Deck 3: Critical Care

Question 1

The nurse is caring for a client with sepsis and acute respiratory failure who was intubated and prescribed mechanical ventilation 3 days ago.  The nurse assesses for which adverse effect associated with the administration of positive pressure ventilation (PPV)?

A)Dehydration
B)Hypokalemia
C)Hypotension
D)Increased cardiac output

Answer 1

Hypotension

Question 2

The charge nurse is evaluating the skills of a new registered nurse (RN) assigned to care for a client with shock.  Which action taken by the new RN indicates a need for further education?

A)Administers furosemide to a client with pulmonary artery wedge pressure (PAWP) of 24 mm Hg with cardiogenic shock
B)Increases norepinephrine infusion rate to maintain mean arterial pressure (MAP) >65 mm Hg in a client with anaphylactic shock
C)Moves pulse oximeter sensor from the finger to the forehead of a client with septic shock
D)Places the head of the bed (HOB) for a client with hypovolemic shock in high Fowler's position

Answer 2

Places the head of the bed (HOB) for a client with hypovolemic shock in high Fowler's position

Question 3

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery.  The client has a mediastinal chest tube.  During assessment, the nurse notes bubbling in the suction control chamber.  Which nursing action is appropriate?

A)Assess the insertion site for presence of subcutaneous emphysema
B)Notify the surgeon of a large air leak
C)Take no action as the chest tube is functioning appropriately
D)Turn down the wall suction until the bubbling disappears

Answer 3

Take no action as the chest tube is functioning appropriately

Question 4

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?

A)Capillary refill of less than 3 seconds
B)Left hand cooler than right
C)Mean arterial pressure of 65 mm Hg
D)Pressure bag at 300 mm Hg

Question 5

The emergency department nurse receives a client with extensive injuries to the head and upper back.  The nurse will perform what action to allow the best visualization of the airway?

A)Head-tilt chin-lift in the supine position on a backboard
B)Head-tilt chin-lift in the Trendelenburg position
C)Jaw-thrust maneuver in semi-Fowler's position
D)Jaw-thrust maneuver in the supine position on a backboard

Question 6

A client is admitted to the intensive care unit with diabetic ketoacidosis.  The client is most likely to exhibit which of the following arterial blood gas results?

A)pH 7.26, PaCO₂ 56 mm Hg (7.5 kPa), HCO₃ 23 mEq/L (23 mmol/L)
B)pH 7.30, PaCO₂ 30 mm Hg (4.0 kPa), HCO₃ 15 mEq/L (15 mmol/L)
C)pH 7.40, PaCO₂ 40 mm Hg (5.3 kPa), HCO₃ 24 mEq/L (24 mmol/L)
D)pH 7.58, PaCO₂ 48 mm Hg (6.4 kPa), HCO₃ 44 mEq/L (44 mmol/L)

Question 7

The nurse is caring for a ventilator-dependent client with neuromuscular degenerative disease and observes the plethysmograph waveform in the image below.  What is the nurse's immediate action?

A)Assess level of consciousness, skin temperature, and color
B)Disconnect pulse oximeter device from the client and restart it
C)Preoxygenate with 100% oxygen and perform endotracheal suction
D)Reset the high and low alarm parameters on the pulse oximeter device

Question 8

A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a dirt bike accident.  Which clinical manifestation does the nurse assess to help best confirm a diagnosis of neurogenic shock?

A)Apical heart rate 48/min
B)Blood pressure 186/92 mm Hg
C)Cool, clammy skin
D)Temperature 100 F (37.7 C) tympanic

Question 9

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure (ICP).  Which nursing interventions help reduce ICP?  Select all that apply.

A)Clustering as many interventions as possible when providing care
B)Hyperventilating before suctioning
C)Maintaining a quiet, dark environment
D)Maintaining the head in a neutral midline position
E)Suctioning for 30 seconds to remove endotracheal tube secretions at regular intervals

Question 10

A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H₂O (11 mm Hg) positive end-expiratory pressure (PEEP).  The nurse should assess for which complication associated with PEEP?

A)Barotrauma
B)Decreased oxygen saturation
C)Hypertension
D)Oxygen toxicity

Question 11

The nurse is supervising a graduate nurse (GN) on a telemetry unit.  An assigned client develops asystole with no pulse, and emergency care interventions are initiated.  Which action by the GN would cause the supervising nurse to intervene?

A)Administers IV epinephrine
B)Applies oxygen with bag-mask
C)Initiates chest compressions
D)Provides defibrillator shock

Question 12

The flight nurse assesses an alert and oriented client at an industrial accident scene who was impaled in the abdomen by a pair of scissors.  Which nursing action is the immediate priority on arrival at the scene?

A)Insert a large-bore IV line and infuse normal saline
B)Obtain blood for type and crossmatch and hemoglobin
C)Remove constrictive clothing to enhance circulation
D)Stabilize the scissors with sterile bulky dressings

Question 13

A registered nurse is precepting a new nurse in the intensive care unit.  The client is sedated with propofol, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube.  The new nurse performs interventions to prevent aspiration.  The preceptor should intervene if the new nurse performs which of the following actions?

A)Assesses gastric residual volumes every 4 hours
B)Measures the number of centimeters the feeding tube is secured at the nare every 4 hours
C)Requests that the physician change the client from continual to bolus feedings
D)Uses a sedation scale to titrate down the sedation (if possible)

Question 14

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU).  The low pressure alarm for the client's radial arterial line sounds.  Which action should the nurse take first?

A)Check for bleeding at tube connection sites
B)Perform a fast flush of the arterial line system
C)Re-level the transducer to the phlebostatic axis
D)Zero and re-balance the monitor and system

Question 15

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery.  The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn.  Which statement made by the RT is most accurate?

A)"The Allen's test is done to determine if capillary refill is adequate."
B)"The Allen's test is done to determine if the radial pulse is palpable."
C)"The Allen's test is done to determine the patency of the ulnar artery."
D)"The Allen's test is done to determine the presence of a neurologic deficit."

Question 16

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis.  Where is it located?

A)Angle of Louis at 2nd intercostal space (ICS) to left of sternal border
B)Aortic area at 2nd ICS to right of sternal border
C)Level of atria at 4th ICS, ½ anterior-posterior (AP) diameter
D)5th ICS at mid clavicular line (MCL)

Question 17

The nurse is caring for a client with an implantable cardioverter defibrillator (ICD).  The client goes into ventricular tachycardia and is pulseless.  The ICD has fired twice.  What action should the nurse take?

A)Administer epinephrine 1 mg IV push
B)Deactivate the ICD with a magnet
C)Initiate chest compressions
D)Take no action and let the ICD work

Question 18

A nurse is caring for an intubated client receiving a continuous sedative infusion.  Which interventions by the nurse reflect correct understanding of preventing ventilator-acquired pneumonia?  Select all that apply.

A)Elevating the head of the bed 30-45 degrees
B)Performing hourly in-line endotracheal suctioning
C)Practicing strict hand hygiene
D)Providing frequent oral care with chlorhexidine
E)Scheduling daily sedation vacations

Question 19

The nurse is caring for a client in the immediate postoperative period following an exploratory laparotomy after sustaining a gunshot wound to the abdomen.  Which assessment finding is most important for the nurse to report to the health care provider?

A)Cold and clammy skin
B)Oxygen saturation of 92%
C)Sinus tachycardia of 108/min
D)Urine output of 0.6 mL/kg/hr

Question 20

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine.  Which assessment finding indicates that the infusion rate may need to be adjusted?

A)Central venous pressure is 6 mm Hg
B)Heart rate is 120/min
C)Mean arterial pressure is 78 mm Hg
D)Systemic vascular resistance is 900 dynes/sec/cm^-5

Question 21

A client with blunt trauma undergoes an exploratory laparotomy to repair the intraabdominal injury.  After 24 hours, the client has a nasogastric tube attached to continual low suction, 2 Hemovac closed-wound suction abdominal drains, and is receiving IV Ringer's lactate and continual epidural morphine.  The client now develops hypotension, tachycardia, oliguria, and severe nausea.  What is the client's priority nursing diagnosis (ND) at this time?

A)Deficient fluid volume
B)Impaired urinary elimination
C)Nausea
D)Risk for infection

Question 22

Emergency medical service personnel are transporting a near-drowning victim who is currently hypothermic.  Based on anticipated vital signs, the nurse needs to prepare for which interventions?  Select all that apply.

A)Covering client with warm blankets
B)Logrolling the client from side to side frequently
C)Mechanical ventilation
D)Warmed blood administration
E)Warmed IV fluids

Question 23

A client at 32 weeks gestation goes into cardiac arrest.  What is the nurse's best action while performing cardiopulmonary resuscitation for this client?

A)Compress chest at second intercostal space, right sternal border
B)Perform chest compressions slightly higher on the sternum
C)Place hands just below the diaphragm to perform chest compressions
D)Position client in the supine position for optimal compressions

Question 24

The nurse is caring for an 11-month-old child in the pediatric hospital.  Which of these child's findings would be a common criterion to activate the rapid response team?  Select all that apply.

A)New-onset right-sided paralysis of extremities
B)Pulse rate sustained at 120/min
C)Respirations continued at 38/min
D)Sudden inability to be aroused to an awake state
E)Temperature of 101.3 F (38.5 C)

Question 25

The nurse is preparing to defibrillate a client who suddenly went into ventricular fibrillation.  Which steps are essential prior to delivering a shock?  Select all that apply.

A)Apply defibrillator pads
B)Call out and look around to ensure that everyone is "all clear"
C)Continue chest compressions until ready to deliver shock
D)Ensure adequate IV sedation has been given
E)Ensure that the synchronization button is turned on

Question 26

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer.  The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control.  The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours.  The postoperative hematocrit is 36% (0.36), and the hemoglobin is 12 g/dL (120 g/L).  Which action should the nurse carry out first?

A)Assess vital signs
B)Increase the IV rate to 125 mL/hr
C)Notify the health care provider
D)Perform a bladder scan

Question 27

The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm.  The nurse would assess for which conditions that can trigger the high-pressure alarm?  Select all that apply.

A)Biting endotracheal tube
B)Disconnected ventilator tubing
C)Endotracheal tube cuff leak
D)Excessive airway secretions
E)Kinked ventilator tubing

Question 28

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN).  The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device.  What is the nurse's priority action before initiating the TPN infusion?

A)Attach a filter to the IV tubing
B)Check baseline fingerstick glucose levels
C)Check the results of the portable chest x-ray
D)Program the electronic infusion pump

Question 29

An emergency department nurse is sent to the scene of a massive motor vehicle collision.  A client there reports neck pain.  Which actions should the nurse perform at this time?  Select all that apply.

A)Apply a hard cervical collar
B)Assess neck range of motion
C)Inspect client's respiratory pattern
D)Position client flat on firm surface
E)Use logrolling technique if moving client

Question 30

Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia.  Which assessment finding prompts the nurse to notify the health care provider immediately?

A)Difficult to arouse
B)Muscle stiffness
C)Pinpoint pupils
D)Temperature 94 F (34.4 C)

Question 31

Which would be the appropriate client criteria for activating a rapid response team at the hospital?  Select all that apply.

A)Glasgow coma scale (GCS) score of 9 throughout shift
B)Heart rate remaining at 58 beats/min for more than 1 hour
C)Postoperative pain rated at 10
D)Respiratory rate maintaining an increase to 30 breaths/min
E)Sustained change in level of consciousness for 10 minutes

Question 32

An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department.  The client's head has hit the windshield, and the client is unconscious.  What nurse actions are appropriate?  Select all that apply.

A)Assess the client for a carotid pulse
B)Determine the client's Glasgow Coma Scale score
C)Maintain airway with head-tilt/chin-lift maneuver
D)Place a hard cervical collar on the client
E)Remove the client from the car onto a backboard

Question 33

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes.  The client is experiencing numbness, and assessment shows mottled skin.  Which interventions should be included in the client's plan of care?  Select all that apply.

A)Apply occlusive dressings after rewarming
B)Elevate affected extremities after rewarming
C)Massage the areas to increase circulation
D)Provide adequate analgesia
E)Provide continuous warm water soaks

Question 34

The nurse is caring for a client on a mechanical ventilator.  The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change.  In anticipation of this blood draw, what intervention should the nurse implement?

A)Avoid suctioning the client
B)Pre-oxygenate the client
C)Raise the head of the bed
D)Reduce the amount of sedation medication

Question 35

A client with hypothermia has just arrived in the emergency department via ambulance.  The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids.  What additional intervention is a priority?

A)Attaching the cardiac monitor
B)Covering the client's head
C)Drawing blood for electrolytes and glucose
D)Placing an additional large-bore IV catheter

Question 36

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV).  The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night.  What should the nurse identify as the priority nursing diagnosis (ND)?

A)Anxiety
B)Disturbed sleep pattern
C)Powerlessness
D)Risk for acute confusion

Question 37

The client is brought to the emergency department after falling off a roof and landing on his back.  A T1 spinal fracture is diagnosed.  The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry.  What nursing action is a priority?

A)Administer IV normal saline
B)Determine if urinary occult blood is present
C)Perform a neurological assessment
D)Verify that there is no stool impaction

Question 38

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight.  Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube?

A)An ecchymotic area on the forehead
B)Frontal headache rated as 10 on a 1-10 scale
C)Nasal drainage on gauze has a red spot surrounded by serous fluid
D)Small amount of bright red blood oozing from cheek laceration

Question 39

The nurse is admitting a client with a possible diagnosis of Guillain-Barré syndrome.  When collecting data to develop a plan of care for the client, the nurse should give priority to which of the following items?

A)Orthostatic blood pressure changes
B)Presence or absence of knee reflexes
C)Pupil size and reaction to light
D)Rate and depth of respirations

Question 40

Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation?  Select all that apply.

A)Maintain the head of the bed at 30-45 degrees
B)Mute ventilator alarms at night to allow the client to rest
C)Pause sedation daily to assess weaning readiness
D)Perform oral care with chlorhexidine solution
E)Place a manual resuscitation bag at the bedside

Question 41

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose.  Which action would be appropriate?

A)Lavage through a small-bore nasogastric tube
B)Place client in Trendelenburg position during lavage
C)Prepare intubation and suction supplies at the bedside
D)Wait an hour after gastric decompression to initiate lavage

Question 42

The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client.  Which of the following actions by a resuscitation team member would cause the charge nurse to intervene?  Select all that apply.

A)Chest compressions are performed at a rate of 70-80/min
B)Chest compressions are stopped for a 10-second pulse check every 2 minutes
C)Defibrillator pads are applied at the left and right sternal borders
D)Manual breaths are delivered at a rate of 2 breaths per 30 chest compressions
E)Resuscitation team is alerted to remain clear of client before defibrillation

Question 43

The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is being mechanically ventilated when the ventilator's apnea alarm sounds.  The nurse finds the client to be unresponsive and pulseless, and there are no other caregivers present.  Which action should the nurse take first?

A)Begin chest compressions
B)Deliver 2 breaths using a bag valve device connected to the tracheostomy
C)Locate and apply an automated external defibrillator
D)Use a phone to call 911

Question 44

The intensive care nurse is caring for a client who has just been extubated.  Which interventions are appropriate at this time?  Select all that apply.

A)Administer prescribed oral narcotics for throat pain
B)Administer warmed, humidified oxygen via facemask
C)Give the client ice chips to moisten the mouth
D)Provide mouth care with oral sponges
E)Start the client on incentive spirometer

Question 45

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury.  Which statement by the student nurse indicates a need for further education?

A)"I will auscultate the neck to assess for endotracheal cuff leaks."
B)"I will perform endotracheal suctioning routinely after oral care."
C)"I will provide oral care and oral suctioning every 2 hours."
D)"I will reposition the client from side-to-side at least every 2 hours."

Question 46

The nurse observes a nursing student performing chest compressions on an adult client.  Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation?

A)Compressing the chest to a depth of at least 2 in (5 cm)
B)Pausing after each set of 15 compressions to allow for 2 rescue breaths
C)Placing the heel of the hand on the upper half of the client's sternum
D)Providing compressions at a rate of at least 80-100/min

Question 47

The nurse is caring for a client who had a near-drowning accident in cold weather.  Which assessment finding indicates the most severe injury?

A)Decreased body temperature
B)Toes pointed straight down
C)Weak and thready pulse
D)Wheezing on auscultation

Question 48

A client with palpitations is admitted with supraventricular tachycardia.  The client's heart rate is 210/min.  Which is the most appropriate initial intervention?

A)Ask the client to bear down as if having a bowel movement
B)Grab the crash cart and apply hands-free defibrillation pads
C)Place ECG leads on client to further assess electrical activity
D)Place IV line distally from the heart for adenosine administration

Question 49

The nurse is caring for an intubated client whose oxygen saturation begins to drop.  What action should the nurse take first?

A)Auscultate lung sounds bilaterally
B)Hyper-oxygenate with 100% oxygen
C)Manually ventilate with bag valve mask
D)Suction the endotracheal tube

Question 50

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest.  The client does not follow commands and remains comatose.  What intervention does the nurse anticipate being added to the client's plan of care?

A)Assisting the health care provider in discussing a do-not-resuscitate order with the family
B)Obtaining equipment and cold fluids for induction of therapeutic hypothermia
C)Placing a small-bore nasogastric feeding tube for enteral nutrition
D)Planning for passive range-of-motion exercises to prevent contractures

Question 51

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse.  CPR is initiated.  When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads.  What is the appropriate action at this time?

A)Continue CPR without using the automated external defibrillator (AED) until paramedics arrive
B)Place one AED pad on the chest and the other on the back
C)Place one AED pad on the upper right chest and the other on the lower left side
D)Place one AED pad on the upper right chest and dispose of the other

Question 52

A nurse is caring for a client on a mechanical ventilator.  The ventilator is sounding an alarm and displaying an alert about low tidal volumes.  The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping.  What should the nurse do next?

A)Call the respiratory therapist to the bedside to troubleshoot
B)Elevate the head of the bed and apply a nonrebreather mask
C)Increase the oxygen delivery on the ventilator to 100%
D)Manually ventilate with a resuscitation bag device attached to the endotracheal tube