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PCCN questions
Two days following a near-drowning accident, a pt is dyspneic, using accessory muscles, expectorating large amounts of secretions and reporting feeling of impending death. Changes to the assessment data include RR- 24 TO 36 CXR clear to bilateral diffuse infiltrates ABG 40% face mask or 100% non-rebreather mask pO2 120 mm Hg to 56 mm Hg pCO2 33 mmHg to 56 mmHg pH 7.42 to 7. HCO3 24 meq/L to 27 mEq/L Which of the ff do these changes most likely represent A. aspiration pneumonia B. pulmonary embolism C. interstitial pneumonitis D. ARDS - answer D. The onset of symptoms occured within 48 hours of the incident. THe bilateral diffuse infiltrates and ABG results indicating hypoxemia and CO retention are all consistent with ARDS. Aspiration pneumonia should include hypoxxemia, respiratory alkalosis. The CXR results would reveal an area of opacity with aspiration pneumonia rather than diffuse infiltrates. Interstitial lung disease invlolves an inflammation of supportive tissue between the air sacs rather than inflammation in the air sacs themselves. Symptoms would be SOB and a dry cough. A pt reports chest pain that is sharp, constant, worse when lying down and alleviated with sitting up and leaning forward. The most likely cause of these findings is A. ACS B. pericarditis C. PE D. AAA - answer B Pericarditis is inflammation of the pericardial sac. The damaged epicardium becomes rough and inflamed and irritates the pericardium lying adjacent to it, precipitating pericarditis. Pain is the most common symptom of pericarditis. THe pain is sharp, constant and is alleviated when sitting up and leaning forward. A pt tells a nurse, "I don't know how I'm going to pay for this hospitalization." The nurse should A. arrange a meeting with hospital social services staff B. Notify the business office so a payment plan can be designed C. redirect the pt toward meeting psychologic needs
D. give the pt applications for public assistance medical coverage - answer A. Collaboration with a social worker is indicated in this case the social worker can assist the pt in identifying ways to address the financial implications of this hospitalization and help identify methods of payments. A cardiac pt with with DNR status is being managed medically. The nurse notes a new cough, thick yellow sputum and a temperature of 101.4 (38.4) Coarse crackles are present in the right upper field. The nurse should most immediately anticipate A. blood and sputum cultures followed by a broad spectrum abx B. mucolytics and judicious IV fluid administration C. an antyipyretic and conservative management D. NPO status and encouragement of frequent activity - answer A. This pt symptoms are consistent with pneumonia. Management should include abx therapy, oxygen therapy for hypoxemia, mechanical ventilation if acute respiratory failure develops, fluid management for hydration, nutritional support, and treatment of associated medical problems and complications. Which of the ff findings is most indicative of a ruptured aortic aneurysm A. Back pain B. bounding peripheral pulses C. intermittent claudication D. warm, flushed skin - answer A. An aneurysm is the localized dilation of an artery. Should an aneurysm rupture, blood will build up under pressure in the tissues surrounding the aorta, which can result in acute pain and tenderness in theses areas. This is particularly the case if the aneurysm leaks from the back of the aorta. Ruptured AAA presents with a classic triad of pain in the flank or back, hypotension and a pulsatile abdominal mass; however, only about half of the full triad. The pt will complain of the pain and may feel cold, sweaty and faint on standing. The pt may also report abdominal pain. A small percentage may have vomiting According to recommendations based on research findings, pain assessment should occur A. based on changes in vital signs B. only when the pt movements indicate the pt is seeking attention C. routinely, regardless of physical findings D. only when the presence of pain can be validated - answer C. Pain is considered the fifth vital sign and must be assessed regularly. Presence of physical findings may be part of the comprehensive assessment of pain. However, physical findings may not be present in all patients with pain A pt with a tracheostomy requires frequent suctioning for thick sputum, A nurse finds a colleague instilling saline in the endotracheal tube prior to suctioning. The most appropriate response by the nurse would be to A. report the colleague to the charge nurse or manager B. noted the practice on the pt chart to ensure consistency of suctioning techniques C. ask the attending physician to review the suctioning policy.
replacement require short term anti-coagulation (3 months). In pt with NSR and no risk factors for thrombus, only aspirin therapy is recommended after bioprosthetic valve replacement. A pt with multiple rib fractures sustained in a motor vehicle collision 4 days ago reports sudden chest pain and difficulty breathing. Chest xray reveals a right hemothorax. The pt appears anxious and has decreased breath sounds on the affected side. Which of the ff procedures should the nurse anticipate A. needle decompression, 2nd ICS at midclavicular line B. bronchoscopy with broncial lavage C. placement of a right-side chest tube in the 6th ICS at the posterior axillary line D. CT scan for further evaluation and diagnosis - answer C. Blunt or penetrating thoracic trauma can cause bleeding into the pleural space, resulting in a hemothorax. This life-threatening condition must be treated immediately. Resuscitation with intravenous fluids is initiated to treat the hypovolemic shock. A chest tube is placed on the affected side to allow drainage of the affected side to allow drainage of blood. A pt with which of the ff is at greatest risk for torsades de pointes A. depressed ST segment B. development of peaked T waves C. prolonged QT interval D. development of a U wave - answer C. The normal QTc is less than 0.46 second (460 msec) in women and less than 0.45 second (450 msec) in men. A prolonged QT interval is significant because it can predispose the pt to the development of polymorphic VT, also known as torsades de pointes. When drugs associated with a high risk of torsades de pointes are started, it is important to record the QT and QTc interval and to continue to monitor the QT and QTc interval during treatment. Prolongation of the absolute QT interval beyond 0.5 second (500 msec) increases the risk of polymorphic VT. A pt is confused about time and place, despite frequent reorientation. For the pt safety, the nurse should initially A. put a vest restraint on the pt B. ask a family member to stay with the pt C. administer a mild sedative D. increase the frequency of pt observation - answer D. Pt have a right to receive safe care in a safe environment. However, the use of restraints is inherently risky. THe decision to use a restrain or seclusion is not driven by diagnosis, but by a comprehensive patient assessment. FOr a given pt at a particular point in time, this assessment determines whether the use of less restrictive measures poses a greater risk than the risk of using a restraint. Increasing the frequency of observation may be all that is required to keep this pt safe. The comprehensive assessment to identify medical problems that may be causing behavior changes in the pt. For example, temperature elevations, hypoxia, hypoglycemia, electrolyte imbalances, drug interactions and adverse effects may cause confusion, agitation and combative behavior. Addressing these medical issues may eliminate or minimize the need for restraint.
A pt with ACS who has undergone cardiac surgery 2 days ago develops new onset of JVD, muffled heart tones, palpitations, difficulty breathing and chest pain that worsens with coughing. Decreased peripheral pulses are noted. Vital signs are as follows BP 110/60 to 90/ HR 96 to 134 RR 20 to 28 Which of the following should the nurse anticipate A. needle decompression B. echocardiogram C. administration of dopamine D. spiral Ct - answer B. This pt is at risk for and is demonstrating signs of cardiac tamponade. Cardiac tamponade may occur after surgery if blood accumulates in the mediastinal space, impairing the heart's ability to pump. Signs of tamponade include elevated and equalized filling pressures (CVP, PADP, PAOP), decreased cardiac output, respiratory rate, jugular venous distention, pulsus paradoxus, and muffled heart sounds. Transesophageal or transthoracic echocardiography may be used to diagnose or confirm cardiac tamponade. A pt is admitted with a severe headache, nausea and vomiting. BP on arrival is 280/ mm Hg. The nurse should anticipate immediate administration of A. atniemetics B. labetalol C. mannitol D. analgesics - answer B. Hypertensive urgencies may be treated with rapid-acting oral antihypertensive agents. There are many drug categories available, including ACEIs, ARBs, calcium channel blockers and beta-blockers. Labetalol is an example of a beta-blocker that may be used in this situation. A pt who is extubated following 3 days of mechanical ventilation is noted to have hot and flushed skin and is expectorating thick yellow sputum. Auscultation reveals bilateral crackles halfway up posterior. Data are as follows BP 112/ HR 138 RR 30 T 102 (38.9) o2 SAT 93% ON 2 l nc Which of the ff orders should the nurse anticipate A. lasix 40 mg ivp and increase 02 to 4 L/min B. albuterol inhaler and methylprednisolone 125 mg IVP C. serum BNP and HCTZ D. blood culture and IV antibiotics - answer D. This pt is demonstrating symptoms of pneumonia. Rapid administration of antibiotics contributes to improved outcomes. Obtaining blood cultures will help the provider determine the appropriateness of selected antibiotics.
D. ARDS - answer A. History and current symptoms are consistent for pulmonary edema Which of the ff patients in the PCU should be further evaluated for malnutrition? The pt with A. a third episode of ARF and poor pulmonary function tests B. hypoactive bowel sounds and normal albumin levels C. sepsis who hasa 10 kg water weight gain and is receiving diuretics D. elevated BMI and Hgb of 14.6 - answer A. Malnutrition and respiratory failure are closely lined. Critically ill pt with respiratory failure are vulnerable to complication of underfeeding or overfeeding. A pt with ESRD and HF is receiving HD through an AV graft. VS are BP 190/94, HR 104, RR 26. The pt has crackles bilaterally and is bleeding from the graft site. The nurse should A. asses for bruit and thrill every 30 min for 2 hours and reasses B. notify the interventional radiologist C. ask the nephrologist to insert a temp catheter into the contralateral arm D. collaborate with the nephrologists regarding not using heparin during dialysis treatment - answer B. If the bleeding is not controlled following application of direct pressure to the site, repair by an interventional radiologist is indicated. A pt presents with a temperature of 105.6 F (40.9) and nuchal rigidity. A nurse obtains blood culture and administers antibiotics. The patient remains febrile, and the family questions the adequacy of the interventions. The nurse's best response should be to A. arrange a social service consult B. assure the family that everything will be explained later. C suggest that the family discuss their concerns with the physician D. acknowledge the family's concerns while explaining rationales for the interventions - answer D. The nurse demonstrating high levels of caring practices and facilitation of learning will acknowledge and address the family's learning A pt who is newly admitted is hemodynamically stable, had sustained a stroke and had been on mechanical ventilation via tracheostomy tube, a continuous sedation infusion and enteral feedings in the ICU for several days. The pt is now off sedation and receiving O2 via a trach collar. Gastric residual volumes of 250 ml every 6 hours over the past 3 days have been noted. Upon collaborating with the nutritionist and physician, the nurse should anticipate which of the ff A. dilution of the enteral feeds by 50% with water B. administration of a prokinetic agent C. decreasing the rate of enteral feedings by 50% D. initiation of pernteral nutrition - answer B. In a studr of 206 critically ill pt, 2 or more GRVs of at least 200 mL and 1 or more GRVs of at least 250 mL were found significantly more often in pt who experienced frequent aspiration. Prokinetics have been advocated to improve gastric emptying.
Which of the ff electrolye abnormalities should the PCU nurse anticipate in caring for a pt with chronic alcohol abuse A. hypomagnesemia B. hyperphosphatemia C. hypercalcemia D. hyponatremia - answer A. Pt with chronic alcohol abuse are at risk of reasons (1) their diet is typically low in magnesium, (2) alcohol diuresis pulls magnesium out of the body, and (3) there is associated poor GI absorption of dietary magnesium in chronic alcohol abuse. A pt develops SVT hypotension and chest pain. The goal of therapy will be to A. reduce HR to increase diastolic filling time B. produce arteriolar constriction to increase perfusion pressure C. dilate coronary arteries to increase myocardial O2 delivery D. promote venous constriction to increase preload - answer A. Rapid heart rates can lead to hemodynamic instability, because the fast rate prevents adequate ventricular filling during diastole and increases myocardial oxygen demand, while decreasing time available for coronary artery filling Which of the following would be the most important immediate concern when managing a pt with an acute ischemic stroke A. preventing pressure ulcers from limited mobility related to hemiparesis B. avoiding HTN while maintaining adequate cerebral perfusion C. performing a CT scan to evaluate for bleeding form tPA infusion D. intubation and mechanical ventilation for airway protection - answer B. The main goals for managing the pt with acute ischemic stroke are twofold: (1) enhancement of cerebral blood flow and (2) neuroprotection, with the aim to reduce the intrinsic vulnerability of brain tissue to ischemia A pt with history of taking gentamicin (Garamycin) is admitted with oliguria, confusion, lethargy, nausea and vomiting. Lab data are as follows BUN 26 Cr 1. Na 130 K 4. Calcium 7. Which of the following should the nurse suspect A. dehydration B. acute tubular necrosis C. GI infection D. chronic renal failure - answer B. This pt has received a nephrotoxic agent, which puts the pt at risk for development of ATN. Lab data support this diagnosis with an elevated BUN, creatinine and potassium. Calcium and sodium levels will be decreased.
A pt with HF is on a diuretic and fluid restriction. Assessment indicated atrial tachycardia with a rate of 130, presence of crackles in all lung fields, an S3 at the left apex and BP of 90/40 (previously 130/60). The patient reports feeling SOB. The nurse should anticipate administration of A. a fluid bolus to enhace preload B. dopamine to support BP C. dobutamine to augment cardiac output D. adenosine to reverse tachycardia - answer C. In pt with decompensated heart failure, use of intravenous inotropic agents such as dobutamine may be indicated to support cardiac function and cardiac output. The dysrhythmia most commonly associated with mitral stenosis is A. 2nd degree AB block type II B. idioventricular rhythm C. sinus bradycardia D. afib - answer D. Mitral stenosis increases the risk of developing atrial fibrillation because of high pressures in the left atrium that will stimulate left atrial remodeling and enlargement. A pt with an elevated BMI is having fluctuations in BP, HR and oxygen saturation, and reports feeling sleepy and fatigued despite intershift report of the pt sleeping. The nurse noted periods of irritability and memory deficits. Which of the ff interventions is indicated A. monitoring for hypotension B. administering small doses of benzodiazepines C. performing a mini-mental status exam D. collaborating with the physician for use of a CPAP mask - answer D. This pt has primary risk factor (obesity) and symptoms of obstructive sleep apnea. Continuous positive airway pressure (CPAP) may be initiated if the pt CO2 level is stable and acceptable. A pt with suspected pulmonary hypertension should be prepared for which of the ff tests to confirm the diagnosis A. angiography B. echocardiography C. electrocardiography D. cardiac catheterization - answer D. RIght heart catheterization is required to confirm a diagnosis of pulmonary hypertension, to assess the severity of the hemodynamic impairment and to test the vasoreactivity of the pulmonary circulation A pt with sepsis has the ff lab data PT 12. aPTT 58. Fibrinogen elevated Fibrin split products elevated Which of the ff is indicated
A. PLT
B. cryoprecitpitate C. Vitamin K D. FFP - answer D. The pt aPTT is elevated, indicating an alteration with the intrinsic pathway or common pathway of the clotting cascade. FFP is needed to help correct this abnormality. What is the recommended initial position to improve oxygenation for a pt with unilateral pneumonia A. prone B. high-fowler's C. side-lying on unaffected side D. supine - answer C. With the affected side uppermost, the lower lung is better ventilated and better pefused. Thise improves V/Q matching and gas exchange A pt with a history of diabetes and hypertension reports onset of numbness in her hands, unusual fatigue, loss of appetite, indigestion and a cough. Which of the following response by the PCU nurse is indicated A. Your doctor will likely order a CT scan without contrast B. I will call the dietitian to review your meal selections and intake with you C. How have you been sleeping the last couple of nights D. I will call the physician to obtain an order for an electrocardiogram - answer D. This pt has risk factors for and is demonstrating symptoms of possible ACS. An ECG will help diagnose this condition. A pt with a history of IV drug abuse is admitted with a fever and a grade III/VI systolic murmur. The patient develops sudden dyspnea and anxiety. Chest auscultation reveals a loud holosystolic murmur and crackles. Which of the ff is the most likely cause A. Mitral valve insufficiency B. ventricular aneurysm formation C. Heart failure D. hemopericardium with tamponade - answer A. This pt has a risk factor (IV drug abuse) and symptoms of endocarditis, which is common in IV drug abusers because of the nonsterile injection into the nervous system. While the tricuspid valve is most typically affected, involvement of the mitral and aortic valves can occur. A pt with history of COPD is receiving 28% oxygen via face mask and has the following ABG values. pH. 7. pCO2 48 pO2 62 HCO3 26 O2 sat 89 Which of the ff is indicated at this time A. continue ongoing therapy and monitoring B. increase the dead space of the oxygen tubing
D. preparing pt for a liver biopsy and transfusing FFP BID - answer B. This pt has a risk factor (hepatic failure) and symptoms of potential fulminant hepatic failure (FHF). Complication of FHF include encepalopathy, cerebral edema and hypoglycemia. Monitoring blood sugar and mental status are indicated for this pt. Which action is best to help reduce anxiety in a pt who has been hospitalized for suspected peptic ulcer disease A. ask all members of the team to reassure the pt about quality of care provided by the staff B. assigned the pt to a room with a talkative optimistic roommate C. explain to the pt what to expect during the hospitalization D. visit the pt frequently, and encourage discussion about pleasant future plans. - answer C. This pt is anxious about being hospitalized. Explaining what can be anticipated during the hospitalization is consistent with caring practices and will likely to help decrease the pt anxiety. A pt is admitted with GI bleeding and a 3 day history of melena. The pt is unresponsive but is breathing spontaneously. Urine output is 15 ml in 8 hours, and skin is cool to the touch. Assessment data include BP 86/54, HR 138, RR 30, T 99.3 (37.3) CVP 3 The nurse should anticipate immediate administration of which of the following A. adenosine B. aggressive fluid resuscitation C. 3 units PRBCs D. dopamine (intropin) - answer B. This pt has risk factors, signs and symptoms of hypovolemic shock. Aggressive fluid resuscita is indicated at this time. An adult pt is admitted with status asmaticus. ABGs are pH 7.45, pCO2 29, pO2 60, HCO3 24. She is given 02 at 6 l per nasal cannula, epinephrine and albuterol (ventolin) treatments. Which of the ff ABG results are most indicative her condition is worsening pH pCO2 pO2 HCO A. 7.50 24 64 23 B. 7.34 47 59 21 C. 7.44 27 72 25 D. 7.43 39 69 24 - answer B. These arterial blood gases reveal a low pO2 and high pCO2 (stage 4 of blood gas progression in pt with status asmaticus, the most serious) which occurs with respiratory muscle insufficiency; this is an even more serious sign that stage 3, and mandates intubation and ventilatory support. The primary goal of thrombolytic therapy for ACS is A. troponin release B. chest pain relief C. myocardial reperfusion D. ectopy prevention - answer C. Thrombolytic therapy is administered to establish and maintain the patency of coronary arteries, thus improving myocardial perfusion.
A patient with dilated cardiomyopathy is admitted with dyspnea, cough, palpitations and decreased level of consciousness. The patient is in sinus tach with no ectopy. The nurse should anticipate management to include A. administration of captopril (Capoten) B. insertion of a temporary left ventricular assist device C. loading the pt with digoxin D. preparation for dynamic cardiomyopathy procedure - answer A. This pt is showing symptoms of heart failure related to dilated cardiomyopathy. ACE inhibitors have been effective in improving both symptoms and survival in these pt. Most pt will tolerate ACE inhibitor therapy as well. Apatient is admitted with acute respiratory failure, left lobar pneumonia and COPD. Physical examination reveals severe fatigue, coarse inspiratory crackles and expiratory wheezing. Data also include HR 132, RR 35, T 102.6 (38.9), pH 7.28, pCO2 72, pO2 48, HCO3 36 Based on this information, the nurse should anticipate which of the following additional clinical findings A. purulent sputum B. mediastinal shift to the right C. bradypnea D. intermittent apneic periods - answer A. Pneumonia is common in pt with COPD. Sputum becomes purulent over time in pt with pneumonia. A pt with end-stage renal disease asks the nurse why is anemic. The nurse explains the anemia is caused by A. blood loss in the urine B. renal insensitivity to vitamin A C. inadequate production of erythropoietin D. inability of the kidney to retain iron. - answer C. As chronic kidney disease progresses to stage 2 and 3, erythropoietin production decreases and anemia may become clinically evident A pt is receiving milrinone therapy should be assessed for which of the following side effects A. hyperkalemia B. chest pain C. thrombocytopenia D. decreased urination - answer B. Chest pain, ventricular dysrhthmias and hypotension are potential side effects of milrinone administration. Thrombocytopenia is a side effect of inamnirone, another PDI but not milrinone. Which of the ff ABG results should the PCU nurse anticipate in caring for a pt. with chronic alcohol abuse pH pCO2HCO A. 7.35 36 18 B. 7.30 50 23
A patient admitted following an episode of new onset sepsis. assessment reveals new onset dyspnea, intercostal retractions and crackles in all lung fields, pt is placed on oxygen via NC at 4Lpm which criteria ABG results should the nurse anticipate. pH pCO2 pO2 O2sat HCO A. 7.5 30 59 89 23 B. 7.3 51 49 81 18 C. 7.26 32 63 91 14 D. 7.48 46 52 85 28 - answer A. As the pt is dyspneic, the initial change in arterial blood gases will be respiratory alkalosis. This will be reflected in a decrease in CO2 and corresponding increase in pH. Pt w/ a hx of heart failure and ACS is admitted following episode of syncope. 2 hours later assessment reveals BP 134/64 (supine) 90/60 sitting HR 115 w weak thready pulse (supine) 130 (sitting RR 32 shallow BS clear UO 30 ml of past 2 hours The nurse should initiate A IV fluids B Nesiritide (natrecor) C. Mannitol (Osmitrol) D. Digoxin (Lanoxin) - answer A. Although this pt has a history of heart failure, data suggest orthostatic hypotension and hypovolemia, which should initially be treated with fluids. While heart failure may be of concern, this pt breath sounds are clear at present. A pt is being discharged and continuing on amiodarone therapy. pt teaching will include monitoring for which of the following long-term complications. A tachyarrhythmias B. renal insuff C. pulmonary fibrosis D. hyperkalemia - answer C. A well-documented side effect of amiodarone after long-term use is pulmonary fibrosis Which of the following dysrhythmias should the RN watch for in a patient following lung resection surgery? A S.V.T. B Sinus bradycardia C V.Fib D P.V.C. - answer A. Post operative cardiac arrhythmia are common after thoracic surgery. Pt undergoing pulmonary resections have postoperative SVT with a frequency and severity proportional to their age and their magnitude of the procedure. Many factors contribute to these dysrhythmias, including underlying cardiac disease, degree of surgical trauma, intraopreative cardiac manipulation, stimulation of the sympathetic nervous system by pain, reduced vascular effects of anesthesia, cardioactive drugs and metabolic abnormalitites.
A pt w resp infection sustained blunt trauma in MVA. Pt is on O2 via face mask and is hemodynamically stable. The RN should anticipate which of the following interventions to prevent development of acute resp distress syndrome. A. Prophylactic mechanical ventilation w/ large tidal volumes B. minimizing transfusion of packed red blood cells C. measures to keep pt pH 7.25-7. D. withholding antibiotic therapy until definitive identification of the organism is made. - answer B. Studies suggest that minimizing transfusions decreases the likelihood of developing ARDS Which of the ff is the most appropriate treatment for COPD, resp distress and an O2 sat of 85% A immediate intubation and mech vent B. 100% NRB and steroid administration C. 02 via NC 2l and brochodilators D. CXR, Bld cx and abx - answer C. COPD is a progressive disease characterized by irrevesible expiratory airflow obstruction. Treatment focuses on relief of symptoms and slowing the progression of the disease. Therapies include oxygen therapy and bronchodilators. A pt is admitted with sepsis. Pt does not desire intubation, vasopressors or resuscitation in the event of cardiac arrest but will accept conservative treatment, including IV fluids, antibiotics and blood products, if needed. In assessing this pt, the nurse notes 2 blood sugar readings are greater than 180 consecutively. The nurse should anticipate A. no treatment, and elevated blood sugar is expected in elderly patients with sepsis B. administration of insulin to maintain a blood sugar of less that or equal to 180 C. monitoring the blood sugar unless it increases to greater than 200 D. no treatment; to avoid increased mortality associated with rebound hyperglycemia - answer B. Administration of insulin is consistent with the pt wishes. Tight glycemic control does not improve outcomes in critical care pt who are septic. A target range of less than or equal to 180 and avoidance of hypoglycemia and highly variable blood glucose values is the evidence-based approach to glycemic control in this population. Which of the ff are signs and symptoms of cardiac tamponade A. HTN, CP, palpitations B. tachypnea, tachycardia, hypotension C. bradypnea, bounding pulses, drowsiness D. bradycardia, anxiety, palpitations - answer B. Pt with cardiac tamponade will present with these symptoms A post op CABG pt questions why he is receiving an insulin drip. The nurse explains the rationale is A. prevent the development of DM B. reduce the risk of infection C. prevent the development of intestinal ischemia
Twelve hours after sustaining a pelvic fracture, a pt reports chest pain, hemoptysis and severe shortness of breath. Respiratory rate is 34. ABG on 02 at 4l via NC are: pH 7.48, pCO2 28, p02 68. The nurse should suspect that the patient has developed. A. tension pneumothorax B. a pulmonary embolism C. post-intubation laryngeal edema D. respiratory failure - answer B. This pt is at risk for developing a PE (postoperative status) and has symptoms of this condition A pt is admitted with hypertrophic cardiomyopathy. For which of the ff dysrhytmias is this patient at risk A. SB B. PAC C. SVT D. asystole - answer C. Hypertrophic cardiomyopathy is distinguished by a hypertrophied, non-dilated left ventricle. A trial dilation results in atrial fibrillation and SVT A nurse caring for a 76 year old patient in the PCU. Which of the ff age related cardiac changes should the nurse anticipate. A. decreased response to catecholamines B. increased myocardial complaince C. decreased audibility of S D. increased resting heart rate - answer A. Aging is associated with a decreased response to catecholamines. It is also associated with decrease in myocardial compliance. It is also associated with an increased audibility of S1 because of increased rigidity of the ventricular wall. It is associated with a decrease in resting HR. A pt with type II diabetes and recent pneumonia is admitted with a serum glucose level of 590. The pt is alert and oriented, denies nausea or vomiting and reports being very thirsty with frequent urination. Data are as follows BP 112/58, HR 114, RR 18, T 100 (37.8), O2 sat 92% on 2 L via NC Which of the ff lab findings should the nruse anticipate Urine ketones Arterial pH A. negative 7. B. positive 7. C. negative 7. D. positive 7.50 - answer B. This pt is demonstrating signs and symptoms of DKA. DKA is associated with an elevated blood sugar, ketonuria and decrease in pH associated with a metabolic acidosis. Which of the ff is initially indicated for a pt diagnosed with an ischemic stroke 2 hours prior to admission to the PCU A. clopidogrel (Plavix) B. heparin
C. argatroban (Acova) D. TPA (activase) - answer D. TPA are used to dissolve clots. TPA dissolves the clots and permits reperfusion of the brain tissue. It should be used as soon as possible after onset of symptoms. The maximum time has been expanded to 4.5 hours or less from the onset of symptoms Three days following STEMI and cardiac catheterization with stent insertion, a pt develops sudden-onset diffuse crackles and a new loud murmur heard most prominently at the 5th ICS mid-clavicular line. The nurse should recognize that this may represent A. mitral regurgitation B left sided heart failure C. stent occlusion D. cardiogenic shock - answer A. The pt has a risk factor (STEMI) and symptoms of mitral regurgitation. The murmur is located at the 5th intercostal space mid-clavicular line A pt with a history of ACS involving the anterior wall develops chest pain, dyspnea, wheezing, diaphoresis, and restlessness. The most likely cause of these findings is A. pulmonary embolism B. pulmonary edema C. severe asthma D. unstable angina - answer B. The pt has risk factors (anterior wall MI) and symptoms of pulmonary edema. Obstruction of coronary blood flow produces myocardial ischemia causes myocardial wall dysfunction. During these episodes, pulmonary edema can develop. The nurse should watch for pulmonary edema after an anterior wall MI. A pt is admitted with hematuria secondary to an overdose of warfarin (Coumaidn). Lab data include: INR 9.8, Hgb 13.5, Hct 35.6. The nurse should anticipate the administration of A. FFP B. cryoprecipitate C. platelets D. vitamin K - answer D. This pt has an elevated INR. Choice of treatment for this pt depends on the degree of coagulopathy and on the clinical impact of potential blood loss if bleeding occurs. One option is to simply hold the warfarin until the INR is again within therapeutic range. Alternatively, vitamin K may be given as a more active management strategy. Vitamin K safely and effectively corrects the INR. Which of the ff conditions is a risk factor for development of delirium during a PCU admission A. hypotension B. immobility C. limited range of motion
