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Sole Final Study Questions with Accurate Answers, Exams of Nursing

Sole Final Study Questions with Accurate Answers

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2024/2025

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Sole Final Study
Questions with
Accurate Answers
10. A community-based external disaster is initiated after a tornado moved through the city. A nurse
from the medical records review department arrives at the emergency department asking how to assist.
The best response by a nurse working for the trauma center would be to
a. assign the nurse administrative duties, such as obtaining patient demographic information.
b. assign the nurse to a triage room with another nurse from the emergency department.
c. thank the nurse but inform her to return to her department as her skill set is not a good match for
patients' needs.
d. have the nurse assist with transport of patients to procedural areas. correct answer A
A nurse in the medical records department is a knowledgeable health care provider who can help in a
disaster by obtaining essential patient information. Assigning the nurse to provide direct care to
patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the
direct care skills are not known. Asking the nurse to return to the medical records department also may
not be appropriate because the nurse offers a skill set that can be used during the disaster.
10. A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following
aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to
normalize. In addition to glucose monitoring, which of the following electrolytes requires close
monitoring?
a. Calcium
b. Chloride
c. Potassium
d. Sodium correct answer C
Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar
hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid
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Sole Final Study

Questions with

Accurate Answers

  1. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to a. assign the nurse administrative duties, such as obtaining patient demographic information. b. assign the nurse to a triage room with another nurse from the emergency department. c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients' needs. d. have the nurse assist with transport of patients to procedural areas. correct answer A A nurse in the medical records department is a knowledgeable health care provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to the medical records department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.
  2. A patient is admitted to the critical care unit with a diagnosis of diabetic ketoacidosis. Following aggressive fluid resuscitation and intravenous (IV) insulin administration, the blood glucose begins to normalize. In addition to glucose monitoring, which of the following electrolytes requires close monitoring? a. Calcium b. Chloride c. Potassium d. Sodium correct answer C Potassium must be closely monitored. In the early stages of diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome, the potassium value is often high, but it may lower to critical levels once fluid

balance has been restored and glucose has returned to more normal levels. Insulin administration used in the treatment of diabetic ketoacidosis further promotes the lowering of potassium as the electrolyte is relocated to the cellular bed. Calcium levels do not drastically change in hyperosmolar states and are not a primary concern unless phosphate replacement is initiated. Chloride levels typically follow sodium levels and normalize with fluid replacement. Sodium levels may initially be elevated as a result of dehydration but will be corrected with fluid replacement.

  1. A patient with end-stage heart failure is experiencing considerable dyspnea. Appropriate palliative management of this symptom includes: a. administration of midazolam (Versed). b. administration of morphine. c. an increase in the amount of oxygen being delivered to the patient. d. aggressive use of inotropic and vasoactive medications to improve heart function. correct answer B Morphine is an excellent agent to control the symptom of dyspnea. Midazolam is used for anxiety. An increase in oxygen or aggressive use of medications to improve the patient's heart function is inappropriate in this case.
  2. Accepted treatments for disseminated intravascular coagulation (DIC) may require (Select all that apply.) a. platelet infusions. b. administration of fresh frozen plasma. c. cryoprecipitate. d. packed RBCs. e. heparin. correct answer A, B, C, D Administration of platelets is the highest priority for transfusion because they provide the clotting factors needed to establish an initial platelet plug from any bleeding site. Fresh frozen plasma is administered for fibrinogen replacement. It contains all clotting factors and antithrombin III; however, factor VIII is often inactivated by the freezing process, thus necessitating administration of concentrated factor VIII in the form of cryoprecipitate. Transfusions of packed RBCs are given to replace cells lost in hemorrhage. Although heparin's antithrombin activity prevents further clotting, it may increase the risk of bleeding and may cause further problems. Its use is controversial when it is administered to patients with DIC.
  3. Acute kidney injury from postrenal etiology is caused by

b. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously c. Methylprednisolone 125 mg intravenously d. Ranitidine 50 mg intravenously correct answer B The patient is exhibiting signs of anaphylaxis. For anaphylaxis with hypotension, epinephrine 0.3 to 0. mg (3 to 5 mL of 1:10,000 solution) is administered intravenously. Diphenhydramine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension. Corticosteroids, such as methylprednisolone, are used to reduce inflammation, but epinephrine is the drug of choice for anaphylaxis with hypotension. Ranitidine will help block histamine release, but epinephrine is the drug of choice for anaphylaxis with hypotension.

  1. The best way to monitor agitation and effectiveness of treating it in the critically ill patient is to use a/the: a. Confusion Assessment Method (CAM-ICU). b. FACES assessment tool. c. Glasgow Coma Scale. d. Richmond Agitation Sedation Scale. correct answer D Various sedation scales are available to assist the nurse in monitoring the level of sedation and assessing response to treatment. The Richmond Agitation Sedation Scale is a commonly used tool that has been validated. The CAM-ICU assesses for delirium. The FACES scale assesses pain. The Glasgow Coma Scale assesses neurological status.
  2. The nurse is calculating the rate for a regular rhythm. There are 20 small boxes between each P wave and 20 small boxes between each R wave. What is the ventricular rate? a. 50 beats/min b. 75 beats/min c. 85 beats/min d. 100 beats/min correct answer B The rule of 1500 is used to calculate the exact rate of a regular rhythm. The number of small boxes between the highest points of two consecutive R waves is counted, and that number of small boxes is divided into 1500 to determine the ventricular rate. 1500/20 = 75 beats/min. This method is accurate only if the rhythm is regular.
  1. The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated. While performing endotracheal suctioning, the patient reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse? a. The patient is exhibiting extension posturing. b. The patient is exhibiting flexion posturing. c. The patient is exhibiting purposeful movement. d. The patient is withdrawing to stimulation. correct answer C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness. Flexion posturing is characterized by rigid flexion and extension of the arms, wrist flexion, and clenched fists. Extension posturing is characterized by rigid extension of arms and legs with plantar extension of the feet. Withdrawing occurs when a patient moves an extremity away from a painful source of stimulation.
  2. The nurse is caring for a patient who has been declared brain dead. The patient is considered a potential organ donor. To proceed with donation, the nurse understands that a. a signed donor card mandates that organs be retrieved in the event of brain death. b. after brain death has been determined, perfusion and oxygenation of organs is maintained until organs can be removed in the operating room. c. the health care proxy does not need to give consent for the retrieval of organs. d. once a patient has been established as brain dead, life support is withdrawn and organs are retrieved. correct answer B After brain death has been determined, the organs must be perfused to maintain viability. Therefore, the patient remains on life support even though he or she is legally dead. A signed donor card indicates the individual's wishes; however, most organ procurement agencies require family consent even if a donor card has been signed. In most states, the health care surrogate or proxy is required to give consent for organ donation. After brain death has been determined, perfusion and oxygenation of organs are maintained until organs can be removed in the operating room.
  3. The patient is being admitted to the hospital. At home, the patient takes an over-the-counter supplement of vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital.

d. Chronic diseases do not have much effect on the older trauma patient. e. Fractures to bones other than hips are uncommon from trauma. correct answer A, B, C Falls are the leading cause of death in the elderly and frequently result in fractures to many different bones, not just hips. Decreased physiologic reserve leads to poorer outcomes. Hypertension can mask hypotension by the blood pressure appearing to be normal. That is just one example of how chronic disease can complicate the picture of an older trauma patient.

  1. When paramedics notice singed hairs in the nose of a burn patient, it is recommended that the patient be intubated. What is the reasoning for the immediate intubation? a. Carbon monoxide poisoning always occurs when soot is visible. b. Inhalation injury above the glottis may cause significant edema that obstructs the airway. c. The patient will have a copious amount of mucus that will need to be suctioned. d. The singed hairs and soot in the nostrils will cause dysfunction of cilia in the airways. correct answer B In inhalation injury, the airway may become edematous quickly, making intubation difficult. Early intubation is recommended to protect the airway. Carbon monoxide poisoning may be present, but a patient with carbon monoxide poisoning may not need to be intubated. Management of secretions is not an indication for intubation. Dysfunction of the cilia is not a reason for intubation.
  2. Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis correct answer C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.
  3. Which of the following are accepted nonpharmacological approaches to managing pain and/or anxiety in critically ill patients? (Select all that apply.) a. Environmental manipulation b. Explanations of monitoring equipment c. Guided imagery

d. Music therapy e. Provision of personal items correct answer A, B, C, D, E Manipulating the environment so that it appears less hostile helps decrease anxiety, as does continually reorienting the patient. Focus techniques such as guided imagery and music therapy can create a state of relaxation. Personal items can reduce anxiety and provide a pleasant distraction.

  1. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? a. Add an additional 0.5 mL of air to the balloon and repeat the procedure. b. Advance the catheter with the balloon deflated and repeat the procedure. c. Deflate the balloon and obtain a chest x-ray study to determine line placement. d. Lock the balloon in the inflated position, and flush the distal port of the PAC with normal saline. correct answer C Balloon inflation should never be forced because the PAC may have migrated farther into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. Advancing a pulmonary artery catheter is not within the nurse's scope of practice. Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.
  2. While instructing a patient on what occurs with a myocardial infarction, the nurse plans to explain which process? a. Coronary artery spasm. b. Decreased blood flow (ischemia). c. Death of cardiac muscle from lack of oxygen (tissue necrosis). d. Sporadic decrease in oxygen to the heart (transient oxygen imbalance). correct answer C Acute myocardial infarction is death (tissue necrosis) of the myocardium that is caused by lack of blood supply from the occlusion of a coronary artery and its branches. Coronary artery spasms and transient oxygen imbalance are not related to a myocardial infarction. Ischemia, if not reversed, will eventually lead to tissue necrosis.

A patient with a hemothorax will need blood transfusions and a chest tube placement for treatment. The nurse should start 2 large bore IVs with crystalloid solution. A cardiac monitor is also necessary, but active measures to treat the patient should be done first. The patient may or may not need intubation and mechanical ventilation. An occlusive dressing is not necessary.

  1. A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low cardiac output b. Low pulmonary artery occlusive pressure and low cardiac output c. Low systemic vascular resistance and high cardiac output d. Normal cardiac output and low systemic vascular resistance correct answer A In cardiogenic shock, cardiac output and cardiac index decrease. Right atrial pressure, pulmonary artery pressures, and pulmonary artery occlusion pressure increase and volume backs up into the pulmonary circulation and the right side of the heart. Pulmonary artery occlusion pressure increases in cardiogenic shock. Systemic vascular resistance is high and cardiac output is low in cardiogenic shock. Cardiac output is low and systemic vascular resistance is high in cardiogenic shock.
  2. A patient is admitted to the oncology unit with a small-cell lung carcinoma. During the admission, the patient is noted to have a significant decrease in urine output accompanied by shortness of breath, edema, and mental status changes. The nurse is aware that this clinical presentation is consistent with a. adrenal crisis. b. diabetes insipidus. c. myxedema coma. d. syndrome of inappropriate secretion of antidiuretic hormone (SIADH). correct answer D SIADH may be induced by ectopic sources of antidiuretic hormone, including small-cell lung carcinoma. The clinical presentation of a dilutional hypervolemia is consistent with SIADH. Adrenal crisis is characterized by fluid loss if secondary to decreased cortisol and aldosterone levels resulting in sodium loss. Diabetes insipidus is characterized by increased urine output and is not typically caused by lung tumors. Myxedema coma, although characterized by facial and peripheral edema, does not result from small-cell lung carcinoma.
  1. A patient with a 60% burn in the acute phase of treatment develops a tense abdomen, decreasing urine output, hypercapnia, and hypoxemia. Based on this assessment, the nurse anticipates interventions to evaluate and treat the patient for a. acute kidney injury. b. acute respiratory distress syndrome. c. intra-abdominal hypertension. d. disseminated intravascular coagulation disorder. correct answer C Intra-abdominal hypertension (IAH) is a serious complication caused by circumferential torso burn injuries or edema from aggressive fluid resuscitation. Signs and symptoms of IAH include tense abdomen, decreased urine output, and worsening pulmonary function. Acute kidney injury will not result from aggressive fluid resuscitation. Acute respiratory distress syndrome would present with signs of hypoxia and hypercarbia, but not a tense abdomen. Disseminated intravascular coagulation disorder may present as a tense abdomen if there is active bleeding, but it would not present with pulmonary symptoms.
  2. A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care? a. Change the intravenous tubing every 24 hours. b. Infuse antibiotics through the intravenous line. c. Monitor the blood glucose every 6 hours. d. Monitor the fluid and electrolyte balance. correct answer B Medications should not be infused through the IV line infusing parenteral nutrition. The other actions are correct.
  3. An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators correct answer B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.
  1. The monitor technician notifies the nurse "stat" that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse's first action? a. Call a code overhead. b. Check the patient immediately. c. Go to the nurses' station and look at the rhythm strip. d. Take the crash cart to the room. correct answer B The first intervention in this situation is to assess unresponsiveness by checking the patient.
  2. The nurse is caring for a patient admitted to the emergency department following a fall from a 10- foot ladder. Upon admission, the nurse assesses the patient to be awake, alert, and moving all four extremities. The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris. What is the most appropriate nursing action? a. Insert bilateral ear plugs. b. Monitor airway patency. c. Maintain neutral head position. d. Apply a small nasal drip pad. correct answer D Patient assessment findings are indicative of a skull fracture. The presence of straw-colored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely. Application of a nasal drip pad is the most appropriate action. Monitoring airway patency and maintaining the head in a neutral position are not priorities in a patient who is awake and alert. Insertion of bilateral ear plugs is not standard of care.
  3. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. Diminished breath sounds over left lung field b. Localized pain at catheter insertion site c. Measured central venous pressure of 5 mm Hg d. Slight bloody drainage around insertion site correct answer A Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.
  1. The nurse is caring for a patient receiving intravenous ibuprofen for pain management. The nurse recognizes which laboratory assessment to be a possible side effect of the ibuprofen? a. Creatinine: 3.1 mg/dL b. Platelet count 350,000 billion/L c. White blood count 13, 550 mm d. ALT 25 U/L correct answer A Ibuprofen can result in renal insufficiency, which may be noted in an elevated serum creatinine level. Thrombocytopenia (low platelet count) is another possible side effect. This platelet count is elevated. An elevated white blood count indicates infection. Although ibuprofen is cleared primarily by the kidneys, it is also important to assess liver function, which would show elevated liver enzymes, not low values such as shown here.
  2. The nurse is caring for a patient who is declared brain dead and is an organ donor. The following events occur: 1300 Diagnostic tests for brain death are completed. 1330 Intensivist reviews diagnostic test results and writes in the progress note that the patient is brain dead. 1400 Patient is taken to the operating room for organ retrieval. 1800 All organs have been retrieved for donation. The ventilator is discontinued. 1810 Cardiac monitor shows flatline. What is the official time of death recorded in the medical record? a. 1300 b. 1330 c. 1400 d. 1800 e. 1810 correct answer B The time of death is when brain death is confirmed and documented in the chart, even though the patient's heart is still beating. Organs are retrieved after brain death has been documented.
  3. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucous membranes for signs of dryness.
  1. The process in which antibody and complement proteins attach to the target cell and enhance the phagocyte's ability to engulf the target cell is known as a. opsonization. b. phagocytosis. c. the lymphoreticular system. d. the portal circulation. correct answer A Neutrophils are attracted to and migrate to areas of inflammation or bacterial invasion, where they ingest and kill invading microorganisms by phagocytosis. Once phagocytes have been attracted to an area by the release of mediators, a process called opsonization occurs, in which antibody and complement proteins attach to the target cell and enhance the phagocyte's ability to engulf the target cell. When infectious organisms escape the local phagocytic responses, they may be engulfed and destroyed in a similar fashion by the tissue macrophages within the lymphoreticular organs. The portal circulation of the spleen and liver filters the majority of blood, where infectious organisms can be removed before infecting the tissues.
  2. Which statement is consistent with societal views of dying in the United States? a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c. People die of distinct, complex illness for which a cure is always possible. d. The purpose of the health care system is to prevent disease and treat symptoms. correct answer A Death is viewed as a failure by society and health care providers, a view that results in aggressive management of disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible. There is a commonly held belief that the health care system exists to treat illness, disease, and injury and to "save" lives.
  3. A patient presents to the ED complaining of severe substernal chest pressure radiating to the left shoulder and back that started about 12 hours ago. The patient delayed coming to the ED, hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. What does the nurse understand about thrombolysis in this patient? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI.

d. Thrombolysis should be started immediately. correct answer A To be eligible for thrombolysis, the patient must be symptomatic for less than 12 hours. Therefore, this patient is not a candidate for this therapy.

  1. A patient requires pancuronium as part of treatment of refractive increased intracranial pressure. The nursing care for this patient includes: (Select all that apply.) a. administration of sedatives concurrently with neuromuscular blockade. b. dangling the patient's feet over the edge of the bed and assisting the patient to sit up in a chair at least twice each day. c. ensuring that deep vein thrombosis prophylaxis is initiated. d. providing interventions for eye care, oral care, and skin care. e. ensuring good nutrition with frequent feedings throughout the day. correct answer A, C, D Pancuronium is a neuromuscular blocking agent (NMB) resulting in complete paralysis of the patient. Patients receiving NMB must be provided total care, including eye, skin, and oral care interventions. Patients are at high risk for deep vein thrombosis secondary to drug-induced paralysis and bed rest. Sedatives must be administered concurrently with NMB, because NMBs have no sedative effects. Although many critically ill patients are assisted to the chair, chair activity is not appropriate for patients receiving NMB; passive exercise is most appropriate. Feeding the patient on an NMB orally is not possible.
  2. An elderly individual from an assisted-living facility (ALF) presents with severe scald burns to the buttocks and back of the thighs. The caregiver from the ALF accompanies the patient to the emergency department and states that the bath water was "too hot" and that the "patient sat in the water too long." What should the nurse do? a. Ask the caregiver at what temperature the water heater is set in the home. b. Ask the caregiver to step out while examining the patient's burn injury. c. Immediately contact the police to report the suspected elder abuse. d. Ask the caregiver to describe exactly how the injury occurred. correct answer B In cases of suspected abuse, especially in vulnerable patients such as children, elderly, and mentally impaired, it is important to assess the injured patient separately from the caregiver. While obtaining safety information on the temperature of the water heater is important, it is not a priority assessment question. The nurse should follow the hospital protocol for contacting appropriate authorities concerning suspected abuse, which may include contacting the police or social services. Asking the caregiver to describe how the injury occurred is important (e.g., there may be discrepancies in the

d. Triglycerides correct answer C Prealbumin is the most sensitive indicator of protein synthesis and catabolism.

  1. In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome? a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis correct answer D In patients with hyperosmolar hyperglycemic syndrome (HHS), glucose is higher; osmotic diuresis is greater, resulting in higher osmolality; and ketosis is usually absent. Glucose values in HHS are typically higher than those of diabetic ketoacidosis and are not typically accompanied by ketosis.
  2. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests? a. Arterial oxygen saturation b. Hourly urine output c. Mean arterial pressure d. Serum lactate levels correct answer D Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by underperfusion (under resuscitation).
  3. The nurse is assessing pain levels in a critically ill patient using the Behavioral Pain Scale. The nurse recognizes __________ as indicating the greatest level of pain. a. brow lowering b. eyelid closing c. grimacing d. relaxed facial expression correct answer C

The Behavioral Pain Scale issues the most points, indicating the greatest amount of pain, to assessment of facial grimacing.

  1. The nurse is caring for a critically ill patient on mechanical ventilation. The physician identifies the need for a bronchoscopy, which requires informed consent. For the physician to obtain consent from the patient, the patient must be able to a. be weaned from mechanical ventilation. b. have knowledge and competence to make the decision. c. nod his head that it is okay to proceed. d. read and write in English. correct answer B Informed consent requires that a person know what is to be done and have the competence to make an informed decision. Most critically ill patients do not have this capacity; however, an assessment should be made to determine the patient's capacity. Some patients on mechanical ventilation are able to give written consent. Reading and writing in English are not requirements for informed consent.
  2. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side- lying position and record hemodynamic values. correct answer C Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and aspiration of tube feeding, and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.