Chapter 14: Nervous System Alterations Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. The nurse admits a patient to the critical care unit following a motorcycle crash. Assessment findings by the nurse include blood pressure 100/50 mm Hg, heart rate 58 beats/min, respiratory rate 30 breaths/min, and temperature of 100.5°F. The patient is lethargic, responds to voice but falls asleep readily when not stimulated. Which nursing action is most important to include in this patient’s plan of care?

a. Frequent neurological assessments b. Side to side position changes c. Range-of-motion to extremities d. Frequent oropharyngeal suctioning

ANS: A

Nurses complete neurological assessments based on prescribed frequency and the severity of the patient’s condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient’s plan of care. Side to side position changes, range-of-motion exercises, and frequent oral suctioning are nursing actions that may need to be a part of the patient’s plan of care, but in the setting of increased intracranial pressure they should not be regularly performed unless indicated.

DIF: Cognitive Level: Apply/Application

REF: p. 350

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

NURSINGTB.COM

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. 54 mm Hg b. 72 mm Hg c. 90 mm Hg d. 126 mm Hg

2. A patient with a head injury has an intracranial pressure (ICP) of 18 mm Hg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mm Hg. What is the cerebral perfusion pressure (CPP)?

ANS: C

CPP = MAP – ICP. In this case, CPP = 108 mm Hg – 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.

DIF: Cognitive Level: Apply/Application

REF: p. 354

OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Both pressures are high. b. Both pressures are low. c. ICP is high; CPP is normal. d. ICP is high; CPP is low.

3. While caring for a patient with a traumatic brain injury, the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg. What is the best interpretation by the nurse?

ANS: C

The ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.

DIF: Cognitive Level: Understand/Comprehension REF: p. 354

OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Hyperoxygenate during endotracheal suctioning. b. Elevate the patient’s head of the bed 30 degrees. c. Apply bilateral heel protectors after repositioning. d. Provide rest periods between nursing interventions.

4. The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the patient to the left side. What is the best action by the nurse?

ANS: D

Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities. All other nursing actions are a part of the patient’s plan of care; however, spacing out interventions is the priority.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application REF: p. 361

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Have the patient blow the nose until clear. b. Insert bilateral cotton nasal packing. c. Place a nasal drip pad under the nose. d. Suction the left nares until the drainage clears.

5. While caring for a patient with a basilar skull fracture, the nurse assesses clear drainage from the patient’s left naris. What is the best nursing action?

ANS: C

In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment. Patients should be instructed not to blow their nose because that action may further aggravate the dural tear. Suction catheters should be inserted through the mouth rather than the nose to avoid penetrating the brain due to the dural tear.

DIF: Cognitive Level: Apply/Application

REF: p. 368

OBJ: Describe the nursing and medical management of patients with skull fractures.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Stimulate the patient hourly. b. Continue to monitor the patient. c. Elevate the head of the bed. d. Notify the provider immediately.

6. The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15. One hour later, the nurse assesses a GCS score of 3. What is the priority nursing action?

ANS: D

These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient, and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the provider is a priority given the severity in change of neurological status.

DIF: Cognitive Level: Analyze/Analysis REF: p. 369

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. ICP of 10 mm Hg b. CPP of 70 mm Hg c. GCS score of 5 d. CVP of 2 mm Hg

7. The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3. Following the administration of mannitol (Osmitrol), which assessment finding by the nurse requires further action?

ANS: D

Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mm Hg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.

DIF: Cognitive Level: Analyze/Analysis REF: p. 362

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Altered cerebral spinal fluid production and reabsorption b. Decreased cerebral blood volume due to vessel constriction c. Increased cerebral blood volume due to vessel dilation d. No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)

8. The nurse is caring for a mechanically ventilated patient with a brain injury. Arterial blood gas values indicate a PaCO2 of 60 mm Hg. The nurse understands this value to have which effect on cerebral blood flow?

ANS: C

Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume. To compensate for increased cerebral blood volume, cerebral spinal fluid may be displaced, but the scenario is asking for the effect of hypercarbia (elevated PaCO2) on cerebral blood flow. PaCO2 of 60 mm Hg is elevated, which would cause cerebral vasodilation and increased cerebral blood volume.

DIF: Cognitive Level: Remember/Knowledge REF: p. 344

OBJ: Describe the pathophysiology of increased intracranial pressure.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Monitor the patient’s airway patency. b. Elevate the head of the patient’s bed. c. Increase supplemental oxygen delivery. d. Support bony prominences with padding.

9. The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3. Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg, heart rate 55 beats/min, respiratory rate 10 breaths/min, oxygen saturation (SpO2) 94% on oxygen at 3 L per nasal cannula. What is the priority nursing action?

ANS: A

A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient’s airway. There is no evidence to support the need for increased supplemental oxygen. A respiratory rate of 10 breaths/min may result in increased CO2 retention, which may further increase ICP through dilatation of cerebral vessels. Elevating the head of the bed and supporting bony prominences are appropriate nursing interventions for a patient in a deep coma; however, airway patency is the immediate priority.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: p. 351 | p. 360 Nursing Care Plan

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation.

10. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?

ANS: C

This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 351 | Figure 14-7

OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad.

11. The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action?

ANS: D

Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: p. 368

OBJ: Describe the nursing and medical management of patients with skull fractures.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Ensure adequate periods of rest between nursing interventions. b. Insert an oral airway and monitor respiratory rate and depth. c. Maintain neutral head alignment and avoid extreme hip flexion. d. Reduce ambient room temperature and administer antipyretics.

12. While caring for a patient with a closed head injury, the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg, heart rate 60 beats/min, respirations 18 breaths/min, and a temperature of 102°F. To reduce the risk of increased intracranial pressure (ICP) in this patient, what is (are) the priority nursing action(s)?

ANS: D

In this scenario, the patient’s temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.

DIF: Cognitive Level: Apply/Application

REF: p. 360 Nursing Care Plan

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Assist the patient to the floor and provide soft head support. b. Insert a nasogastric tube and connect to continuous wall suction. c. Open the patient’s mouth and insert a padded tongue blade. d. Restrain the patient’s extremities until the seizure subsides.

13. The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit. The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure. What is the best nursing action?

ANS: A

To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported. Routine insertion of a nasogastric tube during seizure activity is not indicated unless there is risk for aspiration. Forceful insertion of a padded tongue blade should not be carried out during tonic-clonic activity; most likely the patient’s jaws will be clenched shut. Forceful insertion may lead to further injury. Restraining a patient during seizure activity can be traumatizing and is not standard of care.

DIF: Cognitive Level: Apply/Application

REF: p. 380

OBJ: Describe the pathophysiology and management for status epilepticus.

TOP: Nursing Process Step: Intervention

NURSINGTB.COM

MSC: NCLEX Client Needs Category: Physiological Integrity

14. The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury. Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?

ANS: C

Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 360 Nursing Care Plan

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer acetaminophen as ordered for the headache. b. Assess for a kinked urinary catheter and assess for bowel impaction. c. Encourage the patient to take slow, deep breaths. d. Notify the provider of the patient’s blood pressure.

15. The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24 breaths/min, and 50 mL of urine via indwelling urinary catheter for the past 4 hours. What is the best action by the nurse?

ANS: B

Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction. Treating the patient for a headache will not resolve symptoms of autonomic dysreflexia. Treatment must focus on identifying the underlying cause. Slow, deep breaths will not correct the underlying problem. Assessing for underlying causes of autonomic dysreflexia should precede contacting the provider.

DIF: Cognitive Level: Apply/Application

REF: p. 387 Clinical Alert Box

OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Assess for the presence of a headache. b. Assess the patient’s general orientation. c. Determine the patient’s drug allergies. d. Determine the time of symptom onset.

16. The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness. What is the priority nursing action?

ANS: D

Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.

DIF: Cognitive Level: Apply/Application

REF: p. 374

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. A patient with a complete spinal cord injury at the C5 dermatome level b. A patient with a Glasgow Coma Scale score of 15 on 3-L nasal cannula c. An alert patient with a subdural bleed who is complaining of a headache d. An ischemic stroke patient with a blood pressure of 190/100 mm Hg

17. Which patient being cared for in the emergency department should the charge nurse evaluate first?

ANS: A

A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise. The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg.

DIF: Cognitive Level: Analyze/Analysis REF: p. 382

OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Keep the neck in the hyperextended position. b. Maintain proper head and neck alignment. c. Prepare for immediate endotracheal intubation. d. Remove cervical collar upon arrival to the ED.

18. The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action?

ANS: B

Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury. Hyperextension of the neck is contraindicated with a cervical spine injury. Immediate endotracheal intubation is not indicated with a suspected cervical spine injury unless the patient’s airway is compromised. The use of assist devices to maintain immobilization of the cervical spine is indicated until injury has been ruled out.

NURSINGTB.COM

DIF: Cognitive Level: Understand/Comprehension REF: p. 385 | p. 388

OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Maintain body temperature. b. Monitor blood pressure. c. Pad all bony prominences. d. Use proper hand washing.

19. The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level. The patient is in spinal shock. Following emergent intubation and mechanical ventilation, what is the priority nursing action?

ANS: B

Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority. Hand washing is important for all patients. There is no indication the patient has temperature alterations. Padding bony prominences may or may not be needed.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 386 | p. 388 Nursing Care Plan

OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. 2478 mg b. 5000 mg c. 10,794 mg d. 12,750 mg

20. The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol. The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours. What is the total 24-hour dose for the 70-kg patient?

ANS: C

The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg  70 kg) + (5.4 mg  70 kg)  23 hours = 10,794 mg.

DIF: Cognitive Level: Apply/Application

REF: Table 14-9

OBJ: Describe nursing and medical management of patients with a spinal cord injury.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity a. Mannitol 1 g intravenous b. Portable chest x-ray c. Seizure precautions d. Ancef 1 g intravenous

21. The nurse receives a patient from the emergency department following a closed head injury. After insertion of an ventriculostomy, the nurse assesses the following vital signs: blood pressure 100/60 mm Hg, heart rate 52 beats/min, respiratory rate 24 breaths/min, oxygen saturation (SpO2) 97% on supplemental oxygen at 45% via Venturi mask, Glasgow Coma Scale score of 4, and intracranial pressure (ICP) of 18 mm Hg. Which provider prescription should the nurse institute first?

ANS: A

NURSINGTB.COM

The patient’s GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure. Ancef 1 g intravenous is appropriate given the indwelling ICP line; however, antibiotic therapy is not the priority in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-9

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Blood cultures (2 specimens) for temperature >101°F b. Acetaminophen (Tylenol) 650 mg per rectum c. 500 mL albumin infusion intravenously d. Decadron 20 mg intravenous push every 4 hours

22. The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg, heart rate 110 beats/min, respiratory rate 20 breaths/min, oxygen saturation (SpO2) 95% on 3 L/min oxygen via nasal cannula, and a temperature of 101.5°F. Which provider prescription should the nurse institute first?

ANS: C

Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion. Blood cultures, acetaminophen administration, and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

DIF: Cognitive Level: Analyze/Analysis REF: p. 372 | p. 378 | Table 14-9

OBJ: Describe the nursing and medical management of patients with increased intracranial pressure. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

23. The nurse, caring for a patient following a subarachnoid hemorrhage, begins a nicardipine infusion. Baseline blood pressure assessed by the nurse is 170/100 mm Hg. Five minutes after beginning the infusion at 5 mg/hr, the nurse assesses the patient’s blood pressure to be 160/90 mm Hg. What is the best action by the nurse?

NURSINGTB.COM a. Stop the infusion for 5 minutes. b. Increase the dose by 2.5 mg/hr. c. Notify the provider of the BP. d. Begin weaning the infusion.

ANS: B

Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient’s blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse. Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure. Notifying the provider of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer over 2 minutes. b. Administer with 0.9% normal saline intravenous. c. Contact the provider. d. Assess cardiac rhythm.

24. The nurse is preparing to administer a routine dose of phenytoin. The provider orders phenytoin 500 mg intravenous every 6 hours. What is the best action by the nurse?

ANS: C

The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

DIF: Cognitive Level: Apply/Application

REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Obtain stat serum electrolytes. b. Administer lorazepam. c. Obtain stat portable chest x-ray. d. Administer phenytoin.

25. The nurse is caring for a patient admitted to the emergency department in status epilepticus. Vital signs assessed by the nurse include blood pressure 160/100 mm Hg, heart rate 145 beats/min, respiratory rate 36 breaths/min, oxygen saturation (SpO2) 96% on 100% supplemental oxygen by non-rebreather mask. After establishing an intravenous (IV) line, which prescription by the provider should the nurse implement first?

ANS: B

The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Contact the admitting physician. b. Administer the drug over 10 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

26. The provider prescribes fosphenytoin, 1.5 g intravenous (IV) loading dose, for a 75-kg patient in status epilepticus. What is the most important action by the nurse?

ANS: B

The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient’s weight. Fosphenytoin does not have to be administered with normal saline or via a central line.

DIF: Cognitive Level: Apply/Application

REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Administer over 2 minutes. b. Administer over 20 to 30 minutes. c. Mix medication with 0.9% normal saline. d. Administer via central line.

27. The nurse is to administer 100 mg phenytoin intravenous (IV). Vital signs assessed by the nurse include blood pressure 90/60 mm Hg, heart rate 52 beats/min, respiratory rate 18 breaths/min, and oxygen saturation (SpO2) 99% on supplemental oxygen at 3 L/min by cannula. To prevent complications, what is the best action by the nurse?

ANS: B

In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes. Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario. Administering the medications via central line will not prevent complications related to this scenario.

DIF: Cognitive Level: Apply/Application

REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease. TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Ensure patency of intravenous (IV) line.

28. The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus. To prevent patient complications, what is the best action by the nurse?

NURSINGTB.COM b. Mix drug with 0.9% normal saline. c. Evaluate serum K+ level. d. Obtain an IV infusion pump.

ANS: A

Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis). Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration. Evaluating the serum K+ is not required prior to administration. The dose of phenytoin (Dilantin) ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

DIF: Cognitive Level: Understand/Comprehension

REF: Table 14-9

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Lasix 20 mg intravenous push as needed b. 500 mL albumin intravenous infusion c. Decadron 10 mg intravenous push d. Dilantin 50 mg intravenous push

29. The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm. Assessment by the nurse notes blood pressure 90/60 mm Hg, heart rate 115 beats/min, respiratory rate 28 breaths/min, oxygen saturation (SpO2) 99% on supplemental oxygen at 3L/min by cannula, a Glasgow Coma Score of 4, and a central venous pressure (CVP) of 2 mm Hg. After reviewing the provider prescriptions, which order is of the highest priority?

ANS: B

To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mm Hg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate. Lasix is contraindicated in low volume states. Although Decadron and Dilantin are appropriate medications, in this scenario, they are not the priority medications.

DIF: Cognitive Level: Apply/Application REF: p. 378

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. A patient with meningitis complaining of photophobia b. A mechanically ventilated patient with a GCS of 6 c. A patient with bacterial meningitis on droplet precautions d. A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F

30. After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first?

ANS: D

The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.

NURSINGTB.COM

DIF: Cognitive Level: Analyze/Analysis REF: p. 381

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Implement droplet precautions upon admission. b. Wash hands thoroughly before leaving the room. c. Scrub the hub of all central line ports before use. d. Dispose of all bloody dressings in biohazard bags.

31. The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis. To prevent the spread of nosocomial infections to other patients, what is the best action by the nurse?

ANS: A

Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection. Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection, but added precautions are necessary for preventing the spread of bacterial meningitis. Disposing of all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 381

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment a. Elevate the head of the bed 30degrees. b. Keep lights dim at all times. c. Implement seizure precautions. d. Maintain bed rest at all times.

32. The nurse is caring for a patient admitted with bacterial meningitis. Vital signs assessed by the nurse include blood pressure 110/70 mm Hg, heart rate 110 beats/min, respiratory rate 30 breaths/min, oxygen saturation (SpO2) 95% on supplemental oxygen at 3 L/min, and a temperature 103.5°F. What is the priority nursing action?

ANS: C

Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury. Elevating the head of the bead, keeping the lights dim, and maintaining bed rest are all appropriate nursing interventions but are not the priorities in this scenario.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

REF: p. 381

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment

Multiple Response

1. The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)

a. Use of a heparin flush solution b. Manually flushing the device “prn” c. Recording ICP as a “mean” value d. Use of a pressurized flush system e. Zero referencing the transducer system

ANS: C, E

Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.

DIF: Cognitive Level: Remember/Knowledge

REF: p. 357

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Doll’s eyes absent indicate a disruption in normal brainstem processing. b. Doll’s eyes present indicate brainstem activity. c. Eye movement in the opposite direction as the head when turned indicates an intact reflex. d. Eye movement in the same direction as the head when turned indicates an intact reflex. e. Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f. Presence of cervical injuries is a contraindication to the assessment of this reflex.

2. In an unconscious patient, eye movements are tested by the oculocephalic reflex. Which statements regarding the testing of this reflex are true? (Select all that apply.)

ANS: A, B, C, E, F

In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll’s eye): turn the patient’s head quickly from side to side while holding the eyes open. Note movement of eyes. The doll’s eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

NURSINGTB.COM

DIF: Cognitive Level: Understand/Comprehension

REF: Table 14-10

OBJ: Complete an assessment on a critically ill patient with nervous system injury.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Make frequent neurological assessments. b. Maintain CO2 level at 50 mm Hg. c. Maintain MAP less than 130 mm Hg. d. Prepare for thrombolytic administration. e. Restrain affected limb to prevent injury.

3. The nurse is caring for a patient admitted with new onset of slurred speech, facial droop, and left-sided weakness 8 hours ago. Diagnostic computed tomography scan rules out the presence of an intracranial bleed. Which actions are most important to include in the patient’s plan of care? (Select all that apply.)

ANS: A, C

The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.

DIF: Cognitive Level: Analyze/Analysis REF: Table 14-2 | Table 14-10

OBJ: Discuss the nursing assessment and care of a critically ill patient with cerebrovascular disease.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM

Chapter 15: Acute Respiratory Failure

Sole: Introduction to Critical Care Nursing, 7th Edition

Multiple Choice

1. The nurse is caring for a patient with acute respiratory failure and identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours.

ANS: D

Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan

OBJ: Formulate a plan of care for the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

2. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?

NURSINGTB.COM a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation

ANS: A

Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.

DIF: Cognitive Level: Understand/Comprehension REF: pp. 298-299

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Hyperventilation and respiratory acidosis b. Hypoventilation and respiratory acidosis c. Hypoventilation and respiratory alkalosis d. Respiratory acidosis and normal oxygen levels

3. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?

ANS: B

Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.

DIF: Cognitive Level: Analyze/Analysis REF: p. 390 | p. 392

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

4. Intrapulmonary shunting refers to a. alveoli that are not perfused. b. blood that is shunted from the left side of the heart to the right and causes heart failure. c. blood that is shunted from the right side of the heart to the left without oxygenation. d. shunting of blood supply to only one lung.

ANS: C

Shunting refers to blood that is not oxygenated in the lungs.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

5. When fluid is present in the alveoli,

NURSINGTB.COM a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure.

ANS: B

REF: pp. 390-391

Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome.

DIF: Cognitive Level: Understand/Comprehension REF: p. 391

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

6. In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness.

ANS: D

Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 392

7. The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability.

ANS: C

Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 398 | Figure 15-2

TOP: Nursing Process Step: Assessment

OBJ: Describe the pathophysiology of ARF.

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM

8. The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning.

ANS: C

Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent nonpharmacological approach to manage anxiety; however, the nontraditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated to treat this patient, who is restless and appears to be in discomfort. Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility program for critically ill patients.

DIF: Cognitive Level: Analyze/Analysis REF: p. 400

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Evaluation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device

9. A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

ANS: C

Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is no indication of an obstructed airway.

DIF: Cognitive Level: Analyze/Analysis REF: p. 414

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

10. Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

ANS: C

NURSINGTB.COM

Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 404 a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators

11. An acute exacerbation of asthma is treated with which of the following?

ANS: B

Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.

DIF: Cognitive Level: Understand/Comprehension

REF: p. 403

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

12. The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a. “If you get the pneumococcal vaccine, you’ll never get pneumonia again.” b. “It is important for you to get an annual influenza shot to reduce your risk of pneumonia.” c. “Stay away from cold, drafty places because that increases your risk of pneumonia when you get home.” d. “Since you have been treated for pneumonia, you now have immunity from getting it in the future.”

ANS: B

The influenza vaccine reduces the risk of pneumonia by more than 50%. The pneumococcal vaccine is important but protects only against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it.

DIF: Cognitive Level: Analyze/Analysis REF: p. 406

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

13. The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by:

NURSINGTB.COM a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until the patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a “prn” basis according to symptoms.

ANS: C

Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patient’s activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 405

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing

14. The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?

ANS: B

Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.

DIF: Cognitive Level: Analyze/Analysis REF: p. 402

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

15. The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter.

ANS: B

The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.

DIF: Cognitive Level: Remember/Knowledge REF: p. 410

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility

16. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following?

ANS: D Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.

DIF: Cognitive Level: Apply/Application

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 411 | Box 15-7 a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

17. Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

ANS: A

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the “classic” signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE, and all should receive prophylaxis.

DIF: Cognitive Level: Analyze/Analysis REF: p. 411 | Box 15-7

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

18. A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. “I’m going to contact the pharmacist to see if you can take this medication by mouth.” b. “This injection is being given to prevent blood clots from forming.” c. “This medication will dissolve any blood clots you might get.” d. “You should not be receiving this medication. I will contact the provider to get it stopped.”

ANS: B

Enoxaparin, or low–molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.

NURSINGTB.COM

DIF: Cognitive Level: Apply/Application

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

19. A definitive diagnosis of pulmonary embolism can be made by a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram. d. ventilation-perfusion scanning.

ANS: C

REF: p. 411 | Box 15-8

The angiogram is one test that can confirm pulmonary embolism. A spiral CT scan is the other definitive test. Both tests have the limitation of not always being able to visualize small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is inconclusive.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment

REF: p. 412

MSC: NCLEX Client Needs Category: Physiological Integrity

20. A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours.

ANS: C

A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE.

DIF: Cognitive Level: Apply/Application

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 412 a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics

21. Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?

ANS: D

NURSINGTB.COM

Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 411 a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio >300

22. The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

ANS: B

Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.

DIF: Cognitive Level: Apply/Application REF: p. 399

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. 46.8; meets criteria for ARDS b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio

23. The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).

ANS: B

78/0.60 = 130, which meets the criteria for ARDS.

DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

24. The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance.

ANS: B

A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.

DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family

25. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?

ANS: A

All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.

DIF: Cognitive Level: Understand/Comprehension REF: p. 400

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

26. During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down. c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning.

ANS: A

Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas, such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protection of the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.

DIF: Cognitive Level: Apply/Application REF: p. 400

OBJ: Discuss medical management of the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention

MSC: NCLEX Client Needs Category: Physiological Integrity

NURSINGTB.COM

27. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea.

ANS: A

Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other responses apply.

DIF: Cognitive Level: Understand/Comprehension REF: p. 397

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity

28. From the following illustrations of the alveolar-capillary membrane, select the image that demonstrates shunting.

ANS: C

Figure C shows a shunt. A is a normal alveolar-capillary unit. B is hypoventilation with increased PaCO2 and decreased PaO2. D is a ventilation/perfusion mismatch. E is a diffusion defect.

DIF: Cognitive Level: Remember/Knowledge REF: Figure 15-1

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: N/A

MSC: NCLEX Client Needs Category: Physiological Integrity

Multiple Response

1. Identify diagnostic criteria for ARDS. (Select all that apply.)

a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg

ANS: A, C

Diagnostic criteria for ARDS include bilateral infiltrates, or “white out,” on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. The PAOP description was deleted from the current definition.

DIF: Cognitive Level: Remember/Knowledge REF: pp. 396-397

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Using oral swabs or toothettes are just as effective as brushing the teeth.

2. Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

ANS: B, C, D

A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.

DIF: Cognitive Level: Apply/Application

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Planning

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: Box 15-6 a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention

3. Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)

ANS: A, B, C, D

Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.

DIF: Cognitive Level: Understand/Comprehension

NURSINGTB.COM

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 400 a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours.

4. Which of the following are components of the Institute for Healthcare Improvement’s (IHI’s) ventilator bundle? (Select all that apply.)

ANS: A, B, C, D

Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.

DIF: Cognitive Level: Apply/Application

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 407 a. Graduated compression stockings b. Heparin or low–molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage

5. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

ANS: A, B, C

Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.

DIF: Cognitive Level: Understand/Comprehension REF: Box 15-8

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees. c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation.

6. The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)

ANS: A, B, D

Condensate should be drained away from the patient to avoid drainage back into the patient’s airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily “sedation holidays” help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

DIF: Cognitive Level: Understand/Comprehension REF: Box 15-5

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity a. high Fowler’s. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg.

7. The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)

ANS: A, B, C

Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler’s is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler’s position are all appropriate ways to position the patient to facilitate gas exchange and comfort.

DIF: Cognitive Level: Understand/Comprehension

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity

REF: p. 393 a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant

8. The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)

ANS: A, B, C, E

The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF.

DIF: Cognitive Level: Apply/Application

REF: pp. 413-414

NURSINGTB.COM

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX Client Needs Category: Physiological Integrity