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Critical Care Nursing A Holistic Approach 10th Edition by Patricia Gonce Morton – Test Bank 

 

1. A nurse is the only one in the ICU who has not achieved certification in critical care nursing. She often will ask her fellow nurses what to do in caring for a patient because she doubts the accuracy of her knowledge and her intuition. She loves her work but wishes she could do it with a greater level of competence. What is the most important effect that obtaining certification would likely have on the nurse’s practice?
A) Recognition by peers
B) Increase in salary and rank
C) More flexibility in seeking employment
D) Increased confidence in making decisions

 

 

2. A hospital interviews two different candidates for a position in the ICU. Both candidates have around 10 years of experience working in the ICU. Both have excellent interpersonal skills and highly positive references. One, however, has certification in critical care nursing. Which of the following is the most compelling and accurate reason for the hospital to hire the candidate with certification?
A) The certified nurse will have more knowledge and expertise.
B) The certified nurse will behave more ethically.
C) The certified nurse will be more caring toward patients.
D) The certified nurse will work more collaboratively with other nurses.

 

 

3. A nurse is caring for an elderly man recently admitted to the ICU following a stroke. She assesses his cognitive function using a new cognitive assessment test she learned about in a recent article in a nursing journal. She then brings a cup of water and a straw to the patient because she observes that his lips are dry. Later, she has the patient sit in a wheelchair and takes him to have some blood tests performed. He objects at first, saying that he can walk on his own, but the nurse explains that it is hospital policy to use the wheelchair. That evening, she recognizes signs of an imminent stroke in the patient and immediately pages the physician. Which action taken by the nurse is the best example of evidence-based practice?
A) Giving the patient a cup of water
B) Transferring the patient in a wheelchair
C) Using the cognitive assessment test
D) Recognizing signs of imminent stroke and paging the physician

 

 

4. A nurse is on a committee that is trying to reduce the occurrence of hospital-acquired infections in the ICU. Her role is to conduct research to find which interventions have been shown to be most effective in reducing these infections. She consults many different sources and finds conflicting information. Which of the following sources should she consider the most authoritative?
A) AACN expert panel report
B) A meta-analysis of randomized controlled trials in the American Journal of Nursing
C) A systematic review of qualitative studies in the Journal of Advanced Nursing
D) A single randomized controlled trial in the American Journal of Critical Care

 

 

5. A nurse who has been recently hired to manage the nursing staff of the ICU is concerned at the lack of evidence-based practice she sees among the staff. Which of the following would be the best step for her to take to promote incorporating evidence into clinical practice?
A) Only hire nurses certified in critical care nursing.
B) Leave copies of several different nursing journals in the nurses’ lounge.
C) Demonstrate to the staff the best nursing-related search terms to use in Google or Yahoo!
D) Introduce the staff to the PubMed search engine and assign them topics to research on it.

 

 

6. A physician visits a patient in the ICU while the nurse is out. The patient complains that the pain medication is not effective and that he would like to receive an increased dose. The physician has the nurse paged and consults with him in the hallway regarding the patient’s request for stronger pain medication. The nurse explains that patient was started on a morphine drip only 20 minutes ago and that the drug has not had time to take effect yet. The physician agrees and tells the patient to give it just a bit more time. Which component of a healthy work environment is most evident in this scenario?
A) Skilled communication
B) Appropriate staffing
C) True collaboration
D) Meaningful recognition

 

 

7. A nurse in the ICU is responding to a patient who has just gone into cardiac arrest. A moment later, the nurse is notified that another patient has just gone into anaphylactic shock due to a drug allergy. She is conflicted as to what to do, as she is the only nurse available at the moment to tend to both patients. Which component of a healthy work environment is lacking in this scenario?
A) Effective decision making
B) Appropriate staffing
C) Authentic leadership
D) Meaningful recognition

 

 

8. An ICU nurse has provided excellent care for a 6-year-old girl who had been admitted to the ICU for a head injury. The nurse was attentive not only to the needs of the patient but also went out of her way to care for the needs of the girl’s family. According to research, which of the following forms of recognition would the nurse value the most?
A) A card from the girl’s family
B) A plaque from the ICU physicians naming her as “Nurse of the Year”
C) A letter of commendation from the hospital’s administration
D) A bouquet of flowers from her supervisor

 

 

9. A patient in the ICU has recently been diagnosed with diabetes mellitus. Before being discharged, this patient will require detailed instructions on how to manage her diet, how to self-inject insulin, and how to handle future diabetic emergencies. Which nurse competency is most needed in this situation?
A) Clinical judgment
B) Advocacy and moral agency
C) Caring practices
D) Facilitation of learning

 

 

10. An elderly patient is admitted to the ICU with stage IV lung cancer, diabetes mellitus, and congestive heart failure. The health care team assembled to care for her is large and diverse, including an oncologist, a pulmonologist, an endocrinologist, a cardiologist, and others. The patient is not expected to survive more than a few weeks, and her husband is overwhelmed with stress and grief. Which nurse competency or competencies are most needed in this situation? Select all that apply.
A) Clinical judgment
B) Caring practices
C) Collaboration
D) Response to diversity

 

 

11. An Ethiopian man with AIDS has recently been admitted to the ICU with a case of pneumonia. The man is new to the U.S. and has no health insurance. He would likely be eligible for the state’s Medicaid coverage, but does not understand how to access this coverage. Which competency or competencies are most needed in this situation? Select all that apply.
A) Clinical judgment
B) Advocacy and moral agency
C) Collaboration
D) Systems thinking
E) Response to diversity
F) Clinical inquiry

 

 

12. A nurse decides to seek certification in critical care nursing. What is the most important benefit for the individual nurse in becoming certified in a specialty?
A) It will result in a salary increase.
B) It is required to work in critical care.
C) It demonstrates the nurse’s personal expertise.
D) It is mandated by employers.

 

 

13. The American Association of Critical-Care Nurses (AACN) sponsors certification in critical care nursing for several critical care subspecialties. What is the most important benefit of such certification for the profession of nursing?
A) Provides positive publicity for nursing
B) Validates nurses’ expert knowledge and practice
C) Mandated by government regulations
D) Demonstrates basic knowledge in the field

 

 

14. A nurse has achieved certification in critical care nursing. What is the most important effect that this certification will have on the nurse’s practice?
A) Recognition by peers
B) Increase in salary and rank
C) More flexibility in seeking employment
D) Increased confidence in critical thinking

 

 

15. The nurse cites evidence-based practice as a rationale for a patient care decision. What is the best description of evidence-based practice?
A) Decisions based on expert legal testimony
B) Use of best available research data
C) Evolution of nursing practice over time
D) Individual optimization of patient outcomes

 

 

16. The nurse caring for a critically ill patient implements several components of care. What component is an example of the use of evidence-based practice?
A) Use of a protocol for admission of a patient to the unit
B) Application of an insulin sliding scale method from research
C) Checking the patient’s armband before giving a medication
D) Limiting visits to immediate family only for 2 hours a day

 

 

17. The nurse wishes to increase the use of evidence-based practice in the critical care unit where he works. What is a significant barrier to the implementation of evidence-based practice?
A) Use of computerized records by the hospital
B) Health Information Privacy and Portability Act (HIPPA)
C) Lack of knowledge about literature searches
D) Strong collaborative relationships in the work setting

 

 

18. The nurse has identified an increase in medication errors in the critical care unit over the past several months. What aspect of medication procedures should be evaluated first?
A) Adherence to procedures by nursing staff
B) Clarity of interdisciplinary communication
C) Number of new employees on the unit
D) Changes in administration procedures

 

 

19. A critical care unit has decided to implement several measures designed to improve intradisciplinary and interdisciplinary collaboration. In addition to an expected improvement in patient outcomes, what is the most important effect that should result from these measures?
A) Identification of incompetent practitioners
B) Improvement in manners on the unit
C) Increased staff retention
D) Less discussion in front of patients and families

 

 

20. A nurse wishes to practice using the Synergy Model developed by the American Association of Critical-Care Nurses (AACN). What nursing behavior best supports use of this model?
A) Attending mandatory hospital-wide in-service programs
B) Self-directed study of best practice for the patients she cares for
C) Gathering demographic data on the patients admitted to the unit
D) Participating in a research study as a data collector

 

 

21. As part of the Synergy Model, the nurse has identified a patient characteristic of resiliency. What patient behavior demonstrates resiliency?
A) Dysfunctional grieving behaviors after receiving bad news
B) Developing a list of questions for the physician
C) Denial of any possible negative outcomes for a procedure
D) Assigning blame to others for undesired outcomes of illness

 

 

22. A patient is admitted to the critical care unit after receiving a mechanical heart implantation. In making a nursing assignment, the charge nurse best demonstrates application of the Synergy Model by assigning which nurse to care for this patient?
A) A newly hired new graduate nurse, for the experience
B) A nurse with a patient in the next room, for proximity
C) The most senior nurse on the unit, for political reasons
D) The nurse with most experience with this device, for expertise

 

 

23. A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
A) New graduate female nurse
B) Most experienced female nurse
C) New graduate male nurse
D) Female nurse with postpartum experience

 

 

24. Today’s critical care nursing environment is constantly changing. What nursing behavior best illustrates awareness of current events affecting critical care nursing?
A) Participating in the hospital’s efforts to recruit new nurses
B) Volunteering to serve on a disaster response planning committee
C) Adhering to content taught in basic nursing program
D) Attending hospital-mandated in-services without other education

 

1. A patient in the CCU with chronic heart failure is prescribed an ACE inhibitor. What side effects should the nurse mention to him? Select all that apply.
A) Angioderma
B) Cough
C) Rebound tachycardia
D) Hyperkalemia
E) Night sweats
F) Anxiety

 

 

2. A CCU nurse who works frequently with cardiac patients is putting together a teaching plan to follow when she instructs these patients on how to live with heart failure. Which points should she include in this plan? Select all that apply.
A) Discontinue medications once you are feeling better, to avoid adverse effects.
B) Take your medications about the same time every day.
C) Avoid pepper and spices.
D) Remove the saltshaker from your table.
E) The best time to weigh yourself is in the afternoon.
F) Try to perform 15 to 20 minutes of continuous activity each day.

 

 

3. A patient with chronic cardiac failure in the CCU is on an ACE inhibitor but still has significant pitting edema in his extremities. Which medication, in addition to the ACE inhibitor, is the physician likely to prescribe to this patient?
A) Digoxin
B) A loop diuretic
C) b-blocker
D) Calcium channel blocker

 

 

4. A patient presents to the CCU with acute, decompensated heart failure. The nurse observes that this patient has chronic obstructive pulmonary disease and hypotension. She eats a low-sodium diet and drinks alcohol excessively. Which of the following are contributing factors to this patient’s heart failure? Select all that apply.
A) Chronic obstructive pulmonary disease
B) Hypotension
C) Low-sodium diet
D) Excessive alcohol intake

 

 

5. A patient is in the CCU with dilated cardiomyopathy and asymptomatic right-sided chronic heart failure. What finding will the nurse most likely discover in her assessment of this patient?
A) Mitral regurgitation murmur
B) Cheyne-Stokes respiratory pattern
C) Unilateral crackles
D) Rales

 

 

6. A nurse in the CCU must assess a cardiac patient’s fluid status. Which of the following is the best method for him to use?
A) Having the patient measure and record all liquids taken in and all urine excreted
B) Weighing the patient daily
C) Pulse oximetry
D) Radionuclide ventriculography

 

 

7. A patient presents to the CCU with shortness of breath on exertion. Which diagnostic study would be best for ruling out pneumonia or COPD as the cause of the patient’s symptoms?
A) Echocardiography
B) Radionuclide ventriculography
C) Pulse oximetry
D) Chest radiography

 

 

8. A patient in the CCU with chronic heart failure experiences shortness of breath even when at rest. When he stands up and walks across the room, his shortness of breath worsens. Which class of heart failure does this patient exhibit, according to the New York Heart Association (NYHA) Functional Classification of Heart Failure?
A) Class I
B) Class II
C) Class III
D) Class IV

 

 

9. A patient in the CCU has clear evidence of structural heart failure, as he lacks contractility in his left ventricle and his ejection fraction is only 37%. However, he has never shown any signs or symptoms of heart failure. According to the American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for Stages of Heart Failure, which stage of heart failure best characterizes this patient’s condition?
A) Stage A
B) Stage B
C) Stage C
D) Stage D

 

 

10. A patient presents to the CCU with cardiac heart failure resulting from atrial tachycardia. Which of the following explains how atrial tachycardia can cause heart failure?
A) Premature ventricular beats leading to sudden death
B) Increase in muscle mass in ventricle
C) Pulmonary embolus leading to acute right-sided heart failure
D) Shortened diastole leading to decreased filling and diastolic dysfunction

 

 

11. The nurse is caring for a patient who has been admitted with a diagnosis of heart failure. What does the term “heart failure” mean?
A) It is characterized by rales and alveolar edema.
B) It results from damage caused by acute myocardial infarction.
C) It is a general clinical syndrome with many etiologies.
D) All patients have similar symptoms.

 

 

12. A patient has been diagnosed with left ventricular heart failure. What physical findings would the nurse expect?
A) Enlarged liver
B) Peripheral edema
C) Pulmonary rales
D) Enlarged spleen

 

 

13. An elderly patient with uncontrolled hypertension and atrial fibrillation with rapid ventricular response is admitted with a diagnosis of heart failure. He has crepitant pulmonary rales and his chest x-ray shows pulmonary congestion. The patient probably has what type of heart failure?
A) Left ventricular systolic failure
B) Left ventricular diastolic failure
C) Right ventricular failure
D) Combination heart failure

 

 

14. A patient has been admitted with acute left systolic heart failure secondary to acute myocardial infarction. The patient has dyspnea and orthopnea and a cardiac rhythm of sinus tachycardia. The physiologic dysfunction for this type of heart failure is what?
A) Impaired contractility of the left ventricle
B) Impaired compliance of the left ventricle
C) Cardiac valve disease
D) Acute myocardial infarction

 

 

15. A patient has been admitted with right heart failure. The physiologic basis of right heart failure is what?
A) Left heart failure
B) Impaired right cardiac output
C) Pulmonary hypertension
D) Acute pulmonary embolus

 

 

16. A patient has been diagnosed with acute left heart failure secondary to acute myocardial infarction and increased afterload. What changes in assessment findings does the nurse expect to find?
A) Elevated pulmonary capillary wedge pressure
B) Normal or low blood pressure
C) Enlarged liver and spleen
D) Lungs clear to auscultation

 

 

17. A patient with heart failure is being monitored with a pulmonary artery catheter to assess cardiac output and its components. What pattern of results would indicate a need for immediate intervention?
A) Heart rate, preload, contractility, and afterload are balanced and cardiac output is normal.
B) Heart rate is rapid, preload is reduced, contractility and afterload are normal, and cardiac output is reduced.
C) Heart rate is rapid, preload is high, contractility is high, afterload is low, and cardiac output is normal.
D) Heart rate is low, preload is high, contractility is high, afterload is low, and cardiac output is normal.

 

 

18. A patient has been diagnosed with chronic heart failure, compensated. What symptoms would the nurse expect to find?
A) Frothy sputum progressing to pink frothy sputum
B) Severe hypotension when supine
C) Mild dyspnea on exertion or when supine
D) 4+ pitting edema of the lower extremities when dependent

 

 

19. A patient with long-standing hypertension has a viral upper respiratory illness and is self-medicating with over-the-counter medications. The patient complains of severe dyspnea with activity and has new-onset crepitant rales and pitting edema of the lower extremities. In evaluating the patient’s medications, what medication should the nurse look for in particular?
A) Furosemide (Lasix)
B) Nonsteroidal anti-inflammatory medications (NSAIDs)
C) Hydrochlorothiazide diuretic (HCTZ)
D) Angiotensin-converting enzyme (ACE) inhibitor

 

 

20. A patient with heart failure is being discharged. What discharge instruction should the nurse emphasize most?
A) Date and time of next medical appointment
B) Dietary alterations to reduce sodium intake
C) Structured exercise program
D) Maintaining weight within 1 to 2 pounds

 

 

21. For a patient with heart failure, maintenance of a steady weight is an important goal. The nurse should teach the patient that which of the following is the most accurate method for monitoring fluid volume changes?
A) Intake and output, with 24-hour totals and trends
B) Daily weight at the same time every day
C) Daily assessment of peripheral edema
D) Periodic assessment of serum electrolyte values

 

 

22. A patient with heart failure has been started on an ACE inhibitor. What lab value related to the ACE inhibitor would concern the nurse?
A) Elevated serum potassium
B) Elevated CK-MB
C) Diminished sodium
D) Increased prothrombin time

 

 

23. A patient receiving an ACE inhibitor has a blood pressure of 85/50 mm Hg. The patient is asymptomatic otherwise. What is the best nursing action?
A) Hold the medication because the blood pressure is too low.
B) Recheck the blood pressure in 1 hour.
C) Administer the medication because the patient is asymptomatic.
D) Reschedule time of medication administration to hour of sleep.

 

 

24. The patient is prescribed hydralazine and a nitrate for management of heart failure. The patient tells the nurse he has trouble taking medications that must be taken several times a day. What intervention will be the most helpful to the patient?
A) Stress the importance of taking medications as prescribed.
B) Ask the physician to change his therapy to long-acting medications that can be taken less often.
C) Ask the physician to change his therapy to other drug classes at the same frequencies.
D) Inform the physician that the patient is not taking his prescribed medications.

 

 

25. A patient with heart failure is taking an ACE inhibitor and a diuretic as prescribed but continues to be symptomatic. What patient behavior would explain lack of achievement of therapeutic goals?
A) Exercises regularly (walking and water aerobics)
B) Diet of mostly canned food and soda pop
C) Does not drink any alcoholic beverages
D) Takes medications as prescribed

 

 

26. A patient with heart failure comes to the clinic for a routine monitoring visit. What findings would indicate achievement of therapeutic goals?
A) Lungs have crepitant rales.
B) Complains of dyspnea on exertion
C) Has pitting edema of lower extremities
D) Weight is within 2 pounds of ideal weight.

 

 

1. A patient is recovering in the CCU following carotid endarterectomy. What intervention should the nurse make to ensure that a hematoma is not forming in the patient’s neck?
A) Assess neck size by comparing operative side with nonoperative side.
B) Monitor pupil reactivity.
C) Assess hand grip.
D) Monitor blood pressure.

 

 

2. A patient who recently underwent carotid endarterectomy is exhibiting signs of stroke. Which intervention or interventions should the nurse take to assess this patient’s neurological function? Select all that apply.
A) Measure chest tube output.
B) Assess eye movement.
C) Monitor level of consciousness.
D) Assess urine output.

 

 

3. A patient with left main coronary artery disease (CAD) experiences persistent angina. She would like to exercise more, but is limited by shortness of breath and angina. Her physician believes that she is a good candidate for coronary artery bypass graft. The nurse recognizes that which of the following are indications for coronary artery bypass graft (CABG) surgery in this situation?
A) Having left main CAD
B) Being a good candidate for angioplasty and stenting
C) Having persistent angina
D) Availability of new effective CAD medication
E) Limited exercise tolerance
F) The patient’s spouse was successfully treated with CABG

 

 

4. A patient in the CCU is recovering from coronary artery bypass graft (CABG) surgery. He has had multiple graft surgeries in the past. For this latest surgery, the patient’s radial artery was used in the graft. What complication should the nurse most expect to observe in this patient?
A) Occlusion
B) Infection
C) Arterial spasm
D) Internal hemorrhaging

 

 

5. A patient is recovering in the CCU following off-pump coronary artery bypass graft (OPCABG) surgery involving the internal mammary artery graft. What nursing intervention is most important for the first 48 hours following surgery for this patient?
A) Administration of anticoagulant therapy
B) Administration of calcium channel blockers
C) Monitoring of fluid status
D) Assessment for hematoma

 

 

6. A patient with moderate mitral stenosis with minimal calcification and regurgitation is preparing to have surgery. Which procedure would be most appropriate to restore normal function to this patient?
A) Annuloplasty
B) Valve replacement with biological valve
C) Valve replacement with caged ball valve
D) Commissurotomy

 

 

7. A patient recovering from cardiopulmonary bypass surgery is shivering. For what reason should the nurse be concerned about the shivering?
A) Shivering is a sign of cardiogenic shock
B) Shivering is a sign that the patient has a fever
C) Shivering increases myocardial workload
D) Shivering can cause sutures to rupture

 

 

8. A patient recovering in the CCU following coronary artery bypass graft (CABG) surgery complains of pain in his chest. The patient underwent a sternotomy incision during the surgery. Which of the following types of pain would indicate angina—which may indicate graft failure—as opposed to typical pain resulting from the sternotomy?
A) Radiates to arms
B) Is worse with deep breathing
C) Is worse with movement
D) Is sharp

 

 

9. A patient in the CCU is experiencing premature atrial contractions following coronary artery bypass graft surgery. Which of the following would be the most appropriate nursing intervention?
A) Administration of anticoagulants
B) Administration of potassium and magnesium
C) Administration of dopamine
D) Administration of epinephrine

 

 

10. A patient who underwent carotid endarterectomy is being discharged from the CCU. Which of the following instructions should the nurse give to the patient?
A) Avoid rotating your head.
B) Bruising and discoloration of the neck are not normal and should be reported immediately.
C) Eat a low-fat diet.
D) Avoid washing the incision site.

 

 

11. A patient with severe coronary artery disease is scheduled for coronary artery bypass graft surgery. As part of the preoperative teaching, the nurse explains the surgery. Which of the following statements about this procedure is true?
A) The diseased artery will be removed and replaced with a graft from another artery.
B) A piece of the saphenous vein will be used to go around the diseased part of the artery.
C) After removal of the diseased artery, the remaining ends will be anastomosed.
D) The wall of the heart will be incised to create a new pathway for blood flow.

 

 

12. The patient is scheduled for coronary artery bypass surgery using the off-pump technique. During preoperative teaching, the nurse explains that using the off-pump procedure has what advantage over the on-pump procedure?
A) There is a lower risk of a cerebral embolus.
B) The patient can anticipate a shorter hospital stay.
C) There will be less need for anticoagulation therapy.
D) The procedure will be less painful.

 

 

13. A patient with severe coronary artery disease has persistent angina that is refractory to medical management at maximum drug doses and has severe compromise of activities of daily living from the angina. The patient has had several coronary artery bypass surgeries and has been told that he is not a candidate for any further surgeries or percutaneous interventions such as stents. In discussing options for further therapy, what should the nurse include that would offer the patient the most hope?
A) Unless a new medication is invented, there is nothing that can be done.
B) Discussion of hospice and palliative support for end-of-life care
C) Referral to the social worker for financial assistance
D) Referral to the transmyocardial laser revascularization program for evaluation

 

 

14. The patient has been diagnosed with severe mitral valve stenosis. What physical changes would the nurse expect to find as a result of the stenosis?
A) Prolonged capillary refill
B) Normal left atrial and ventricular pressures
C) Clear lung sounds
D) Angina pectoris

 

 

15. The patient has been diagnosed with mitral valve insufficiency and left ventricular hypertrophy. What effect would the nurse expect from the left ventricular hypertrophy?
A) Improved cardiac output from increased left ventricular contractility
B) No appreciable signs or symptoms or effects until late in the disease process
C) A more obvious and easier-to-auscultate mitral valve regurgitant murmur
D) Early onset of pulmonary edema and right-sided congestive heart failure

 

 

16. The patient has been diagnosed with severe aortic valve stenosis. Considering the most common symptoms caused by aortic valve stenosis, what is the most important nursing intervention?
A) Document characteristics of the aortic stenosis murmur.
B) Teach patient to rise slowly from a supine position.
C) Assess peripheral circulation more frequently.
D) Assess for and document pulmonary adventitious sounds.

 

 

17. The patient has developed acute aortic valve insufficiency after experiencing blunt chest trauma. What symptom, if found by the nurse, is indicative of a counterproductive compensatory mechanism that should be treated?
A) Low cardiac output
B) Pulmonary edema
C) Elevated blood pressure
D) Aortic insufficiency murmur

 

 

18. The patient has had coronary artery bypass surgery involving the cardiopulmonary bypass pump, systemic hypothermia, topical cardiac hypothermia, and cold cardioplegia. As a result of the various hypothermic therapies, numerous postoperative complications may ensue. What collaborative postoperative intervention is specifically directed at ameliorating one or more of these complications?
A) Use of intravenous pain and sedation medications
B) Mechanical ventilation and supplemental oxygen therapy
C) Vital signs every hour until stable or transferred to step-down unit
D) Management of mediastinal chest tube drainage

 

 

19. The nurse is caring for a patient who has just had coronary artery bypass grafting. As part of the admission procedure to the critical care unit immediately after surgery, what nursing assessment has the highest priority?
A) Urine output
B) Cardiac index measurement
C) Chest tube drainage measurement
D) Core body temperature

 

 

20. After coronary artery bypass surgery, the patient experiences significant fluid volume shifts and losses. What nursing assessment would be most indicative of fluid volume deficit?
A) Low central venous pressure
B) Urine output 40 mL/hr
C) Brisk capillary refill
D) Diminished core body temperature

 

 

21. A patient who has just has coronary artery bypass surgery has developed tachycardia, a low-grade fever, and an elevated total white blood cell count. What additional sign or symptom would support the nurse’s suspicion of a postoperative infection?
A) Purulent drainage from the chest incision
B) Chest incision edges are red and swollen.
C) Elevated immature neutrophils or bands
D) Severe incisional pain with cough

 

 

22. The nurse is caring for a patient who has just had coronary artery bypass grafting and is experiencing significant hypotension. What nursing assessment would best confirm that the hypotension is related to blood loss?
A) Low hemoglobin and hematocrit, with high central venous pressure
B) Chest tube drainage in excess of 200 mL/hr
C) Urine output 40 to 50 mL/hr
D) Chest tube drainage less than 30 mL/hr

 

 

1. An elderly male patient in the ICU is diagnosed with acute kidney injury. This patient demonstrates a decreased glomerular filtration rate and lowered urine sodium concentration, as well as increased BUN and serum creatinine levels. The nurse observes that the patient takes several minutes to empty his bladder when he uses the bathroom. His blood pressure and blood glucose levels are normal. What should the nurse suspect as the cause of this patient’s acute kidney injury?
A) Tubular necrosis as a result of accumulation of radiocontrast dye in the renal tubular cells
B) Obstruction of the flow of urine due to benign prostatic hypertrophy
C) Lack of perfusion due to congestive heart failure
D) Hypotension due to systemic inflammatory response to sepsis

 

 

2. A patient develops toxic acute tubular necrosis (ATN) as a result of exposure to a radiocontrast dye. Which of the following should the nurse most expect to observe in this patient as this condition progresses beyond the onset phase?
A) Normal potassium levels
B) Duration of 7 to 14 days
C) Normal urine concentrating function
D) Normal urine volume

 

 

3. A patient with acute kidney injury (AKI) demonstrates blue mottling of the skin in her fingers. What other finding would tend to indicate that the cause of this condition is intrarenal?
A) Distended bladder
B) Edema
C) Strep throat infection
D) Kinked Foley catheter

 

 

4. A patient with acute kidney injury (AKI) demonstrates oliguria, a urine osmolality of 550 mOsm/kg H2O, increased urine specific gravity, urine sodium of 15 mEq/L, and a BUN:creatinine ratio of 23:1. Which of the following is a cause of AKI that would best fit with these findings?
A) Congestive heart failure
B) Nephrotoxicity due to aminoglycoside antibiotics
C) Hypertension
D) Retroperitoneal tumor

 

 

5. A patient is concerned about her steadily worsening chronic kidney disease and asks the nurse at what point she will require dialysis or renal transplantation. Which of the following should the nurse mention?
A) When your urine albumin-to-creatinine ratio is greater than 25 mg/g
B) When your urine output is less than 0.5 mL/kg/h × 6 h
C) When your glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m2
D) When your urine osmolality is greater than 500 mOsm/kg H2O

 

 

6. A patient with chronic kidney disease is receiving an ACE inhibitor. The nurse understands that this medication helps slow the progression of this disease through what process?
A) It lowers the level of blood glucose.
B) It prevents nephron hyperfiltration.
C) It increases the urine output.
D) It filters waste from the blood.

 

 

7. A patient with prerenal acute kidney injury is oliguric. The nurse is administering an IV bolus to the patient. What should be of primary concern to the nurse while performing this task?
A) Restricting the patient’s protein intake
B) Monitoring the patient’s potassium level
C) Evaluating the patient for signs of nephrotoxicity
D) Preventing fluid overload

 

 

8. A patient with acute kidney injury (AKI) complains of a headache. He vomits several times and breathes deeply and rapidly. His heart rate is 110 bpm, and his serum potassium level is elevated. The nurse recognizes in this patient which condition commonly associated with AKI?
A) Fluid overload
B) Anemia
C) Metabolic acidosis
D) Pericarditis

 

 

9. A patient with chronic kidney disease has a serum potassium level of 5 mEq/L and no changes on the ECG. What is the proper nursing intervention?
A) Administer sodium polystyrene as an enema.
B) Administer IV calcium gluconate.
C) Administer IV insulin and dextrose.
D) Begin dialysis.

 

 

10. A patient has been diagnosed with prerenal acute renal failure. What condition most likely caused this situation?
A) Toxic levels of medications