Cumulative Review

The nurse is caring for a patient in cardiogenic shock secondary to an MI. Hemodynamic monitoring shows an increased left sided preload. The nurse would anticipate which intervention?

• Increasing the IV fluids

• Administering furosemide

• Prepare for CABG

• Administering labetalol

A patient presents to the ICU with an ABG of PH of 7.29, CO2 of 48, PaO2 of 81, HCO3 of 24. The nurse anticipates which action with the ventilator:

• Increase the fiO2

• Increase the respiratory rate

• Increase the PEEP

• Prepare for weaning

A patient presents to the emergency room with chest pain. What is the nurse’s priority intervention?

• Prepare to administer aspirin

• Prepare to administer sublingual nitroglycerin

• Obtain a 12 lead EKG

• Prepare to draw a troponin and CK-MB level

A client with type 1 diabetes is admitted to the ED. Which assessment finding is most concerning?

• Kussmaul respirations

• S3 heart tone

• Red lesion on the medial great toe

• Concentrated urine

A patient who was coughing stimulated his vagal nerve and his heart rate dropped from 78 to 50. What is the nurse’s priority action?

• Auscultate the heart tones

• Prepare for atropine administration

• Take the client’s blood pressure

• Give a PRN anti-tussive medication

A patient with a chest tube for a hemothorax in the right lung, shows signs of respiratory distress with minimal output into the canister. What is the nurse’s primary action?

• Prepare for mechanical ventilation

• Check for kinks in the tubing of the chest tube

• Prepare to remove the chest tube

• Auscultate a blood pressure

A patient is found unresponsive and without a pulse. What is the nurse’s first priority?

• Check a carotid pulse

• Place the patient on the cardiac monitor

• Obtain a blood pressure

• Call a code blue

A patient present to the ICU in acute respiratory failure. The nurse knows that it is progressing to ARDS when:

• PaO2 levels do not increase with increased fiO2

• PEEP levels are lowered

• PaO2 levels are stable with 40% fiO2

• HCO3 levels begin to compensate

The nurse assesses that the patient is presenting with cardiac related chest pain when they state:

• I take a deep breath and it hurts worse.

• The pain gets better when I eat.

• I feel so fatigued.

• The pain is in the center of my chest.

During the resuscitative phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation?

• Serum creatinine level of 2.5ml/dL

• Little fluctuation in daily weight

• Hourly urine output of 60ml/hr

• Serum albumin level of 3.8mg/dL