subacute cardiac tamponade. J Cardiovasc Nurs, 20, 271-275, 2005.

2-56. (D) The preceptor needs to use evidence-based interventions such as testing via pH paper to assess nasogastric tube placement and prevent potential harm. Option A is refuted by case reports in which bubbling did not occur despite malpositioning of the tube within the airways. Option B is incorrect because the literature contains numerous reports of the ineffectiveness of air insufflation and auscultation for verification of tube location. Option C is also not optimal. Although observing for respiratory distress may be useful, there have been reports of failures of this method such that 16 Fr to 18 Fr NG tubes malpositioned in the respiratory tract did not induce immediate respiratory distress in patients with neurologic debilitation or advanced respiratory disease.

Reference: AACN Practice Alert. Verification of Feeding Tube Placement. Available at www.aacn.org/AACN/practiceAlert.nsf/Files/FTP/$file/Verification%20of%20Feeding%20Tube%20Placement.pdf Retrieved on July 1, 2006

2-57. (C) The diet plan for patients with acute renal failure is restricted in intake of fluid, protein, phosphorus, and potassium, making an adequate intake of calories, vitamins, and minerals difficult. Protein is restricted on a renal diet to prevent increasing the patient’s BUN. This restriction is necessary despite the renal patient’s increased requirements for protein secondary to metabolic acidosis, catabolic conditions, and losses from dialysis, wounds, or corticosteroid drugs. The protein deficit weakens muscles and increases the patient’s susceptibility to infection. Carbohydrates are encouraged in the renal diet to provide energy for metabolism and healing. Fluid overload may be the precursor of other conditions, such as heart failure and respiratory failure, which may lead to risk for infection. Fluid restriction is a requirement of the renal diet and does not place the patient at risk for infection.

Reference: Mitchell, J. G. Renal disorders and therapeutic management. In L. D. Urden, K. M. Stacy, M. E. Lough (eds.). Priorities in Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2004, pp 333-356.

Moore, M. C. Nutritional alterations. In L. D. Urden, K. M. Stacy, M E. Lough (eds.). Priorities in Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2004, pp 51-64.

2-58. (C) In patients on diuretic therapy, the vascular system may be depleted and need fluid augmentation despite the presence of rales and heart failure. This patient has an elevated HCT suggesting hypovolemia, a low serum albumin that would contribute to loss of fluid into the interstitial spaces, and a BUN/creatinine ratio greater than 20:1, indicating hypovolemia. Dobutamine infusion would increase the force of ventricular contraction but would not raise BP if the stroke volume remained low owing to intravascular volume depletion. Norepinephrine (Levophed) could temporarily increase BP via vasoconstriction, but vasopressors should be used only after volume deficits are corrected. Furosemide (Lasix) would further decrease intravascular volume.

Reference: Baird, M. S., Keen, J. H., Swearingen, P. L. Manual of Critical Care Nursing. St. Louis, Elsevier, 2005.

2-59. (D) Insofar as it is possible, allowing patients to continue their customary routines and practices while in the hospital is the best approach because it offers COPD patients the greatest amount of control, which can lessen anxiety and maintain a more positive outlook. A mental health consult may be advisable for some COPD patients but is not warranted for others. The health care team should consider continuing antidepressants and other medications during the exacerbation, but benzodiazepines are not indicated for all COPD patients.

References: Hynninen, K. M., Bretieve, M. H., Wiborg, A. B., et al. Clinical characteristics of patients with chronic obstructive pulmonary disease: a review. J Psychosomatic Res, 59, 429-443, 2005.

Nici, L., Donner, C., Wouters E., et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med, 173, 1390-1413, 2006.

2-60. (C) Spirituality has potential importance for acute and critically ill patients and families. Spirituality may influence understanding of suffering and illness and how a patient or family copes with the situation. By addressing spiritual issues, critical care nurses can create more holistic and compassionate systems of care. Option A is incorrect since spirituality may promote a patient’s clinical stability. Option B is incorrect because spirituality issues can be addressed during all phases of health and illness. Option D is incorrect and demonstrates lack of respect for a patient’s beliefs.

Reference: Puchalski, C. Spirituality in health: the role of spirituality in critical care. Crit Care Clin, 20(3), 487-504, 2004.

2-61. (B) Intra-aortic balloon counterpulsation increases myocardial oxygen supply by increasing coronary artery perfusion when balloon inflation occurs during diastole. Just prior to ventricular systole, the balloon is deflated, allowing the left ventricle to eject against a low volume in the aorta. This reduction of afterload effectively decreases the left ventricular workload. Balloon augmentation improves contractility by supporting more efficient left ventricular emptying, thus increasing cardiac output. Neither myocardial oxygen supply nor left ventricular filling volume is directly affected. Although the balloon-augmented systolic pressure is higher than the aortic systolic pressure, left ventricular systolic pressure is not increased.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-62. (D) In sepsis, activated protein C is used to increase fibrinolysis, decrease coagulation, and decrease inflammation. Protein C is a natural component of the anticoagulant system. In sepsis, decreased levels of circulating APC result in increased formation of clots and decreased fibrinolysis. Thrombin plays a role in activating the inactive form of protein C by binding with thrombomodulin. Owing to the decreased levels of protein C during sepsis, increased thrombin activity will not increase the risk of bleeding in this patient. Increased platelet activity and coagulation will propagate the formation of clots.

References: Dellinger, R. P., Carlet, J. M., Masur, H., et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32(3), 858-873, 2004.

Tazhir, J. Sepsis and the role of activated protein C. Crit Care Nurse 24(6), 40-45, 2004.

2-63. (A) Option A shows the nurse taking the initiative to find a solution to the patient’s problem with compliance in medication administration. Neither Option B nor Option D helps the patient with her vision problem. Option C might be considered as collaboration; however, this patient does not warrant long-term placement until all possible solutions to keep her independent have been exhausted.

References: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

2-64. (B) Thrombolytic therapy is indicated in patients with chest pain onset of less than 3 hours associated with ST segment elevation in indicative leads or new onset of LBBB and positive serum markers. The normal value for troponin I is less than 0.1 ng/mL. Troponin levels do not rise after myocardial injury until 4 hours after onset of symptoms. ST segment elevation in leads V₁-V₆ indicates pericarditis. Thrombolytic therapy is contraindicated in pericarditis as it may cause bleeding and cardiac tamponade.

Reference: Field, J. M., Hazinski, M. F., Gilmore, D. (eds.). Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, American Heart Association, 2006.

2-65. (C) The most common symptom of pulmonary hypertension associated with cor pulmonale is exertional dyspnea. Other clinical manifestations include those characteristic of right heart failure (i.e., fatigue, increased central venous pressures, jugular venous distention, hepatomegaly, splenomegaly, and peripheral edema, especially in dependent areas). Distant heart sounds are heard in pericardial tamponade or effusion. Although patients with COPD may experience cough, that finding reflects their pulmonary rather than cardiac disorder.

References: Calverley, P. Chronic obstructive pulmonary diseases. In M. P. Fink, E. Abraham, J. L. Vincent, P. M. Kochanek (eds.). Textbook of Critical Care, 5^th ed. Philadelphia, Elsevier, 2005.

Ellstrom, K. The pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

2-66. (A) Sodium nitroprusside and esmolol are used in combination to achieve blood pressure reduction, heart rate control, and decreased contractility. Titration of infusions is typically ordered to achieve a MAP of 70 mm Hg and heart rate of 70/min.

Reference: Stone, C. K., Humphries, R. L. Current Emergency Diagnosis and Treatment, 5^th ed. NewYork, McGraw-Hill, 2004.

2-67. (C) Normal arterial pCO₂ is 35 to 45 mm Hg. Generally, hyperventilation is avoided in the early hours after head injury in order to prevent ischemia and worsening of related secondary injury. Chronic prophylactic hyperventilation therapy should be avoided during the first 5 days after severe TBI, particularly during the first 24 hours. Mild hyperventilation (arterial pCO₂ 30 to 35 mm Hg) is considered for management of intracranial hypertension when measures such as osmotic therapy (mannitol), cerebrospinal fluid drainage (in patients with an external ventricular drain), sedation, and chemical paralysis are ineffective. More severe hyperventilation resulting in severe hypocapnia (Options A and B) is generally avoided to prevent ischemia. Higher levels of hyperventilation (Option D) can cause vasodilation, increasing cerebral blood volume and raising ICP.

References: Bullock, R., Chesnut, R. M., Clifton, G., et al. Guidelines for the management and prognosis of severe traumatic brain injury. J Neurotrauma, 17, 451–553, 2000.

Robertson, C. Critical care management of traumatic brain injury. In H. R. Winn (ed.). Youmans Neurological Surgery, 5^th ed. Philadelphia, Elsevier, 2004.

2-68. (A) Permanent pacemakers have a pre-set delay after a sensed P wave called the AV delay, in which there is a longer interval allowed after an intrinsic P wave for the P wave to conduct to the ventricle. If no P wave is sensed, the pacemaker will pace the ventricle in a shorter time period. This rhythm strip demonstrates the occurrence of paced ventricular impulses occurring at a later time period when no intrinsic SA node activity is present. Failure to sense would result in inappropriate pacemaker discharge. Failure to pace would be demonstrated by the presence of a pacemaker artifact without a corresponding paced P or QRS. Over-sensing would be demonstrated by an interval where a pacemaker artifact would be anticipated but is absent.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-69. (A) The endoscopy procedure may evoke patient responses that include tachycardia, dysrhymias, and hypoxia. As a result, it is important to monitor for cardiac ischemia during the examination. In patients such as this with known heart disease, there is an increased risk of these cardiovascular effects. IV fluids should be administered as indicated by the patient’s hemodynamic status; however, during endoscopy, risk of a cardiopulmonary event is a greater concern than fluid monitoring. The need to monitor this patient’s ABGs and electrolytes is part of overall patient assessment and is not heightened by the endoscopy procedure. Maintenance of normothermia is not a particular concern for this patient.

Reference: Krumberger, J., Parrish, C. R., Krenitsky, J. Gastrointestinal system. In M. Chulay, S. Burns (eds.). AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, p 321.

2-70. (A) Pulmonary contusion causes impairment of gas exchange at the gas tissue interface. The most common etiology of pulmonary contusion is trauma related to a motor vehicle crash. The greater the degree of pulmonary contusion, the greater the degree of ventilatory impairment. Administration of pain medication will improve ventilation and decrease splinting, and the administration of oxygen will improve oxygenation and gas exchange. Auscultation of lung sounds is appropriate; however, pulmonary contusions do not require insertion of chest tubes as there is no hemothorax or pneumothorax. Patients can be managed without mechanical ventilation if their PaO₂ is greater than 60 mm Hg on 50% FiO₂, their respiratory rate is less than 24 breaths/min, spontaneous tidal volume is more than 5 mL/kg, and vital capacity exceeds 10 mL/kg. There is no evidence of a pleural effusion. A subsequent intervention would be to obtain a chest x-ray. If a chest x-ray revealed a pleural effusion, then a thoracentesis would be done if the effusion was significantly impairing the patient’s ventilatory status.

References: Ellstrom, K. Pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 149.

Yamamoto, L., Schroeder, C., Morely, D., Beiveau, C. Thoracic trauma: The deadly dozen. Crit Care Nurse Q, 28(1), 22-40, 2005.

2-71. (A) Myocardial contusion may result from blunt cardiac trauma. Hypotension and cardiac dysrhythmias place the patient at high risk of complications. Diagnostic findings of myocardial contusion include chest pain, ECG changes including tachycardia, bundle branch block, and dysrhythmias. Echocardiogram findings are generally nonspecific in myocardial contusion and include wall motion abnormalities. Pulmonary contusion may lead to ARDS, and symptoms include respiratory failure and hypoxia. Cardiac chamber rupture would result in the development of a murmur and signs of cardiogenic shock. Cardiac tamponade would cause decreased QRS amplitude on the 12-lead ECG, muffled heart tones, JVD and hypotension.

Reference: American College of Surgeons Committee on Trauma. Advanced Trauma Life Support for Doctors, 7^th ed. Chicago, American College of Surgeons, 2004.

2-72. (B) Allowing the group to complete their prayer session supports the patient’s cultural and perhaps religious beliefs and displays cultural sensitivity. Interrupting the prayer (Option B) is inappropriate, unwarranted, and insensitive to the patient’s belief system. Option C would not be appropriate as movement into the group could disrupt the prayer session. Observing the session (Option D) appears unwarranted as there is no indication that patient safety has been jeopardized in any way.

References: Hardin, S. R. Response to diversity. In S. R. Hardin, R. Kaplow, R. (eds.). Synergy for Clinical Excellence. Sudbury, Jones & Bartlett, 2005, pp 91-96.

Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

2-73. (A) Hypokalemia predisposes the patient to development of ventricular dysrhythmias. The normal values for serum potassium are 3.5-5.0 mEq/L. The normal serum sodium is 135-145 mEq/L, and abnormal sodium levels generally have effects on blood pressure, muscle strength, and sensorium but do not predispose to ventricular dysrhythmias. Magnesium is used in the treatment of ventricular tachyarrythmias and may be beneficial even when serum magnesium levels are normal. Low serum calcium may have a negative inotropic effect on the myocardium but does not affect the ventricular rate unless the dysrhythmia is caused by calcium channel blocker toxicity and resulted in heart block.

Reference: Sole, M. L., Klein, D. G., Moseley, M. J. Introduction to Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2005.

2-74. (B) The combination of respiratory alkalosis and metabolic acidosis, as evidenced by an elevated anion gap, is the hallmark of salicylate toxicity. Salicylates such as aspirin (acetylsalicylic acid) stimulate the respiratory center, causing hyperventilation that results in respiratory alkalosis along with a compensatory renal loss of bicarbonate. Salicylates also cause the uncoupling of oxidative phosphorylation, which leads to deceased ATP production, increased oxygen consumption, increased CO₂ production, and increased heat production. Derangements in the Krebs cycle and in carbohydrate metabolism leads to an accumulation of organic acids, including pyruvate, lactate, and acetoacetate, resulting in a metabolic acidosis. Acetaminophen toxicity leads to hepatic necrosis and massive liver damage. Patients will present with GI irritation, lethargy, and diaphoresis/pallor and, in rare cases of massive poisoning, will develop metabolic acidosis (low pH and low HCO₃) within the first 24 hours. Signs and symptoms of NSAID toxicity include metabolic acidosis (low pH and low HCO₃), lethargy, hypotension, bradycardia, apnea, renal failure and hepatotoxicity. Benzodiazepine overdose manifests as behavior associated with excessive alcohol ingestion, respiratory depression, dilated pupils, and weak and rapid pulse. ABG results would show a respiratory acidosis (low pH and elevated pCO₂) secondary to respiratory depression.

Reference: Newberry, L., Criddle, L. M. (eds.). Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2005, pp 464-465.

2-75. (B) Seizures are defined as a discrete event characterized by an excessive and disorderly discharge of cerebral neurons with associated sensory, motor, and/or behavioral changes. Seizures warrant treatment when they last longer than 3 minutes in order to avoid the possibility of permanent neurological injury. Frequent neurological examinations (Option A) are appropriate in the early postoperative period. High-dose phenobarbital (Option C) may be given if seizures are refractory to other medications. A postoperative imaging study (Option D) may be obtained to evaluate structural changes after surgery and to identify any complications, such as a blood clot.

References: Bader, M. K., Littlejohns, L. R. (eds.). AANN Core Curriculum for Neuroscience Nursing, 4^th ed. St. Louis, Elsevier, 2004.

Greenberg, M. S. (ed.). Handbook of Neurosurgery, 6^th ed. New York, Thieme Medical Publishers, 2006.

2-76. (D) Norepinephrine (Levophed) is a potent vasoconstricting agent that rapidly increases blood pressure. Dopamine is indicated in pulmonary edema when blood pressure is at least 70 mm Hg. Dobutamine is a positive inotropic agent that is indicated in pulmonary edema when the blood pressure is 70 to 100 mm Hg and signs of shock are not present. Nitroglycerin may be indicated in pulmonary edema to reduce systemic vascular resistance and cardiac work when the systolic blood pressure is greater than 90-100 mm Hg.

Reference: Field, J. M., Hazinski, M. F., Gilmore, D. (eds.). Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, American Heart Association, 2006.

2-77. (A) Complementary therapy (such as music or touch) has not been shown to be associated with safety concerns and appears to reduce pain and tension during early recovery from open heart surgery. Option B is incorrect because it negates the family’s interest in providing a therapy that may assist the patient. The first portion of Option C and Option D are untrue (there are no biomedical or electrical safety concerns) for battery-operated music players, but the latter portion of Option C is not true, as there are data to suggest that pain may be reduced in the immediate postoperative period with use of complementary therapies.

Reference: Kshettry, V. R., Carole, L. F., Henly, S. J., et al. Complementary alternative medical therapies for heart surgery patients: feasibility, safety, and impact. Ann Thor Surg, 81(1), 201-205, 2006.

2-78. (D) Blunt traumatic injuries include lung contusion, spontaneous pneumothorax, myocardial contusion, and rupture of trachea, as well as soft tissue injuries such as abrasions, lacerations, burns, and hematomas. Frequent evaluation of breath sounds, thoracic symmetry, and tracheal position is important for the early identification of secondary injury development such a spontaneous or tension pneumothorax. Reduction in oxygen saturation can indicate the development of pulmonary barotrauma, the most common fatal primary blast injury, evidenced clinically with chest wall motion changes, unequal breath sounds, decreased pulmonary compliance, subcutaneous emphysema, decreased oxygenation, pulmonary embolism, or pneumothorax. Thoracic blast injury produces a unique cardiovascular response that may cause death in the absence of any demonstrable physical injury. The immediate cardiovascular response to pulmonary blast injury is a decrease in heart rate, stroke volume, and cardiac index. The normal reflex increase in systemic vascular resistance does not occur, so blood pressure falls. This effect occurs within seconds and, if it is not fatal, recovery usually occurs within 15 minutes to 3 hours.

References: Ellstrom, K. Pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 140.

Lavonis, E., Pennardt, A. Blast Injuries. Accessed October 17, 2006 at http://www.emedicine.com/emerg/topic63.htm

Yamamoto, L., Schroeder, C., Morely, D., Beiveau, C. Thoracic trauma: the deadly dozen. Crit Care Nurse Q, 28(1), 2005, 22-40.

2-79. (A) Acute MI with papillary muscle rupture requires both revascularization and valve repair or replacement. Immediate treatment may be accomplished with open heart surgery. If immediate cardiac surgery is not available, PTCA and IABP may stabilize the patient until transfer to a facility that performs cardiac valve repair can occur. IABP therapy decreases afterload and reduces mitral valve regurgitation. Thrombolytics should not be administered to the patient with papillary muscle rupture because that would delay valve replacement surgery and allow cardiogenic shock to continue without definitive treatment until the half-life of the thrombolytics has transpired. IABP and vasopressor support may be used to stabilize the patient until surgery but will not reperfuse the occluded coronary artery.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-80. (C) Administration of normal saline will help replace fluids, providing volume to improve the blood pressure and urinary output, while helping to dilute glucose levels and blood viscosity. Administration of bicarbonate would fail to benefit the patient in that it would result in alkalemia, too rapid a shift of potassium back into the cells, and potentially cause cerebral edema, central acidosis, and death. Glargine insulin is a long acting, basal analog preparation that provides a more physiologic control of glucose; however, it would not provide the rapid correction required for this patient. Correction of serum potassium will be needed as glucose is corrected; however, it would be inappropriate to administer it while the patient is oliguric.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 426-431.

Urden, L. D., Stacy, K. M., and Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 934-937.

2-81. (C) Patients with COPD have some degree of nonreversible damage to their lungs, so, rather than regaining textbook “normal” function or laboratory or diagnostic study values (Option A), COPD patients—in the best of situations—will regain their former baseline function and laboratory values. Pressure support and spontaneous breathing trials are both used for weaning COPD patients from mechanical ventilation.

Reference: Calverley, P. Chronic obstructive pulmonary diseases. In M. P. Fink, E. Abraham, J. L. Vincent, P. M. Kochanek (eds.). Textbook of Critical Care, 5^th ed. Philadelphia, Elsevier, 2005.

2-82. (D) Acetaminophen is the most appropriate medication to administer to this elderly patient to reduce pain and permit participation with planned exercise. It will not cloud sensorium and does not affect blood pressure or sodium reabsorption. Nonsteroidal anti-inflammatory medications are contraindicated in heart failure because they may cause sodium and water retention, which would exacerbate symptoms of failure. Corticosteroids also cause sodium and water retention. Morphine sulfate 5 mg is a large dose for an 80-year-old patient and may cause hypotension and drowsiness, which would impede participation in the exercise program.

Reference: Wheeler, M., Wingate, S. Managing non-cardiac pain in heart failure patients. J Cardiovasc Nurs, 19, S75-S83, 2004.

2-83. (D) No action is needed for this patient as all of the parameters are within acceptable range. Normal cerebral perfusion pressure decreases from 80 mL/min/100 g at age 30 years to 40 mL/min/100 g at age 70 years. Normal intracranial pressure is up to 15 mm Hg. Option D is incorrect because even if ICP were elevated, hyperventilation down to a p_aCO₂ of 30 mm Hg is no longer recommended based on research findings.

Reference: Kane R. L., Ouslander, J. G., Abrass, I. B. Essentials of Clinical Geriatrics, 5^th ed. New York, McGraw-Hill, 2003.

2-84. (C) The absolute neutrophil count (ANC) is calculated by multiplying the total WBC by the percentage of neutrophils in the differential WBC count. The percentage of neutrophils consists of the segmented (fully mature) + the bands (almost mature neutrophils). The normal range for the ANC = 1.5 to 8.0 (1,500 to 8,000/mm³). Below 1.5 indicates that the patient is severely immunosuppressed and will require neutropenic precautions to prevent the development of overwhelming infection. In this patient, 4000 × 25% (10% + 15%) = 1000/mm³ or an ANC of 1.0.

Reference: Marr, J. A. Care of patients with neutropenia. Clin J Oncol Nurs 10(2), 164-166, 2006.

2-85. (C) Labetolol (Normodine, Trandate), an alpha- and beta-blocking agent, would be the most appropriate medication to lower blood pressure in a patient with hypertensive crisis, tachycardia, and chest pain. Nitroprusside (Nipride) could increase tachycardia owing to decreased preload, thus increasing myocardial ischemia. Although diazoxide (Proglycen) can lower BP via arteriolar dilation, it is contraindicated here because it may also precipitate a reflex sympathetic response that can provoke angina, ischemia, and cardiac failure in patients with ischemic heart disease. Nicardipine (Cardene) is a calcium channel blocker; its side effects include tachycardia, which could worsen angina.

Reference: Chulay, M., Burns, S. M. AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006.

2-86. (B) These laboratory results reflect a patient with active hemorrhage and hypovolemia resulting in dropping hemoglobin/hematocrit, elevation of creatinine, and increase in lactate levels owing to tissue hypoxia. In patients with active hemorrhage, the laboratory results may lag behind the patient’s current condition prior to or after resusitation. With resolution of the hemorrhage and stabilization of the patient, a majority of the laboratory results should return to normal ranges. The patient is still being resuscitated; if the still-abnormal values are corrected at this time, overcorrection and introduction of new problems may occur. It is normal for serum creatinine to become transiently elevated in hypovolemic shock, so the patient does not likely have acute renal failure. Diagnosis of DIC requires evaluation of fibrinogen and fibrin split products, not elevation of INR.

Reference: Krumberger, J., Parrish, C. R., Krenitsky, J. Gastrointestinal system. In M. Chulay, S. Burns (eds.). AACN Essentials of Critical Care Nursing. New York, McGraw Hill, 2006, p 320.

2-87. (A) Magnesium needs to be administered because this patient is exhibiting ECG evidence that suggests hypomagnesemia. Although the patient may be hypokalemic and/or hypocalcemic owing to diuretic therapy, the patient’s ECG changes are consistent with hypomagnesemia. Hypertonic saline would be administered for hypoosmolar disorders such as syndrome of inappropriate ADH (SIADH). Potassium would be administered for hypokalemia, and acetazolamide is used to treat hyperphosphatemia.

References: Hinkle, C. Renal system. In M. Chulay, S. Burns (eds.). AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, pp 341-355.

Lough, M. E. Renal disorders and therapeutic management. In L. D. Urden, K. M. Stacy, M. E. Lough (eds.). Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 813-846.

Stark, J. L. The renal system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 525-607.

2-88. (D) This patient’s ABG shows hypoxemia that may respond to judicious increases in FiO₂. The elevated PaCO₂ is not accompanied by a commensurately acidotic pH, so the patient likely retains high levels of CO₂ on a chronic basis, negating any need for intubation. Since the patient is tachypneic, the CO₂ level does not reflect a diminished respiratory drive. There are no data provided that suggest a need for diuresis.

Reference: Calverley, P. Chronic obstructive pulmonary diseases. In M. P. Fink, E. Abraham E, J. L. Vincent, P. M. Kochanek (eds.). Textbook of Critical Care, 5^th ed. Philadelphia, Elsevier, 2005.

2-89. (B) In general, Mexican families do not discuss sexual or genitourinary issues across genders or age groups. Based on this, the best person with whom to discuss the patient’s condition would be his brother who is close to the patient’s age.

Reference: Chang, M., Harden, J. Meeting the challenge of the new millennium: caring for culturally diverse patients. Urol Nurs, 22(6), 372-377, 2002.

2-90. (A) The hallmark symptom of compartment syndrome is pain not controlled by narcotic administration. Other symptoms in compartment syndrome are subtle and include a doughy muscle mass. Pulse pressure decrease and loss of motor function are usually late signs. Graft occlusion would cause loss or decrease of distal pulses and signs of poor perfusion in the extremity, such as increased capillary refill time, pallor, paresthesia, and weakness. False aneurysm would cause a pulsatile mass at the suture site, hematoma, and a tense thigh or calf. Signs of heparin-induced thrombocytopenia include oozing at the sutures sites, petechiae, and decreased platelet count.

Reference: Fahey, V. A. Vascular Nursing, 4^th ed. St. Louis, Elsevier, 2004.

2-91. (C) Although the usefulness of antibiotics for treatment of acute exacerbations of asthma continues to be debated, there is no consensus advocating their use, and treatment aims primarily toward relieving the bronchoconstriction experienced by patients with status asthmaticus (Option C). All of the other interventions (Heliox, magnesium, and general anesthetics) can be used effectively to relax the airways (Options A, B, D).

References: Corbridge, T., Corbridge, S. J. Severe asthma exacerbation. In M. P. Fink, E. Abraham, J. L. Vincent, P. M. Kochanek (eds.). Textbook of Critical Care, 5^th ed. Philadelphia, Elsevier, 2005.

Ellstrom, K. The pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

Little, F. Treating acute asthma with antibiotics—Not quite yet. N Engl J Med, 354, 1632-1634, 2006.

2-92. (C) A major source of common ethical conflict occurs when the physician and patient or patient surrogate disagree. With beneficence, the person is trying to do good for the other person as the physician is attempting to do in this situation. Option A is incorrect because the nurse is acting as a surrogate. Option B is incorrect because the nurse is displaying justice in her comments but is not advocating according to the family’s expressed wishes. Option D is incorrect in that the nurse is advocating for the physician rather than the patient.

Reference: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

2-93. (A) The combination of heparin, eptifibatide, and aspirin increases the risk of bleeding. Cardiac catheterization and PCI use the groin for access, and the groin site may exhibit signs of bleeding such as oozing and hematoma formation. Risk of coronary artery spasm is reduced with infusion of nitroglycerin. Abrupt closure may be seen in the immediate post-PCI period. Restenosis may occur days to years after PCI. Heparin-induced thrombocytopenia may occur in a patient who has received prior heparin therapy, or after receiving heparin therapy for greater than 24 hours.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-94. (C) CO-Hb binding causes a shift to the left in the oxyhemoglobin dissociation curve, resulting in hemoglobin not releasing oxygen and impeding oxygen delivery to the tissues. The affinity of hemoglobin molecules for carbon monoxide is approximately 200 times greater than that for oxygen. Inhalation of carbon monoxide (CO) results in its bonding to available hemoglobin, producing carboxyhemoglobin (HbCO), which effectively decreases oxygen saturation of hemoglobin. Carboxyhemoglobin binds poorly with oxygen, reducing oxygen-carrying capacity of blood and leading to hypoxia.

Reference: Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, p 1057.

2-95. (A) Atrial fibrillation commonly occurs within 3 days after open heart surgery. Multiple trials have compared the effects of various pharmacologic agents to treat or prevent the occurrence of atrial fibrillation, including digoxin, beta blockers, amiodarone, and magnesium, but none has been shown to be clearly superior. Supraventricular dysrhythmias such as AVNRT and SVT may occur after coronary artery bypass surgery, but more commonly occur with surgery involving the cardiac septum. Atrial flutter may occur with digoxin toxicity.

Reference: Hilleman, D. E., Hunter, C. B., Mohiuddin, S. M., Maciejewski, S. Pharmacological management of atrial fibrillation following cardiac surgery. Am J Cardiovasc Drugs, 6, 361-369, 2005.

2-96. (D) Option D is the best response because early detection of acute confusion is best evaluated with a screening tool. The nurse should seek to apply research findings and to evaluate current literature and research on complex issues such as acute confusion in diverse patient populations. Screening tools can be useful to identify and more thoroughly assess specific clinical problems. For example, the Hartford Institute for Geriatric Nursing recommends the Confusion Assessment Method (CAM) as a screening tool. Interpreters can offer only limited help in more fully understanding the patient’s status for this problem. The clinical problem is not directly related to cultural values or communication patterns.

References Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

Wang, J., Mentes, C. Detection of acute confusion in Taiwanese elderly individuals. J Gerontol Nurs, 32(6), 7-12, 2006.

Waszynski, C. M. Confusion Assessment Method (CAM). Try This: Best Practices in Nursing Care to Older Adults, Issue 13, November 2001. Hartford Institute for Geriatric Nursing. Access at www.hartfordign.org/publications/trythis/issue13.pdf

2-97. (A) Administration of additional oxygen is the first priority in this situation. The patient may be found to need placement of a new right chest tube (Option D) or adjustment of the existing chest tube (Option C), but meanwhile requires more oxygen and either an increase in pressure support or placement on mechanically controlled ventilation. Drawing laboratory studies will likely provide useful data but is secondary in importance to supporting this patient’s oxygenation.

Reference: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

2-98. (A) Packed red blood cells do not contain clotting factors, so replacement of clotting factors with transfusion of fresh frozen plasma and platelets should occur after administration of each five units of packed red blood cells. Acetaminophen and diphenhydramine (Benadryl) are generally administered prior to transfusion to prevent transfusion reaction. Furosemide (Lasix) is indicated if pulmonary congestion is apparent after transfusion. Normal saline is administered concurrently with transfusion to prevent hemolysis and increased blood viscosity. Salt poor albumin is indicated to increase blood volume in hypovolemic patients with excess interstitial fluid volume and is not indicated if blood replacement has been adequate. Calcium chloride is sometimes administered to patients who receive large volumes of banked blood containing citrate as a preservative.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-99. (B) The nurse could appropriately implement any of these activities, except pointing out to the husband that his current behavior is inappropriate and unacceptable. Under the circumstances, the husband may be lashing out from anger at his wife’s status and his own difficulty coping with that situation. Confrontation without accompanying empathy may just escalate the behavior. Indeed, his anger may represent a step in the grieving process. Certainly, social services (Option A) could provide supportive resources and assistance to both the staff and the patient’s spouse in such a difficult situation. The nurse should speak calmly and directly to the patient’s husband regarding the situation (Option C), acknowledging the impact of the situation and what he may be experiencing. Arranging for a family conference (Option D) may be an appropriate way to provide information to the family, share the husband’s burden of repeated retelling about the situation from him alone to the family, and provide the husband some support during this difficult time.

Reference: Henneman, E. A. Psychosocial aspects of critical care. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

2-100. (B) The normal C-reactive protein level is 0.03 to 1.1 mg/dL. C-reactive protein elevation indicates the presence of inflammation in the coronary arteries due to plaque, which may be ready to embolize. The normal brain natriuretic peptide (BNP) is less than100 pg/mL. BNP elevation indicates LV dysfunction owing to strain on the ventricle from volume or pressure overload and indicates risk of heart failure. The desired cholesterol level to reduce risk of CAD is less than 200 mg/dL. The desired value of HDL to reduce risk of coronary artery disease is greater than 40 mg/dL. Total cholesterol value of 180 mg/dL and HDL of 60 mg/dL indicate low risk of coronary artery disease.

Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St. Louis, Elsevier, 2005.

2-101. (D) Hemodynamic instability, as demonstrated by tachycardia and hypotension, indicates that the patient is not tolerating rotational therapy and should be returned to a supine position. Hemodynamic values obtained while the patient is in the lateral or prone position are reliable as long as the zero level is maintained at the phlebostatic axis. Neither side lying nor prone positioning increase the risk of aspiration. SpO₂ is not a good indicator of positioning tolerance and for this reason, arterial blood gases are used to gauge the effectiveness of rotational therapy.

Reference: Wiegand, D. J., Carlson, D. J. (ed.). AACN Procedure Manual for Critical Care, 5^th ed. St. Louis, Elsevier, 2005.

2-102. (A) Patients who have undergone bariatric surgery may develop deficiencies in calcium, iron, vitamin B₁₂, and folate owing to the bypassing of the gastric fundus, body, and antrum, as well as the duodenum and variable lengths of the proximal jejunum. Bypassing these structures results in malabsorption. Option B identifies symptoms characteristic of hyperglycemia. Option C lists symptoms associated with pancreatic cancer. Option D includes findings associated with hepatic encephalopathy.

Reference: Elliot, K. Nutritional considerations after bariatric surgery. Crit Care Nurse Q, 26(2), 133-138, 2003.

2-103. (B) Since the patient has an elevated FT₄ and low TSH, the nurse needs to search the literature to identify drugs associated with thyroid dysfunction. Nurses should be vigilant in seeking information on drug-drug and drug-food interactions. Clinical inquiry seeks to validate whether available literature can answer the clinical question. Holding medications one at a time (Option A) could be both time-consuming and dangerous and suggests a lack of direction in searching for relevant evidence. Option C would not afford sufficient information to identify the problem. Option D is inappropriate because Wolf-Chaikoff is a protective mechanism against the development of hyperthyroidism.

References: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

Porsche, R., Brenner, Z. R. Amiodarone-induced thyroid dysfunction. Crit Care Nurse, 26(3), 34-42, 2006.

2-104. (A) Right ventricular failure may occur after mitral valve replacement in patients with pulmonary hypertension. When the right ventricle fails it requires larger volumes to ensure adequate output. This is easily accomplished with crystalloid fluid boluses to maintain the pulmonary artery diastolic or wedge pressure at 15-18 mm Hg. Nesiritide or nitroglycerin may be ordered with fluid bolus to reduce right ventricular afterload. Furosemide would decrease preload and worsen right ventricular failure. Norepinephrine or vasopressin would increase vasoconstriction and worsen right ventricular failure.

Reference: Bojar, R. M. Manual of Perioperative Care in Adult Cardiac Surgery, 4^th ed. Berlin, VT, Blackwell, 2005.

2-105. (A) Because complications from HHNK result from an increase in blood viscosity, IV normal saline will help to replace fluids lost to polyuria, diminish blood viscosity, and improve perfusion. Regular insulin, rather than glargine, would be used in insulin drips since regular insulin does not promote antigen development and is short acting. Unless the patient has other concurrent health problems, oxygen administration and seizure precautions are usually not needed for hyperosmolar patients.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 431-433.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, p 934.

2-106. (D) Torsades de pointes is a polymorphic ventricular rhythm characterized by varying QRS morphology and is associated with prolonged QT intervals. Magnesium sulfate is the medication utilized to treat dysrhythmias associated with long QT syndromes. Medications such as procainamide and lidocaine prolong the QT interval and may potentiate the development of torsades de pointes in patients with pre-existing prolonged QT intervals. Adenosine is used to manage supraventricular tachycardias.

Reference: Stone, C. K., Humphries, R. L. Current Emergency Diagnosis and Treatment, 5^th ed. New York, Lange Medical Books, 2004.

2-107. (B) The patient is presenting with the hallmarks of cryptogenic organizing pneumonia (COP), previously termed bronchiolitis obliterating organizing pneumonia (BOOP). Her laboratory results suggest an inflammatory rather than an infectious process (Option A), and there is no evidence suggesting cardiac failure (Options C and D). Since certain infections may be contributive factors to COP, Option B is the best answer.

Reference: Cordier, J. F. Cryptogenic organizing pneumonia. Clin Chest Med, 25, 727-737, 2004.

2-108. (B) This patient should avoid taking aspirin because both aspirin and a low platelet count predispose the patient to potential bleeding. Green, leafy vegetables need to be avoided when a patient is on warfarin, not aspirin. Individuals on reverse isolation for leukemia may have fruit restricted, but this patient’s immediate concern is the low platelet count. Prednisone is not prohibited with a low platelet count.

Reference: Cheek, D. J., Hall, M. A. Hematologic and immunologic systems. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 671-673.

2-109. (B) The ECG demonstrates premature ventricular contractions and ST segment elevation in leads V₁, V₂, V₃, and V₄, indicating acute anterior wall myocardial infarction. Administration of nitroglycerin may vasodilate the affected coronary artery and reperfuse the myocardium. Reperfusion may eliminate myocardial irritability, causing PVCs. Although low potassium may cause development of PVCs, initial laboratory studies for this patient should include cardiac biomarkers. A coagulation panel should be drawn if nitroglycerin is ineffective and thrombolytic therapy is ordered. Amiodarone is not indicated unless PVCs continue after interventions directed at reperfusion.

Reference: Sole, M. L., Klein, D. G., Moseley, M. J. Introduction to Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2005.

2-110. (B) Dextrose in water (D₅W) is the IV solution most often associated with aggressive fluid resuscitation. This fluid can be used to replace mild volume loss and provide calories to the patient. Extremely common in critically ill patients, hypoosmolar disorders are the result of an excess of water and can be caused by replacement of fluid loss with pure water. Patients who have experienced volume loss, such as the patient with a GI bleed, require balanced fluid replacement. Half-strength saline solution is indicated for free water replacement, correction of mild hyponatremia, and free water/electrolyte replacement. Normal saline solution is used to maintain fluid volume, replace mild fluid loss, and correct mild hyponatremia. Lactated ringer’s solution is indicated in fluid and electrolyte replacement but is contraindicated for patients with renal or liver disease or lactic acidosis.

Reference: Hinkle, C. Renal system. In M. Chulay, S. M. Burns (eds.). AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, pp 341-355.

Stark, J. L. The renal system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 525-607.

2-111. (B) The physician should be contacted regarding the use of pneumatic compression stockings owing to the use of warfarin in this patient. The warfarin may contribute to bruising and increased risk of bleeding when using the pneumatic compression stockings. Monitoring the PT/INR daily is appropriate until a stable level is reached, which is usually 1.5 to 2 times the normal ratio. If the patient is able to protect his/her airway, there is no contraindication for advancement of diet. The reduction in oxygenation is appropriate based on the recent arterial blood gas results.

Reference: Ellstrom, K. Pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 148.

2-112. (D) Mental status and renal perfusion are the best indicators of cardiac output as the brain and kidneys receive one fourth of the cardiac output. Patients with pulmonary edema due to diastolic dysfunction may have normal ejection fractions. Peripheral edema may be absent in left ventricular failure if it is not accompanied by right ventricular failure. Although a respiratory rate of 20 or less and an SpO₂ of 94% may be therapeutic target goals for this patient, they do not indicate cardiac output adequacy in the mechanically ventilated patient.

Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St. Louis, Elsevier, 2005.

2-113. (A) Recent data suggest that clinically chilled hypothermia to 33-35° C can improve neurologic outcomes and survival after hospital discharge. These patients are at risk for a decrease in white blood cell and platelet counts owing to immune response suppression from hypothermia. Blood sugar levels are ideally maintained at 80-110 mg/dL. Option B is incorrect as, based on the data provided, the patient is not at risk for development of hyperkalemia.

Reference: Holden, M., Makic, M. B. Clinically induced hypothermia. Why chill your patient? AACN Adv Crit Care, 17(2), 125-32, 2006.

2-114. (C) If the implanted cardioverter defibrillator fails to terminate the rhythm, the nurse should institute ACLS measures that include prompt defibrillation with 360 joules monophasic or 120 to 200 joules biphasic. It is not necessary to turn the ICD off with a magnet prior to performing manual defibrillation. Placement of defibrillation paddles may be anterior–anterior or anterior–posterior, but the pads should be at least 2 inches away from the ICD generator, and 360 joules should be delivered.

References: Field, J. M., Hazinski, M. F., Gilmore, D. (eds.). Handbook of Emergency Cardiovascular Care for Healthcare Providers. Dallas, American Heart Association, 2006.

Wiegand, D. J., Carlson, K. K. AACN Procedure Manual for Critical Care, 5^th ed. St. Louis, Elsevier, 2005.

2-115. (C) While the decision to draft an advanced directive should have been made prior to this admission, that is not the issue at this time. The patient has a need to confer with his family, physician, and significant others so that they understand his wishes. Attempting to placate the patient by saying he will probably change his mind later belittles the decision-making process that led to this conclusion. While he is experiencing an alteration in oxygenation, he may not be legally responsible to make such a decision; however, he may have been thinking about and discussing this issue over a period of time. Ascertaining the patient’s true wishes and supporting that decision will enable the nurse to serve more effectively as an advocate for the needs of patients and their families.

References: Nettina, S. M. The Lippincott Manual of Nursing Practice, 7^th ed. Philadelphia, Lippincott Williams & Wilkins, 2000, p 192.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, p 163.

2-116. (C) It is common for persons treated with glucagon to vomit, so positioning the patient to avoid aspiration would be the next most important nursing measure. Each of the other choices can be appropriate measures at a later time. Ongoing assessment of neurological status would represent the next appropriate intervention, with a recheck of capillary glucose to evaluate the effectiveness of the glucagon dose in 30 minutes, and then preparation to feed the patient after he or she regains conciousness.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 428-432.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, p 926.

2-117. (B) Each of the options will be part of the process, but it is important for all of the units who will be using the new equipment to be part of the evaluation process from the beginning. Central to any successful change process are communication and input. As multiple units may be involved in the change, it is essential that the decision be based on input from each of the involved areas.

Reference: Bacal, R. Managing change—step by step change implementation for change leaders. Available at www.work911.com/managingchange/stepbystepchange.htm. Retrieved September 2, 2006.

2-118. (D) Neuromuscular blocking agents may cause prolonged myopathy in any patient, so their relative benefit must always be weighed against their potential for harm. As a result, NMBs should be used with caution and only after other options have proven ineffective. The myopathy associated with NMBs is particularly problematic for patients concomitantly receiving steroids (Option A), so NMB use would only be as a last resort. Because of the risks associated with NMBs, they are not used routinely (Option B). NMBs act on skeletal, rather than smooth, muscle (Option C).

References: Corbridge, T., Corbridge, S. J. Severe asthma exacerbation. In M. P. Fink, E. Abraham, J. L. Vincent, P. M. Kochanek (eds.). Textbook of Critical Care, 5^th ed. Philadelphia, Elsevier, 2005.

Ellstrom, K. The pulmonary system. In J. G. Alspach (ed.).Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

2-119. (A) Pulmonary artery hypertension causes enlargement of the pulmonary artery, which makes obtaining PCWP pressures unreliable or unobtainable. Therefore, a left atrial line is used to obtain left ventricular end diastolic pressures to reflect preload status. Left atrial lines predispose the patient to development of air embolus but are not used to evacuate left atrial air emboli. A left atrial line is not superior to a pulmonary artery catheter in diagnosing pericardial tamponade. During cardiac surgery, there is no need for continuous monitoring of cardiac chambers since the patient is on cardiopulmonary bypass.

Reference: Bojar, R. M. Manual of Perioperative Care in Adult Cardiac Surgery, 4^th ed. Berlin, VT, Blackwell, 2005.

2-120. (C) The hemodynamic values indicate that the patient is experiencing a decrease in cardiac output (in relation to the SVR) as a result of decreased preload (CVP: 4 mm Hg). Administering a fluid bolus of normal saline is the most appropriate intervention that would improve the patient’s hemodynamic status. If the patient were anemic, then the fluid of choice would be PRBCs. Based on the Society of Critical Care Medicine guidelines for patient management for sepsis and septic shock, the preload (as measured by CVP) should be at least 8 to 12 mm Hg. Other hemodynamic values that reflect the patient’s inadequate fluid resuscitation are HR, BP, and PAP. Norepinephrine would increase the patient’s BP and SVR but would likely increase rather than reduce the patient’s tachycardia. Administering fluid would lessen the need for vasopressor therapy. Metoprolol is a negative chronotropic and inotropic agent (β-blocker) that is not indicated for this patient. The patient is hypotensive and would not tolerate the administration of a β-blocker. Dobutamine results in a positive inotropic and chronotropic effect with afterload reduction. The patient is tachycardic and has a low SVR secondary to the septic shock. Administering dobutamine would result in an increased HR and lower SVR, which would further compromise the patient’s clinical status.

References: Dellinger, R. P., Carlet, J. M., Masur, H., et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med, 32(3), 858-873, 2004.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 1023-1030.

2-121. (B) The tidal volume settings for a patient with ARDS should be 5-8 mL/kg. An optimal tidal volume for this patient, then, is 350 to 560 mL. Excessive tidal volumes and high PEEP levels increase the risk of volutrauma and barotrauma, so the PEEP should not be increased until the tidal volume is adjusted and PaO₂ levels do not improve. SIMV is an acceptable mode for the patient because the rate of 12/min ensures that the patient will receive at least 12 breaths per minute. Pressure control ventilation may be used in ARDS to prevent volutrauma, but other modes of ventilation are also acceptable.

Reference: Chulay, M., Burns, S. M. AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006.

2-122. (A) Prevention of stroke is the primary concern when a patient presents with hypertensive crisis. Prevention centers around rapid lowering of systolic blood pressure. End organ failure is generally preventable when blood pressure and vasoconstriction are reduced in a timely manner. Renal failure from chronic hypertension may precipitate the hypertensive event. Seizures are not common with hypertensive crisis but may occur if there is intracerebral bleeding or encephalopathy. Left ventricular hypertrophy is common in patients with chronic hypertension and may result in heart failure.

Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St: Louis, Elsevier, 2005.

2-123. (B) The nurse recognizes that explanation of significant risks should be discussed with the patient and family to ensure informed consent. Allowing the physician to leave without discussing the risks of the procedure does not advocate for the patient. Option C provides collaboration with another discipline but does not provide informed consent. Option D facilitates knowledge of the family but does not ensure that the risks of the procedure are reviewed by the physician prior to signing consent.

References: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

Stannard, D., Hardin S. R. Advocacy and moral agency. In S. R. Hardin, K. Kaplow (eds.). Synergy for Clinical Excellence, Sudbury, Jones & Bartlett, 2005, pp 63-68.

2-124. (D) Intestinal obstruction can occur in pregnant patients who have had prior operative procedures and may result from the enlarging uterus exerting pressure on preexisting adhesions. Obstruction of this nature is most common in the third trimester, and the symptoms are similar to those of a nonpregnant patient. Ectopic pregnancy would have evidenced and been detected before 26 weeks’ gestation. If an ectopic pregnancy goes undetected for 6 to 8 weeks, there is severe lower abdominal pain and fainting. These symptoms indicate rupture of the fallopian tube and hemorrhage. Abruptio placenta would present with fetal cardiac distress and maternal shock. Peptic ulcer disease presents with intermittent colicky pain, which increases 2 to 3 hours after meals. It can also occur in the middle of the night. Eating usually decreases the symptoms. It is not associated with fever.

References: Charles, A., Domingo, S., Goldfadden, A., et al. Small bowel ischema after roux-en-y gastric bypass complicated by pregnancy: a case report. Am Surg, 71(3), 231-235, 2005.

Pakfetrat, M. A pregnant lady with abdominal pain. Shiraz E-Medical J, 6, 1-2, 2005.

2-125. (B) Ischemic colitis may occur after aortic surgery owing to embolization, occlusion, or ligation of mesenteric vessels, or hypoperfusion from long aortic cross-clamp times or hypovolemia. Initial symptoms of ischemic colitis may include edema, elevated white count, tachycardia, pain, acidosis, hypotension, and diarrhea. Graft infection is not usually evident within 2 days, but symptoms would include tachycardia, hypotension, and elevated white count without GI symptoms. Fistula formation is also a late-onset finding and may cause signs of peritonitis, GI bleeding, or visible fistula formation. Abdominal compartment syndrome may present as abdominal pain, rigidity, and myoglobinuria.

Reference: Fahey, V. A. Vascular Nursing, 4^th ed. St. Louis, Elsevier, 2004.

2-126. (C) The use of mechanical compression devices should be initiated. The devices will not increase the risk of bleeding, yet will provide prophylaxis for deep vein thrombosis. The pelvic fracture, splenic laceration, and compound fracture of the femur would prevent the use of low-molecular-weight heparin in the early stages of this patient’s treatment because the risk of increased bleeding is too great. Once it can be verified that there is no active bleeding, low-molecular-weight heparin may be administered. Elastic stockings could be used on the uninjured extremity; however, mechanical compression devices have been found to be more effective for this purpose. Physical therapy can be initiated but will be limited on the injured extremity and is only provided intermittently, so it is not likely to be as effective as continuous mechanical compression devices.

References: Ellstrom, K. Pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 146.

Yang, J. C. Prevention and treatment of deep vein thrombosis and pulmonary embolism in critically ill patients. Crit Care Nurse Q, 28(1), 72-79, 2005.

2-127. (A) ACE inhibitors should be discontinued if the serum creatinine level increases above 3.0 mg/dL because they prevent conversion of angiotensin I to angiotensin II, which decreases glomerular filtration and may potentiate renal insufficiency. Serum creatinine is an indicator of renal function. Serum potassium levels less than 3.5 mEq/L indicate a need for potassium replacement. An SpO₂ of 95% is still adequate to maintain oxygenation. An increased number of atrial premature contractions could herald the onset of atrial fibrillation and warrants continued monitoring, but a reduced heart rate indicates that therapy is appropriate.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-128. (D) Infection is the leading cause of morbidity associated with SLE. Ulcers around the mouth could become infected but are not, in themselves, a major cause of morbidity for SLE. Anemia and weight loss can be effectively treated on an outpatient basis.

Reference: Lash, A. A., Lusk, B. Systemic lupus erythematosus in the intensive care unit. Crit Care Nurse, 24(2), 56-65, 2004.

2-129. (A) HELLP syndrome derives its name from severe preeclampsia characterized by hemolytic anemia, elevated liver enzymes, and a low platelet count. Decreased hemoglobin and hematocrit are related to blood loss and hemodilution owing to crystalloid and colloidal infusions to replace depleted circulating volume. Magnesium levels rise if a magnesium drip is used to slow electrical impulses and prevent seizure activity; however, this laboratory value increases secondary to magnesium administration, not from pathophysiology. Albuminuria and increased serum creatinine levels occur related to the renal response to hypertension. Generally, BUN is elevated rather than decreased with renal impairment.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, p 804.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 214-215.

2-130. (A) The patient is alkalotic with a pH of 7.60. Acetazolamide (Diamox) is a diuretic used in alkalosis to decrease hydrogen ion loss that may occur with diuresis. Alkalosis hinders release of oxygen to tissues, and so should be avoided in patients with pulmonary edema, who may be hypoxemic. Additional furosemide (Lasix) will continue diuresis without correcting alkalosis. Endotracheal intubation will improve oxygenation but is not indicated when PaO₂ is 78 mm Hg and pCO₂ is normal. Hydrochlorthiazide is a thiazide diuretic that will induce diuresis but not preserve hydrogen ions and thus would increase alkalosis.

Reference: The Task Force on Acute Heart Failure of the European Society of Cardiology. Executive summary of the guidelines on the diagnosis and treatment of heart failure. Eur Heart J, 26, 384-416, 2005.

2-131. (A) Regardless of the cause or type of diabetes insipidus, the patient’s electrolyte values will govern appropriate treatment for this disorder. In nephrogenic diabetes insipidus, the kidney has been damaged and no longer responds to vasopressin, so aggressive replacement of fluids is required to sustain life. Neurogenic diabetes insipidus is a problem caused when too little vasopressin is released by the pituitary gland, possibly due to increased intracranial pressure; therefore, supplemental vasopressin administration sustains life. Whether because of a lack of vasopressin or a lack of response, urinary output exceeds 500 mL/hr, resulting in dehydration and altered electrolytes. The goal of therapy is to reestablish and maintain a normal fluid and electrolyte balance.

References: Newberry, L., Criddle, L. Sheehy’s Manual of Emergency Care, 6^th ed. Philadelphia, Elsevier, 2006, pp 433-434.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management, 5^th ed. St. Louis, Elsevier, 2006, pp 952-953.

2-132. (C) Hemodialysis is the “gold standard” for management of chronic renal failure because it is the most effective of all renal replacement therapies. Although the patient managed her renal failure using CAPD at home, peritoneal dialysis is not currently an option due to the patient’s abdominal surgery. SCUF is used in patients with volume overload and some degree of renal function, but it has minimal impact on urea and creatinine levels. CVVH is used for patients who require fluid removal and are hemodynamically unstable.

Reference: ANNA. Continuous Renal Replacement Therapy. Pitman, NJ, American Nephrology Nurses Association, 2005, pp 1-12.

Hinkle, C. Renal system. In M. Chulay, S. M. Burns (eds). AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, pp 341-355.

Mitchell, J. K. Renal disorders and therapeutic management. In L. D. Urden, K. M. Stacy, M. E. Lough (eds). Priorities in Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2005, pp 333-356.

2-133. (B) The goal of ventilator management with persistent air leaks is to minimize airway pressures in order to prevent further injury to the affected area (Option B). Maximizing PEEP or using large tidal volumes may worsen the clinical situation by increasing the volume lost through the air leak (Options A and D). Using the minimal effective FiO₂ is always a good idea, but it will not aid management of an air leak (Option C).

Reference: Lois, M., Noppen, M. Bronchopleural fistulas: An overview of the problem with special attention to endoscopic management. Chest,128, 3955-3965, 2005.

2-134. (D) The GI tract harbors organisms that may trigger an inflammatory focus if they are translocated from the gut into the portal circulation, where they may not be adequately cleared by the liver. Common enteric organisms with this potential include Enterococcus, Escherichia coli, Clostridium perfringens, and Enterobactor cloacae. Bacterial translocation has been associated with paralytic ileus and with drugs commonly used in critically ill patients such as antibiotics, antacids, and histamine blockers. Antibiotics alter the function of normal protective bacteria located in the gut. Antacids and histamine blockers increase the intragastric pH, allowing ingested bacteria to survive in the GI tract and potentially become pathologic. Conditions thought to increase gut permeability and microbial translocation include mucosal ischemia, mucosal hypoperfusion, immunoglobulin A deficit (associated with TPN), thermal injury, glucocorticoid administration, endotoxin release, glutamine, and fiber deficiencies. The use of mechanical ventilation prevents ischemia by increasing arterial oxygenation. Inotropic agents increase oxygen delivery and prevent hypoperfusion of the gut by increasing cardiac output. Enteral feeding prevents the development of microbial translocation by maintaining the gastrointestinal mucosal barrier, immune function, and blood flow to the GI tract.

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 762.

Urden, L. D., Stacy, K. M., Lough, M. E. Thelan’s Critical Care Nursing: Diagnosis and Management,5^th ed. St. Louis, Elsevier, 2006, pp 1040-1041.

2-135. (A) The Hmong believe that a soul may be lost through sudden fright, such as from loud noises or a fall; fear or excessive grief; capture by an evil spirit; or one soul transferring to another. Providing a quiet environment is therefore important in caring for members of the Hmong culture. Hot tea, visit by a shaman, and food temperature are not associated with prevention of loss of souls in the Hmong culture.

Reference: Cheng, H., Culhane-Pera, K. Culturally responsive care for Hmong patients. Postgrad Med, 116(6), 39-45, 2004.

2-136. (D) Rapid culture and antibiotic administration (Option A) are important interventions in treating any pneumonia; however, preventing hypoxia and hypoperfusion are the priorities (Option D) for this patient. Completing confirmatory diagnostic tests such as a chest x-ray and treating the patient’s fever are secondary priorities (Options B and C).

References: American Thoracic Society. Guidelines for the management of adults with hospital-acquired, ventilator-associated and healthcare-associated pneumonia. Am J Respir Crit Care Med, 171, 388-416, 2005.

Ellstrom, K. The pulmonary system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

2-137. (A) The nurse knows that sensitivity to family needs is required when brain death is declared. Family members have the option to obtain a second opinion about brain death. Documentation of the discussion (Option B) is an important aspect but is superceded by the need to advocate on behalf of the family during a time of crisis. Options C and D may come later in the course of this patient’s care. Organ donation should not be discussed immediately after the family has just learned of a flat EEG. Option D is inappropriate because there is no apparent conflict in this situation that needs to be resolved.

Reference: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 31.

2-138. (C) Ideally, corrective surgery for aortic dissection should not be delayed. One exception is when a patient with aortic dissection develops profound hypotension or pulseless electrical activity (PEA). In this instance, emergency pericardiocentesis may be performed prior to surgery. Pericardial tamponade is an anticipated complication of aortic dissection, so clinical evidence of this disorder as increased right atrial pressure or widened mediastinum on chest x-ray would not represent reasons for delay. Stable patients should proceed directly to surgery.

Reference: Zipes, D. P., Libby, P., Bonow, R. O., Braunwald, E. (eds.). Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 7^th ed. Philadelphia, Elsevier, 2005.

2-139. (C) The presence of pacemaker artifacts following intrinsic QRS complexes demonstrates failure to sense. Several pacemaker artifacts fall within the refractory period following the intrinsic QRS when, as expected, they would not result in capture. If the pacemaker artifact occurred slightly later on the T wave, however, it might produce R on T phenomenon, precipitating ventricular tachycardia or fibrillation. Failure of the pacemaker to output would be evidenced on the ECG by the absence of pacemaker artifacts where a pacemaker output would be expected.

Reference: Woods, S. L., Froelicher, E. S., Motzer, S. U., Bridges, E. J. Cardiac Nursing, 5^th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

2-140. (A) Administration of normal saline fluid bolus is used to treat prerenal acute renal failure (ARF). The fluid bolus will increase the patient’s blood pressure and renal perfusion. Urine in prerenal ARF is concentrated with low sodium. Restricting the patient’s fluid or administering a diuretic such as furosemide will further exacerbate the patient’s prerenal condition. Both fluid restriction and administration of diuretics are used for patients who are in ARF and are fluid overloaded. Discontinuing the administration of cefazolin, which is nephrotoxic, would be appropriate if the patient was in intrarenal ARF.

References: Mitchell, J. G. Renal disorders and therapeutic management. In L. D. Urden, K. M. Stacy, M. E. Lough (eds.). Priorities in Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2004, pp 333-356.

Schera, M. Renal assessment and diagnostic procedures. In L. D. Urden, K. M. Stacy, M. E. Lough (eds.). Priorities in Critical Care Nursing, 4^th ed. St. Louis, Elsevier, 2004, pp 323-332.

Stark, J. L. The renal system. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 525-607.

2-141. (A) The location of the AVM suggests which deficit the nurse needs to anticipate. A lesion in the right frontal area would be expected to affect voluntary motor control on the left side of the body. Comprehension of spoken language (Option B) is controlled in the dominant temporal lobe; in most patients, this would be in the left hemisphere. A visual field deficit such as a homonymous hemianopsia (Option C) would result from a temporal lobe or optic tract disorder. The sensory deficits described in Option D would most likely result from a lesion in the parietal lobe. AVMs are abnormal vascular networks connecting arteries directly to veins. The lack of a capillary network bridging the high-pressure arterial system to the low-pressure venous system creates a risk of bleeding at that junction, where aneurysms are found in these malformations. Small AVMs commonly present with intracranial hemorrhage, whereas large AVMs present most often with seizures.

References: McQuillan, K. A. Table 4-1: functional localization in the cerebral cortex. Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, p 384.

Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 484-487.

2-142. (C) Acute intra-abdominal blood loss results in decreased venous return to the heart and reduces preload and thus cardiac output. This reduction in cardiac output results in the clinical signs of hypovolemia, hypotension, and diminished cerebral blood flow and triggers compensatory changes such as tachycardia and narrow pulse pressure. The compensatory vasoconstriction that increases blood flow to vital organs also reduces blood flow to peripheral tissues, causing cold, clammy, pale skin. Increased intracranial pressure is often associated with a widened pulse pressure and the development of bradycardia. In this scenario, the patient’s pulse pressure narrows and the heart rate increases, reflective of a hypovolemic shock state. In acute MI, the patient typically exhibits chest pain, diaphoresis, nausea, vomiting, and shortness of breath. A patient suffering from pulmonary embolism will exhibit symptoms of tachypnea, anxiety, light-headedness, sharp chest pain, hemoptysis, and rales.

Reference: Krumberger, J., Parrish, C. R., Krenitsky, J. Gastrointestinal system. In M. Chulay, S. M. Burns. AACN Essentials of Critical Care Nursing. New York, McGraw-Hill, 2006, p 317.

2-143. (D) Administration of sedation/analgesia will treat operative pain and allow the patient to tolerate mechanical ventilation; a bronchodilator can help to open constricted airways to improve ventilation and oxygenation; and postoperative antibiotics are a standard treatment following contaminated bowel surgery. IV steroids (Option A) have not demonstrated definitive benefits in patients with ARDS and are not a priority intervention for this patient. Diuretics (Option B) are not indicated in a fresh postoperative patient who has no evidence of fluid overload. Volume status needs to be assessed before administration of additional fluids (Option C) to minimize volume overload in ARDS.

References: Alspach, J. G. (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006.

Steinberg, K. P., et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome. N Engl J Med, 354(16), 1671-1684, 2006.

2-144. (B) Increased QRS duration indicates loss of capture in one of the ventricles. In biventricular pacing, the programmed A-V interval is shorter than 0.20 owing to asynchronous conduction. The shorter A-V interval accommodates the ventricular conduction defect to ensure synchronous ventricular conduction. T-wave inversion is common in ventricular pacing. Since atrial fibrillation is common in heart failure, the presence of more P waves than QRS complexes is to be expected.

Reference: Carey, M. G., Pelter, M. M. Resynchronization therapy. Am J Crit Care, 15, 103-104, 2006.

2-145. (D) The nurse competency of clinical inquiry relates to the nurse applying a change in practice when evidence exists to support the change. Especially since the preceptor is not familiar with the practice change, the best course is for the nurse to conduct a literature review to identify studies that support or refute the use of the lower arm for noninvasive blood pressure monitoring. Option A is likely not necessary since there is no evidence that the orientee does not know how to perform standard BP measurement. Option B would be of limited value since it affords a single set of measurements, though current literature indicates that upper and lower arm readings are not interchangeable in either the supine position or with the head of bed elevated 45 degrees. Rather, a difference in measurements of up to 33 mm Hg can exist between the upper arm and lower arm locations. Designing a research study would be a time-consuming activity that may not be justified if literature addressing the issue is already available.

References: Molter, N. Professional caring and ethical practice. In J. G. Alspach (ed.). Core Curriculum for Critical Care Nursing, 6^th ed. St. Louis, Elsevier, 2006, pp 1-44.

Schell, K., Lyons, D., Bradley, E., et al. Clinical comparison of autonomic, noninvasive measurements of blood pressure in the forearm and upper arm with the patient supine or with the head of the bead raised 45°: A follow-up study. Am J Crit Care, 15(2),196-205, 2006.

2-146. (D) Febrile nonhemolytic reactions occur in about 1% of transfusions and manifest with a temperature increase of more than 1° C (2° F) during or shortly following a transfusion. The reaction is thought to represent the action of antibodies against white cells or the actions of cytokines either present in the transfused component or generated by the recipient to the transfused component. The initial nursing intervention for this patient would be to immediately stop the transfusion to prevent additional exposure to the offending antigen or infectious agent. Following the termination of the transfusion, the physician would be contacted for additional orders to administer antipyretics and/or antihistamines. Individual institutions have policies and procedures regarding the disposition of the remaining unit contents and post reaction testing.

Reference: Lynn-McHale Wiegand, D. J., Carlson, K. K. (eds.). AACN Procedure Manual for Critical Care, 5^th ed. St. Louis, Elsevier, 2005, pp 1024-1030.

2-147. (A) Aspirin and GpIIb-IIIa inhibitors have antiplatelet activities. There is no antidote, but transfusion of platelets may reverse bleeding caused by platelet dysfunction. Packed red blood cells do not contain clotting factors and are used to increase hematocrit and red cell volume. Protamine sulfate is an antidote for heparin and may be used after coronary artery bypass surgery to reverse heparin administered during bypass. Vitamin K is the reversal agent used when the patient has received warfarin/Coumadin. Agatroban is used for patients with heparin-induced thrombocytopenia.

Reference: Whitlock, R., Crowther, M. A., Heng, J. M. Bleeding in cardiac surgery: its prevention and treatment—an evidence based review. Crit Care Clin, 21, 589-610, 2005.

2-148. (D) Pressure regulated volume controlled ventilation is an appropriate choice for a patient with chronic obstructive bronchitis because it prevents hyperventilation and barotrauma by adjusting flow rates to provide consistent tidal volumes. A rate of 10/min permits the patient to have a physiologically regulated exhalation time. Patients with obstructive disoders may develop lung injury with volume cycle modes of ventilation. Chronic obstructive disease generally results in elevated PaCO₂, which is compensated by elevated bicarbonate. When the CO₂ is corrected, this results in a metabolic alkalosis, which is to be expected in this patient. Increasing the FiO₂ in this patient may decrease the patient’s respiratory drive and prevent weaning. Short-term ventilation while the obstruction causing respiratory failure is relieved is the goal for the patient. Increasing FiO₂ would delay the patient’s spontaneous respiratory drive and prolong mechanical ventilation.

Reference: Diepenbrock, N. H. Quick Reference to Critical Care. Philadelphia, Lippincott Williams & Wilkins, 2004.

2-149. (C) The family has expressed a need for information, and the nurse is responsible for providing answers to questions posed. Using knowledge of the disease process, the nurse explains that fluid repletion decreases blood sugar levels independently of insulin administration (Option A), prevents/treats intravascular collapse (Option D), and improves organ perfusion (Option B). Option C is the incorrect reply because fluid resuscitation does not affect fat breakdown.

Reference: Brenner, Z. R. Management of hyperglycemic emergencies. AACN Clin Issues, 17(1), 56–65, 2006.

2-150. (A) A patient who has received heparin in the past has an increased risk of developing heparin-induced thrombocytopenia because prior exposure causes development of antibodies that are already present when the patient is next exposed to heparin. Patients undergoing cardiac catheterization and PCI receive heparin during the procedure. Chronic conditions such as asthma, diabetes, hypertension, and renal failure do not influence the development of heparin-induced thrombocytopenia.

Reference: Baird, M. S., Keen, J. H., Swearingen, D. L. Manual of Critical Care Nursing: Nursing Interventions and Collaborative Management. St. Louis, Elsevier, 2005.