Multisystem
Which of the following clinical findings is highly indicative of organ dysfunction caused by sepsis?
A. Positive SIRS, information; B. lung infiltrate; C. fever; D. lactate 2 mmol/L or greater
D. lactate 2 mmol/L or greater
(Question 5)
What are the priority nursing interventions for a patient with an acetaminophen overdose?
A.) Administer N-acetylcysteine, and monitor hepatic function. B.) Administer activated charcoal, and perform dialysis. C.) Administer flumazenil (Romazicon), and support the patient's airway.
A. Administer N-acetylcysteine, and monitor hepatic function.
(Question 14)
The patient sustained a large right cerebral ischemic stroke. What clinical sign is this patient most likely to exhibit?
right pupil dilation
(Question 14)
Which clinical findings and/or interventions are detrimental to brain perfusion?
an elevated ICP and hypotension
(Question 10)
Meticulous oral care, CHG rinse
A. CAUTI B. CLABSI
C. MDRO D. VAE
D. VAE
A patient with septic shock is likely to have which of the following measurements of oxygenation?
A. elevated mixed venous oxygenation (SvO2,) B. decreased oxygen content (CaO2,) C. elevated central venous oxygen (ScvO2,) D.decreased arterial oxygen (Pa02)
A. elevated mixed venous oxygenation (SvO2,)
(Question 18)
The nurse is caring for a patient who requires mechanical ventilation, a central venous line, and an indwelling urinary catheter. Which strategy should be used to prevent a hospital-acquired infection (HAI)?
chlorhexidine (CHG) mouth rinse to prevent VAP
(Question 1)
The patient presented with right-sided paralysis, a right Babinski reflex, and eye deviation to the left. Based on this patient's clinical presentation, what is the patient most likely experiencing?
left brain bleed or infarct
(Question 7)
The patient is being treated for a brain tumor and develops signs of increased ICP. What intervention is appropriate for this patient but would not be used for other causes of increased ICP?
steroids
Neuro (Question 2)
Maintenance of tubing free of kinks or dependent loops
A. CAUTI B. CLABSI
C. MDRO D. VAE
A. CAUTI
The patient is admitted with a change in level of consciousness secondary to alcohol and benzodiazepine ingestion. What is the primary goal for this patient upon arrival?
Address the patient's airway, breathing, and circulation.
(Question 7)
The patient is agitated and is attempting to pull at the enteral feeding tube and IV line. Which of the following nursing interventions is indicated in this situation?
A. Attempt to verbally calm the patient. B. Administer a sedation agent. C. Administer an analgesic. D.Assess for hemodynamic instability.
D. Assess for hemodynamic instability.
(Question 16)
The patient sustained an ischemic stroke and developed a loss of vision in the left half visual field of each eye (left homonymous hemianopsia). This is a sign that the stroke has affected which cranial nerve?
optic nerve
(Question 11)
What are the expected interventions for a patient following surgery for a subarachnoid hemorrhage (SAH)?
administration of nimodipine (Nimotop) and isotonic saline
Neuro (Question 5)
Appropriate isolation precautions
A. CAUTI B. CLABSI
C. MDRO D. VAE
C. MDRO
The patient sustained a traumatic injury while driving. Prior to arrival, the patient's spine was stabilized with a cervical collar. The patient was also receiving bag-mask ventilation via an advanced airway, and two large bore Is were in place. What is a priority assessment at this time?
Perform a quick neurological assessment.
(Question 10)
The patient has been receiving targeted temperature management
(TTM) following resuscitation for ventricular fibrillation. Rewarming is now scheduled to begin. The nurse anticipates that what intervention will be needed during this phase of TTM?
discontinuing the potassium supplementation
(Question 20)
The presence of which of the following criteria is necessary for the confirmation of brain death?
A. negative apnea test B. absence of all cortical and brain stem function C. absence of brain flow on a cerebral angiogram D. reversible comatose state
B. absence of all cortical and brain stem function
(Question 16)
The patient is 5 days post-op aneurysm repair following a subarachnoid hemorrhage (SAH). What is an appropriate nursing intervention that is specific to the care of this patient?
Contact the surgeon if there is a decrease in the serum Nat.
(Question 12)
Chlorhexidine skin antisepsis
A. CAUTI B. CLABSI
C. MDRO D. VAE
B. CLABSI
Important interventions for the treatment of sepsis/ septic shock include administering 30 mL/kg of isotonic fluid and initiating a vasopressor if the patient is not responsive to fluids. What is the pathology of sepsis that is addressed by administering fluids and initiating a vasopressor?
vasodilation and increased capillary
(Question 11)
The patient develops severe respiratory distress and bronchospasm with complaints of not being able to breathe after the initiation of a scheduled antibiotic. What interventions is indicated first?
A. fluids. B. 1:1000 epinephrine IM. C. inhaled albuterol. D. a steroid IV.
B. 1:1000 epinephrine IM
(Question 21)
The patient sustained a head injury and an epidural hematoma. Post-operatively, the patient developed signs of brain herniation. What are signs of brain herniation?
an increase in systolic pressure, a decrease in heart rate, a decrease in respirations
(Question 9)
The patient presented with a generalized seizure. The patient's history includes a pulmonary embolus and current anticoagulation with warfarin (Coumadin). A CT scan demonstrated a brain hemorrhage secondary to an A-V malformation. What is a priority intervention for this patient?
Administer vitamin K.
(Question 8)
Full barrier precautions
A. CAUTI B. CLABSI
C. MDRO D. VAE
B. CLABSI