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CRITICAL CARE EXAM COMPLETE
ANSWERS WITH FREQUENTLY TESTED
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According to the
paramedics, the victim was stabbed by a male attacker
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2 cm) in length and 1 inch (2
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The "point of entry"
of the stab wound is two inches above and left of the victim's xiphoid
process
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The family asks
when the client will be extubated
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The client reports abdominal pain and nausea, and presents with
fruity-scented breath
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Which intervention is most important for the
nurse to implement? - CorreCt Answers -Initiate a one liter IV bolus of
0
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The client has become very detached and does not
want to participate in the plan of care
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The cardiac monitor
displays a normal sinus rhythm
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Which
action is most important for the nurse to take to prevent life-threatening
complications from pulmonary artery monitoring? - CorreCt Answers -Fast
flush the PA distal port for no more than 2 seconds

Define: Cardiogenic shock - CorreCt Answers -pump failure, occurs when
heart is so inefficient that it cannot sustain adequate circulation

How do you verify placement of a PA catheter? - CorreCt Answers -Fastflush square waveform test/dynamic frequency response test

How often should you verify placement of a PA catheter? - CorreCt
Answers -Once a shift

What is indicated if a waveform of a PA catheter is dampened or flat? CorreCt Answers -Air bubbles
Clots
Tubing is kinked

What should a wave test look like if working properly? - CorreCt Answers Square wave

The nurse is caring for a client in the critical care unit who is experiencing
end-stage chronic obstructive pulmonary disease (COPD)
...
The healthcare provider
informs the client and family that there is no further treatment available for
the COPD
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The nurse's initial assessment findings include a Glasgow Coma
Scale score of (3), pupils fixed and dilated with an absence of corneal reflex,
blood pressure of 80/30 mmHg, core temperature of 95
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4° C)
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How should the
nurse respond? - CorreCt Answers -Let me contact the healthcare provider
to answer your questions

The nurse is analyzing an arterial blood gas (ABG) of a client who has a
nasogastric tube to low suction
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48; paCO 2 - 50
mmHg; HCO 3 - 27mEq/liter
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The only significant medical history of the client is 4 days
post-operative laparotomy appendectomy without complications and
discharged to home 2 days ago
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The client's assessment is significant for crackles scattered throughout the
lungs, dependent peripheral edema +3/+4, S3 and S4 heart sounds,
temperature of 102
...
1° C), heart rate of 110 beats/minute,
respirations of 20 breaths/minute, and blood pressure of 105/60 mmHg
with a mean arterial pressure of (75)
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The vehicle
was stopped at a traffic light when the vehicle was hit on the left side by
another vehicle traveling at speeds exceeding 60 mph (97 kmh)
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The
significant assessment findings include: weak and thready pulse; diffuse
abdominal pain, tenderness and guarding present upon palpation; skin is
diaphoretic and extremities cool to touch, capillary refill +4 in extremities,
and bruising is present in the (L) flank area and progresses towards the

abdomen
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2° F (36
...

- CorreCt Answers -Fractured liver & ruptured spleen

The nurse is analyzing an arterial blood gas (ABG) of a client who is
mechanicallly ventilated
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52; paCO2- 30 mmHg;
HCO3- 28 mEq/liter
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Which protocol prescription should the nurse
implement first? - CorreCt Answers -Obtain serum sodium every 4 hours

The nurse is caring for a client who is demonstrating signs of impending
death
...
Which information should the nurse provide the family
to facilitate the process? - CorreCt Answers -Encourage the family to give
the patient permission to die

The nurse is caring for a client with severe sepsis related to a ruptured
appendix
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The
nurse observes respirations that are uneven and labored
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60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2
24 mmHg
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Which
intervention should the nurse implement during the therapeutic paralysis? CorreCt Answers -Administer a sedating medication

A client returns to the intensive care unit (ICU) after having a permanent
pacemaker inserted
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The client's myocardium is
illiciting a QRS after a delay of several seconds
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Which medication should the nurse administer immediately? CorreCt Answers -Lorazepam IV

What should you give a client experiencing epilepsy? - CorreCt Answers CNS depressant

Define: Thyroidectomy - CorreCt Answers -Surgical removal of the thyroid
gland

A client who returns to the postoperative unit after a total thyroidectomy
suddenly becomes short of breath and develops stridor
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Which assessment finding requires additional nursing action? CorreCt Answers -Crackles in the lungs

What do crackles compromise? - CorreCt Answers -Oxygenation

A client with diabetic ketoacidosis is admitted to the intensive care unit and
is manifesting respirations that are rapid and deep
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Which action should the
nurse implement when preparing to administer the medication? - CorreCt
Answers -Use a filtered needle to draw up the medication and an in-line
filter during infusion
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The nurse reports findings to the healthcare provider for a client who is
admitted to the intensive care unit today with chronic obstructive
pulmonary disease (COPD)
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The ventilator is alarming
continuously indicating high peak pressures for the client
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Which action should the nurse do first prior to suctioning the
client's ETT? - CorreCt Answers -Hyper-oxygenate with 100% FiO2 for 30
seconds

Why would you place sterile saline in an ETT prior to suctioning? - CorreCt
Answers -Loosen secretions

What can the use of normal saline prior to suctioning cause? - CorreCt
Answers -Oxygen desaturation
Backwash deeper into the lungs
Increased intracranial pressure
Excessive coughing
Bronchospasm

Which intervention should the nurse perform prior to the removal of an
endotracheal tube from a client? - CorreCt Answers -Suction the tube
thoroughly

A client diagnosed with heart failure has hemodynamic monitoring in
place
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Which assessment should the
nurse obtain prior to beginning the procedure? - CorreCt Answers -Weight
using the ICU bed scales

The nurse is caring for a client who is 4 days postoperative for abdominal
surgery
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The nurse
obtains the vital signs which include a heart rate of 120 beats/minute and
respirations of 35 breaths/minute
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Which radiographic finding represents the
pathological processes of pulmonary edema and consolidation of the lungs
as ARDS progresses ? - CorreCt Answers -White-out appearance

What does a white-out on a chest x-ray indicate? - CorreCt Answers Pulmonary edema and density in the lungs

Define: Cardiac bypass surgery - CorreCt Answers -Redirects blood around
a blocked section of your heart

Two days following cardiac bypass surgery, the nurse places a client's
mediastinal chest tube to water seal
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Which assessment finding warrants
intervention by the nurse? - CorreCt Answers -Water seal level 2cm below
the fill line

What is indicated if the water seal level is below or above the fill line? CorreCt Answers -Increased work of breathing which can lead to
pneumothorax

What is the diagnostic criteria for systemic inflammatory response
syndrome? - CorreCt Answers -2/4 criteria are present
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) Abnormal vital signs
2
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) WBC

Define: Decompressive craniectomy - CorreCt Answers -Brain surgery that
removes a portion of the skull

The nurse is caring for a client admitted to the intensive care unit with a
traumatic brain injury from a motor vehicle collision
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The healthcare provider

explains to the family that the client needs to go to surgery for
decompressive craniectomy
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The client
has a Glasgow Coma Score of 6
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Nitroprusside is infusing at 10 mcg/kg/min and 0
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Which intervention should the nurse implement
first? - CorreCt Answers -Stop the nitroprusside infusion

Define: Anastomosis - CorreCt Answers -Surgical connection between an
artery & a vein

Define: Aortic abdominal aneurysm - CorreCt Answers -Enlargement of the
aorta

A client falls off a ladder approximately 15 feet high and is admitted to the
ICU for observation due to a small intracranial bleed noted in the left
occipital area of the brain as observed on the CT Scan done in the
emergency department
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The client reports to the nurse a new onset of pain in the left shoulder
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Which should the nurse assess prior
to obtaining the arterial blood sample? - CorreCt Answers -Ulnar blood
flow

Define: Allen test - CorreCt Answers -Evaluates circulation to the wrist

What indicates the patient should not take blood for ABG? - CorreCt
Answers -Failed Allen test

What does a pointed T test indicate? - CorreCt Answers -Hyperkalemia

Define: Extravasation - CorreCt Answers -Leakage outside of the intended
area

What does dopamine cause if extravasation occurs? - CorreCt Answers -Soft
tissue necrosis

The nurse is caring for a client who is recently extubated in the post
anesthesia care unit (PACU)
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Which action
should the nurse implement? - CorreCt Answers -Call a rapid response
team for emergency airway management

A client reports shortness of breath and chest pressure radiating down the
left arm
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The nurse performs a 12 lead
electrocardiogram (ECG) that shows ST segment elevation in leads II, III,
aVF, and V4R
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9% sodium chloride bolus

What is the purpose of an IV fluid bolus? - CorreCt Answers -To fill the
right ventricle for the heart to pump

What do morphine & nitroglycerin cause? - CorreCt Answers -Hypotension

What does an elevated ST segment indicate? - CorreCt Answers -MI

A client diagnosed with gastric ulcers is admitted for a cauterization
procedure
...
) - CorreCt Answers -Decreased level of
consciousness
Decreased urine output

Define: Cauterization - CorreCt Answers -Destruction of tissue by burning

What is a late sign of hypovolemic shock? - CorreCt Answers -Hypotension
Decline in consciousness
Low urine output

What reflects blood loss greater than 1000mL? - CorreCt Answers -Systolic
<100mmHg
HR >120bpm

The nurse is caring for a client who underwent surgical repair of the aorta
after sustaining injuries in a fall
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0
...
The
client is flushed, diaphoretic, and slow to respond to verbal stimuli
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3° C), heart
rate 124 beats/minute, respirations 26 breaths/minute, and blood pressure
88/24 mmHg
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3 mg sublingual dose of
nitroglycerin when the client reports crushing chest pain
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Which
intervention should the nurse implement? - CorreCt Answers -Initiate a
rapid 0
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Which medication should the
nurse administer? What problem is here? - CorreCt Answers -Calcium
gluconate IV push due to hyperkalemia

A client diagnosed with heart failure has hemodynamic monitoring in
place
...
Which actions should the nurse perform to obtain accurate readings
from the hemodynamic monitor? - CorreCt Answers -Measure the pressure
readings in between the breaths
Calibrate it to 0 at the start of each shift

What can the use of normal saline prior to suctioning cause? - CorreCt
Answers -Oxygen desaturation
Backwash deeper into the lungs
Increased intracranial pressure

What can the use of normal saline prior to suctioning cause? - CorreCt
Answers -

The nurse is caring for a client who is receiving mechanical ventilation for
acute respiratory distress syndrome (ARDS)
...
Which
pathologic changes in the client is causing the ventilator alarms? - CorreCt
Answers -

The nurse reports findings to the healthcare provider for a client who is
admitted to the intensive care unit today with chronic obstructive
pulmonary disease (COPD)
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When the nurse completes the report using the
SBAR format, which statement best supports the nurse's reason for calling
the healthcare provider? - CorreCt Answers -

Define: Mannitol - CorreCt Answers -Diuretic

A client in the intensive care unit receives a STAT prescription for mannitol
IV for cerebral edema post closed head injury

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