NUR 2755 Multidimensional Care IV MDC IV Exam 2 1) A vena cava filter is one of the preventions used for patients with pulmonary emboli to prevent further ... [Show More] PEs - True False 2) Whi ch IV fluid is the best choice for a patient in hypovolemic shock? A. 0.45% Sodium Chloride B. 0.9% NS C. Dextrose 10% D. Lactated Ringers 3) A patient with a tension pneumothorax and cardiovascular compression is at risk for distributive shock - True False 4) What is a classic sign of a flail chest? A. Paradoxical chest movement B. Cyanosis C. Hypotension D. Pain with exhalation 5) A disconnected ET tube from a ventilatory will sound a high alarm on the vent - True False RATIONALE: - False - a disconnection is a low alarm 6) To prevent a patient from getting VAP the nurse should include what in her patient's care? A. Perform mouth care q 12 hours B. Suction q 1-2 hours around the clock C. Elevate the head of the bed 30 degrees D. Keep the patient on their left side RATIONALE: - Elevate the head of the bed 30 degrees mouth care q 2 hours* suction prn* 7) A post op patient complains of sudden SOB and pleuritis chest pain. What is the most likely cause? A. Pneumothorax B. Pulmonary emboli C. Heart attack D. Congestive heart failure 8) Stupor is a sign of respiratory distress - True False 9) Calculate the TBSA: Burn to half of the front torso, entire right arm, back of right leg - 27% half of the front torso (9%) + entire R arm (9%) + back of R leg (9%) 10) A patient is showing early signs of shock. How should the patient be positioned? A. Head flat with legs elevated B. Elevate HOB 30 degrees C. Prone D. Side-lying 11) What finding is a sign of shock after a spinal cord injury? A. Stabbing pain in the extremities B. Apical heart rate 50 C. Inspiratory crackles D. Elevated WBC count 12) One of the biggest risks of neurogenic shock is severe bradycardia - True False 13) Which statement is true regarding DIC? A. DIC is caused by abnormal clotting involving fibrinogen B. Patients with DIC will be on lifelong heparin C. DIC is caused by a vitamin K deficiency D. DIC is a genetic disorder 14) The nurse should always lower the temperature of the room for a patient with neurogenic shock - True False RATIONALE: - False! They need a warm room w/ warm fluid 15) Which patient should be seen first? A. An intubated patient with a flail chest B. A patient with rib fractures asking for pain meds C. A patient who just extubated themselves D. A patient with a fracture and weak distal pulses 16) Which lab would the nurse anticipate for a patient with a pulmonary embolus? A. Sed rate B. Urinalysis C. CBC D. D-dimer 17) Norepinephrine is often used for patients in distributive shock due to its ability to cause A. Increased MAP by increasing vascular tone B. Decreased MAP by decreasing vascular volume C. Decreased MAP from capillary leak D. Increased MAP without change to vascular tone 18) TBSA 55%, Wt 160 lbs, what is the initial IV rate if the client arrived immediately after the injury? A. 1000 mL/hr. B. 800 mL/hr. C. 750 mL/hr. D. 1200 mL/hr. CALCULATION: - 1,000 mL/hr. Use Parkland Formula: 4mL x TBSA% x kg 4mL x 55% x (160/2.2) = 16,000 divided by 2 = 8,000 mL in the first 8 hours...8,000mL/8 hr. = 1,000mL/hr. 19) Which patient is at the lowest risk for developing ARDS? A. A client following coronary artery bypass graft surgery B. A client who has a hemoglobin of 10.1 mg/dL post 1-unit PRBC C. A client who experienced a near-drowning incident in freshwater D. A client who is experiencing acute pancreatitis and vomiting 20) The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A. Assess and treat pain. B. Evaluate airway and circulation. C. Place two IV catheters and initiate fluid resuscitation. D. Use the rule of nines to estimate percent of body surface area burned. 21) It has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? A. Check the patient's Spo2 level. B. Notify the physician immediately. C. Re-assess breathing in 1 hour. D. Document improvement in patient's condition. 22) A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret this finding? A. Electrolyte imbalance B. Infection is improving C. Impending kidney disease D. Possible allergic reaction to silver sulfadiazine (Silvadene) 23) Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)? A. 24-year-old male admitted with blunt chest trauma and aspiration B. 56-year-old male with a history of alcohol abuse and chronic pancreatitis C. 72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells D. 82-year-old female on antibiotics for pneumonia 24) A patient is being discharged to home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates a need for further teaching by the nurse? A. "I should limit my alcohol consumption." B. "I should eat more green leafy vegetables like spinach." C. "I should take the medication at the same time every day." D. "I should make a doctor's appointment for weekly blood draws." 25) A patient in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential cause of ventilatory failure? A. Pulmonary edema B. Hypovolemic shock C. Pulmonary embolus D. Opioid analgesic overdose 26) A 37-year-old male is admitted with a severely abscessed tooth, BP 90/42, HR 136, RR 28, Spo2 90% on room air, temperature 38.7º C. The nurse suspects that the patient has developed sepsis. What is the priority nursing intervention? A. Insert an indwelling urinary catheter. B. Initiate intravenous fluid resuscitation. C. Obtain a complete chemistry for laboratory analysis. D. Administer prescribed antibiotics prior to blood cultures. 27) When assessing a patient for shock, the nurse knows that which symptom is the earliest manifestation of shock? A. Anuria B. Increased heart rate C. A decrease in respiratory rate and depth D. A change in both systolic and diastolic blood pressure 28) Which clinical manifestations does the nurse recognize that indicates worsening in the condition of a patient in the refractory phase of shock? A. Warm, flushed skin B. Urine output of 20 mL/hr. C. Increasing respiratory rate D. Bleeding, oozing from IV sites 29) Clinical manifestation of a Pneumothorax include A. Fever B. Paradoxical chest movement C. Diminished breath sounds D. Decrease urinary output RATIONALE: - Diminished breath sounds ▪ also asymmetry - Paradoxical chest movement = flail chest (when pt inhales the good side goes out and the bad side goes in, like a see saw) * - Fever = sepsis - Decrease urinary output = a good measure of perfusion/kidneys (ideally 30 mL/hr.; formula = 0.5/kg/hr.) 30) Treatment for flail chest - ET tube...patient needs to be intubated 31) Rib fractures can lead to hypovolemic shock! - Pain! teach them to splint when coughing and use pain meds Uncomplicated rib fracture - most common symptom 32) Tracheal deviation is a clinical manifestation of: A. Rib fracture B. Tension Pneumothorax C. ARDS D. Septic shock RATIONALE: - Tension Pneumothorax - first thing you do is a needle thoracotomy (aka needle decompression) then chest tube 33) What does ARDS look like on a chest x-ray? - Ground glass appearance 34) Treatment for ARDS - Prone positioning & PEEP 35) All the following are interventions for a client on a ventilator, except: A. Have an Ambu Bag available at bedside B. Suction as needed C. Assess the client respiratory status every 4 hours D. Prevent pressure ulcers around the mouth for the ETT 36) Septic shock interventions - Blood cultures then antibiotics (broad spectrum) - Lactate level - Fluids!!! NS or LR usually 30 mL/kg rapid infusion or vasoconstrictors (epinephrine, norepinephrine, dopamine, vasopressin...side effects = ischemia, hypertension) 37) Patient education for septic shock - Infection prevention 38) Complications of PEEP - Pneumothorax - Hypotension 39) Causes of high-pressure alarms - Obstruction - Excessive secretions - listen to lungs - Kinked tubing - Increased pulmonary pressures 40) Causes of low-pressure alarms - Leak - check that the balloon is inflated 41) What medication are you immediately put on if you are on mechanical ventilation? - Lovenox (enoxaparin) 42) Clinical manifestations of a pulmonary embolism include all of the following except: A. Decreased O2 Sat B. Hypotension C. Shortness of Breath-sudden D. Stridor RATIONALE: - Stridor - this can be caused by anaphylaxis, obstruction, inhalation injury; when the stridor is no longer heard this might mean the airway is closed! 43) PE diagnostics - D-dimer - Spiral CT with contrast - ABGs - CT with contrast - CT angiogram 44) A weak, thready pulse is a clinical manifestation of: A. Hypovolemic shock B. Inhalation injury C. Fluid volume excess D. DIC 45) An escharotomy involves a surgical incision though the hardened dermal layer of the skin. - True False 46) Rule of 9's: Left arm, left leg, and upper chest A. 9 B. 27 C. 18 D. 36 RATIONALE: - 36 (4.5+4.5+9+9+9) 47) A client with hypovolemic shock should be positioned: A. Prone B. High Fowler's C. Supine (with elevated legs) D. In the recovery position 48) The priority Nursing diagnosis during the Acute Phase of Burn injury include all except: A. Risk for infection B. Impaired Skin Integrity C. Nutrition: Less than body requirements D. Hyperkalemia 49) Clinical manifestation of neurogenic shock include all of the following except: A. Bradycardia B. Poikilothermia (inability to control temperature) C. Angioedema D. Hypotension RATIONALE: - Angioedema (this would be in burns or anaphylactic shock) remember neurogenic shock is LOW and SLOW 50) A client allergic to Sulfa should not receive: A. Vancomycin B. Atropine C. Furosemide D. Silver Sulfadiazine RATIONALE: - Silver Sulfadiazine - used for wound care (debridement) 51) The client receiving norepinephrine has a painful IV site. What should you do first? A. Continue to monitor B. Notify the Provider C. Document the finding D. Stop the infusion RATIONALE: - Stop the infusion - vasoconstrictors should be in a central line 52) An elevated Pulmonary Artery Wedge Pressure indicates fluid volume deficit. - True False RATIONALE: - False - it indicates fluid volume excess! 53) Signs of Cardiogenic shock include: A. Crackles, SOB, Pink frothy sputum B. Low BP, Increase Temp, purulent drainage from a wound C. Low BP and Low HR D. Pallor, low H/H, and ALOC RATIONALE: - Crackles, SOB, Pink frothy sputum think left ("lung") sided heart failure s/s 54) Treatment of cardiogenic shock - MONA inotropes: dobutamine, milrinone - remember cardiogenic shock is caused by MI 55) A Pulmonary Embolism can be diagnosed by: A. CT of the head B. CT angiogram C. Lumbar Puncture D. Blood Cultures 56) For a BP 100/40 the MAP is 75 - True False RATIONALE: - False "MAP easy as 1,2,3" {(1xSBP) + (2xDBP)}/3 {(1x100) + (2x40)/3} = 60 57) The following are related to ARDS except: A. Refractory hypoxemia B. Vasopressin administration C. Non-cardiac pulmonary edema D. Prone Positioning and PEEP RATIONALE: - Vasopressin administration - this is given for shock 58) The client in the non-progressive stage of shock will have: A. Increased thirst and decreased UO B. Normal MAP C. MODS D. Hypokalemia RATIONALE: - Increased thirst and decreased UO - MAP will drop 10* - MODS is late stage* - Hyperkalemia* 59) Which of the following is not a type of distributive shock? A. Anaphylactic B. Septic C. Cardiogenic D. Neurogenic RATIONALE: - Cardiogenic (pump failure) - distributive shock means fluid is in areas it doesn't belong 60) #1 cause of obstructive shock - Cardiac tamponade r/t pericarditis Clinical manifestations: distant heart sounds 61) A client with a DVT will be prescribed: A. Esomeprazole B. Warfarin C. Sildenafil D. Furosemide 62) A characteristic of full-thickness burn include: A. Very painful B. Heals without intervention C. Needs skin grafting D. Blisters develop 63) A client in septic shock is 80Kg. An appropriate fluid volume infusion would be 2400MLs of LR - True False RATIONALE: - True 30mL/kg 30mL x 80kg = 2,400mL 64) What would the [Show Less]
