Which statement made by a new graduate nurse about invasive mechanical ventilation is incorrect?

A patient with ARDS is on a mechanical ventilator with a heart rate of 128, SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to:

Which nursing action would best optimize overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)?

An older client is experiencing hypovolemic shock. Which action would be given the highest priority for this client?

A client being treated for hypovolemic shock is prescribed a titrating dose of dopamine. Which evaluation will the nurse anticipate while administering this medication?

The nurse is caring for a client experiencing anaphylactic shock. Which of the following should be included in the plan of care for this client?

Select all that apply.

A six-year-old pediatric client, who recently underwent a tonsillectomy 27 hours prior, presented to the emergency department after an episode of severe coughing, resulting in continuous bright red bleeding from back of throat. The patient is hypotensive, pale and slow to respond. The patient is afebrile. The mother teaches critical care nursing and asks what type of shock her child is in, you respond with _______ shock.

A patient with neurogenic shock is demonstrating symptomatic bradycardia. What action will the nurse take at this time?

A patient with acute lung injury is being started on enteral nutrition. Which interventions will the nurse provide to ensure nutritional support for this patient? Select all that apply.

During an assessment, a ventilated patient has a furrowed brow and grimaced expression and also begins to move about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?

An 86-year-old client is admitted with pneumonia related sepsis. What manifestations might the nurse expect to find when assessing this client?

Select all that apply.

Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complication is true except:

The nurse is administering intravenous nitroglycerin to a patient admitted with hypertensive crisis. The infusion has been titrated based on the physician titration orders and the guidelines of the facility. During the next assessment the nurse notices that the patient is pale, diaphoretic, lethargic, disoriented and severely hypotensive. Which intervention by the nurse is most appropriate?

A patient has been diagnosed with septic shock. The patient has received a 3L normal saline bolus. Hemodynamics are as follows: ABP 78/44 MAP 56, CVP 18, HR 133, O2 90% with FIO2 at 100%. Which intervention would the nurse anticipate next?

A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient’s family noted that he was more lethargic and dizzy and was falling frequently. The patient’s vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate.

Which intervention would the nurse anticipate first?

A 40-year-old man with a history of IV drug use is admitted with cellulitis and multiple abscesses of the right upper extremity. His current weight is 70 kg. He rapidly develops worsening respiratory distress, hypotension and ultimately requires intubation and mechanical ventilation. Blood gas analysis shows a pH of 7.23, Paco2 of 68, Pao2 of 80, and an oxygen saturation of 91%. His ventilator settings are assist-control mode with a tidal volume of 420 mL, respiratory rate of 16 breaths/min, positive end-expiratory pressure (PEEP) of 5 cm H2O, and Fio2 of 100%. His end tidal CO2 is 22mmHg. The nurse understands that which setting on the ventilator would have the greatest affect on PaCO2 and ETCO2 of this patient?

In a client with a tracheostomy, the nurse should monitor for complications related to the loss of which protective mechanism?

The nurse is caring for a patient on the ventilator. Which assessment findings requires immediate response?

The nurse is caring for a patient that was admitted for respiratory distress. The patient has a history of peripheral vascular disease and coronary artery disease. The patient appears cyanotic, dyspnic, has tracheal tug, respiratory rate 38, and oxygen saturation reading of 84% on 2L nasal cannula. Which action by the nurse is most appropriate for this patient? 

The nurse is administering blood to a patient who was admitted for potential sepsis. The initial vital signs were T- 36.8, P- 102, BP- 101/58 RR- 18, SPO2- 94% 8L hi-flow nasal cannula after 15 minutes the patient is complaining of back and flank pain. The 15 minute vital signs are: T- 38.8, P- 122, BP- 90/58 RR- 28, SPO2- 94% 10L hi-flow nasal cannula. Which action by the nurse is most appropriate given the situation? 

The nurse is caring for a patient on the ventilator and the ventilator continues to alarm related to low volume during inspiration. The patient's oxygen saturation is 90% and the patient continues to move head back and forth on pillow and raising arms up against soft restraints. Given this presentation, what is the most appropriate initial intervention by the nurse?

What should the nurse do when administering antibiotics to a patient with sepsis?

What is the overall goal of providing fluid resuscitation and vasopressors to a patient in septic shock?

A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you anticipate the physician to order which medication to improve tissue perfusion?

A patient has just been intubated and placed on mechanical ventilation. What is the first assessment immediately after tube placement?

A patient who has been on mechanical ventilation for three days develops a fever of 101.0°F, green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

The nurse is assessing a patient and auscultates crackles within the poster lower lobes that do not clear with coughing. The nurse understands that which medication will provide the most benefit for this patient?

A nurse is caring for a patient immediately after extubation of the endotracheal tube. During post extubation assessment, which of the following findings indicates the patient is not tolerating extubation well?

A patient is brought to the emergency department after a motor vehicle accident. The patient is demonstrating signs of hypovolemic shock. Which of the following types of fluids would be most appropriate to administer initially during the resuscitation period?

While caring for a patient with sepsis, the nurse suspects that disseminated intravascular coagulation is developing. What did the nurse assess in the patient? Select all that apply.

A patient receives a fluid challenge as part of care for sepsis. Which outcome indicates that the challenge was successful? Select all that apply.

A patient receiving care for sepsis is having blood samples drawn to evaluate specific organ functioning. Why is this being done?

Which nursing intervention is the highest priority during blood administration?

While caring for a patient with sepsis, the nurse suspects that disseminated intravascular coagulation is developing. What did the nurse assess in the patient? Select all that apply.

The nurse is caring for a patient that was admitted for respiratory distress. The patient has a history of peripheral vascular disease and coronary artery disease. The patient appears cyanotic, dyspneic, has tracheal tug, and respiratory rate 44. The pulse oximeter displays an irregular waveform and does not display an oxygen saturation percentage. Which action by the nurse is most appropriate for this patient? 

The nurse is evaluating the effectiveness of a normal saline fluid bolus for Mr. Nguyen, an 80-year-old patient admitted with hypovolemic shock and acute renal failure. Which assessment finding indicates that the fluid bolus is having the desired effect?

Select all that Apply.

Select all that apply.

Select all that apply.

The nurse recognizes that utilizing the prone position to enhance oxygenation in a patient with acute respiratory distress syndrome is contraindicated when the patient has:

Select all that apply

A patient has been admitted to the cardiac unit with a diagnosis of right ventricular failure due to post myocardial infarction complications. Which of the following assessment findings would the nurse anticipate based on this complication?

The nurse is prepping the patient for a Treadmill Cardiac Stress test. The nurse explains the test is used to demonstrate how the heart functions during increased activity. Understanding the purpose of the test and the heart's normal compensatory mechanism for increased myocardial demand, the nurse knows which medication is contraindicated prior to the test?

What is the primary reason for administering morphine to a client having a STEMI?

The nurse is reviewing discharge medications for a patient being discharged post stent placement after a myocardial infarction of the LAD. The patient has not had any cardiac or renal complications after the MI. The nurse anticipates that the patient will be on which medications?

The nurse is caring for a patient admitted to the cardiac unit for shortness of breath, productive cough, elevated troponin levels, and fever. Fungal pneumonia is listed as the admitting diagnosis, and physician H&P states cardiac function normal. The patient's 12 lead EKG was normal and free of ST elevation, ST depression or bundle branch block. The patient's chest x-ray image is indicative of pulmonary congestion, and bilateral infiltrates. The patient was cyanotic prior to being placed on 15 liters non-rebreather. Results of a sputum culture shows penicillium fungal growth. The patient asks the nurse how bad his heart attack was, because the previous nurse in the emergency department told him he had a heart attack because his troponin level was elevated.

Based on the patient presentation, which statement by the nurse is most accurate?   

The nurse is assessing a patient newly admitted to the cardiac observation unit. The nurse auscultates a systolic murmur and a pericardial friction rub. The patient complains of shortness of breath and fine crackles are heard on auscultation of the posterior lower lobes. The patient has an elevated white blood cell count but is afebrile. The echocardiogram interpretation states there is vegetation adherence to the valve, as well as regurgitation back to the left atrium. Based on the patient presentation and diagnostic results, which valve is regurgitating?   

A nurse is taking care of a neonate, who was noted to have a heart murmur during the newborn assessment. It would be especially important for the nurse to advise the parents to notify the nurse if the baby exhibits which of the following signs/symptoms?

The nurse is providing nutritional education to the parents of an infant recently diagnosed with a congenital heart defect. The nurse knows that the parents understand the dietary education with which of the following responses?

Which of the following patterns is indicative of infection in the postoperative period following cardiac surgery for the infant?

In the newborn patient the presence of decreased ventricular function and the presence of atrial arrhythmias increases the baby’s risk for: 

A 6-month-old client with a ventricular septal defect is receiving digoxin elixir for regulation of his heart rate. Which finding should be reported to the doctor?

The nurse is assessing the patient, who was admitted post CVA. During the NIH Stroke Scale Assessment the nurse notes that the patient does not verbalize the H sound when asked to state Huckleberry. What is a priority safety intervention for this patient?

A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy using the recombinant tissue plasminogen activator alteplase. What should the nurse explain to the client's family about the use of this medication?

When assisting a patient with a cane to transfer or ambulate, what does the nurse instruct the patient to do?

You are working dayshift in the emergency department and have just admitted an 74 year old male patient having difficulty speaking and unable to lift his left arm.Vitals are BP 198/88, MAP 118, HR 84, Pulse 84, SPO2 92% on room air, temperature 37.1 C, respiratory rate 22. Given the presentation of the patient, what is a priority test for this patient?

The nurse is caring for a patient that has complaints of weakness on one side, and slurred speech. The patient's blood pressure is 228/162 mmHg and pulse 92 BPM. The patient has just come back to the ED after a CT scan that was negative for bleeding. Given the patient situation, which medication does the nurse anticipate administering next?

The nurse is caring for a patient diagnosed with an ischemic stroke. The patient has been admitted into the ICU for 24 hours, and during the previous shift his NIHSS was charted as a 16 and that the patient was alert and scored a 0 for aphasia and dysarthria. The nurse completes the NIHSS at the beginning of the shift and the patient scores a 38 and unable to pronounce the H sound. Which immediate response by the nurse is most appropriate?

The nurse is caring for a patient that has recently been admitted to the ICU after a right carotid endarterectomy. The patient is complaining of a headache, pain on right side of neck, and difficulty swallowing and speaking. The nurse assess for which post carotid endarterectomy surgical complication?

While providing oral medications to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. Which of the following interventions would be most appropriate?

A patient being treated with warfarin experiences a hemorrhagic CVA. What should the nurse anticipate being prescribed for this patient?

The nurse is preparing medications for the patient experiencing acute decompensated heart failure related to history of cardiomegaly. Which medication should be administered to help decrease oxygen demand for the patient?

During an assessment the nurse notes that the patient with dilated cardiomyopathy has pitting edema in bilateral lower extremities and fine crackles on inspiration during auscultation of lung fields with dyspnea. The nurse assesses that the patient has had an intake of 1200 ml total and an output of 50 ml from Foley catheter over the last 4 hours. Which of the following PRN medications would be most appropriate given the patient presentation?

Which of the following medications would the nurse anticipate administering to a patient with decreased cardiac output related to poor contractility of the heart muscle?

A 14 year old patient is diagnosed with cardiomyopathy and makes the statement "I am too young to have cardiomyopathy, my grandpa has that, I just got over heated playing baseball." The nurse understands that the patient might be diagnosed with what type of cardiomyopathy?

The nurse is caring for a patient in the ICU. The nurse has referred the patient for organ procurement. Which of the following make the patient a viable candidate? Select all that apply.

When providing end-of-life care for patients, what will the nurse prioritize highest?

A patient who has died an unexplained death has numerous catheters and drainage tubes in place and is being prepared for an autopsy. In providing care for the body after the patient has been pronounced dead, how shall the nurse manage the tubes prior to the autopsy?

The nurse is caring for a patient post organ transplant. Which of the following might the nurse anticipate including in the discharge education? Select all that apply.

The nurse is assisting with an apnea test on a patient to determine brain death after noting no brain activity on the EEG. The nurse does not note any diaphragmatic or chest wall movement after 8 minutes off of the ventilator. The post apnea test ABG shows a PCO2 level of 68. The nurse notes the apnea test as:

The nurse is caring for a patient that was diagnosed with pre-eclampsia and has just started a bolus infusion of magnesium sulfate. The patient's respiratory rate is 10/min and deep tendon reflexes are flaccid. What priority intervention should the nurse implement?

A patient experiences vaginal bleeding and complete placental abruption at 28 weeks of gestation. What interventions can the nurse expect?

The nurse is caring for a patient who is 32 weeks gestation. She presented to the ED with diaphoresis, tachycardia, sudden onset of severe abdominal pain, and severe vaginal bleeding. Upon review of the patient's history and physical assessment, the OB physician determined that the patient was experiencing a grade 3 placental abruption. What nursing interventions should you provide for this patient? Select all that apply.

A pregnant client is diagnosed with HELLP syndrome. The client's nurse understands that which clinical finding is not a manifestation of this condition?

The nurse is caring for a patient admitted for observation to the OB unit. The patient is complaining of headache, fatigue and edema. Blood pressure is 188/124, protein on dipstick 4+ and the patient is 33 weeks pregnant. Which interventions can the nurse anticipate? Select all that apply.

The goal of treatment for placenta previa is to stop vaginal bleeding. Which of the following is a common intervention for a client diagnosed with placenta previa?

John is a 67-year-old male who recently underwent a stent placement. He is following up with his primary care provider for a medication reconciliation. Which medications would the provider anticipate John to be taking (select all that apply)?

Which patient is not at an increased risk for MI or strokes?

As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply (select all that apply):

You are doing hourly rounding on your patient within the ICU. At 5:00pm the patient was eating his dinner. Now the patient is lethargic, slow to answer, and showing signs of weakness. What is the first step the nurse should take?

You are orientating a new graduate nurse within the emergency department. Your patient presents with stroke-like symptoms. What would warrant the preceptor to step in after seeing the new graduate do what wrong during the NIH stroke scale?

Which nursing intervention is the highest priority during blood administration?

What is the correct interpretation for this pacemaker rhythm?

What is the correct interpretation for this pacemaker rhythm?

What is the correct interpretation for this pacemaker rhythm?

What is the correct interpretation for this pacemaker rhythm?

What is the correct interpretation for this pacemaker rhythm?

Which coronary artery is potentially occluded?

Interpret the 12-lead.

The nurse is caring for a patient recovering from the cath lab after presenting to the emergency department with this EKG. The nurse anticipates the patient will be discharged on which types of medications?

The nurse is caring for a patient that was recently admitted from the cardiac catheterization lab after receiving two stents to the left anterior descending artery. The patient is complaining of chest discomfort 2/10, which is down from admission 10/10. A post catheterization 12 lead EKG was just completed, and the nurse is comparing it to the patient's pre catheterization 12 lead EKG. Based on the comparison, which actions by the nurse is most appropriate?  

The nurse is caring for a patient that has just been admitted to the cardiac ICU after having a stent placed in the right coronary artery for an inferior myocardial infarction. A repeat EKG has just been completed on arrival to the cardiac ICU from the catheterization lab. The nurse is assessing the patient and the patient states that they are having pain 9 out of 10 in their upper back. Given the patient pain assessment, and comparing the pre-catheterization lab and post-catheterization lab EKGs, what is the most appropriate response by the nurse?

Your patient presents to the emergency room with complaints of chest pain. Patient’s vitals are as followed: 80bpm, 20RR, 140/96 BP, 96% 2L. Troponin was elevated at 0.5. Her EKG is below:

You need to transfer the patient to a different hospital for stent placement. What is a medication you can start her on while she waits to be transported to another hospital?

Your patient is awake, watching television, and has no complaints. You place them on the cardiac monitor and above is the rhythm you assess. Vital signs are as followed: 200bpm, 26 RR, 110/70 BP, 96% on room air.  What is the first intervention the nurse should do? 

A client with a head injury is demonstrating signs of increased intracranial pressure (IICP). Which medications will the nurse anticipate administering that will decrease symptoms and potential complications related to IICP?

Select all that apply.

A patient is brought into the Emergency Department after jumping off of a moving food truck. The client has suffered a traumatic injury involving multiple body systems. What is the priority for the nurse?

The nurse is caring for a trauma patient in the emergency department that had a positive FAST exam. Which medication will the nurse anticipate administering to this trauma patient in relation to the FAST results?

The nurse becomes concerned when a client who sustained a head injury, while playing a virtual reality video game, begins to demonstrate decerebrate posturing. What does this posture suggest to the nurse about the client's brain functioning?

The nurse is determining ways to decrease environmental stimuli for a client with increased intracranial pressure. Which action by the nurse will decrease environmental stimuli?

Coma stimulation is being implemented for a patient who sustained a traumatic brain injury. Which of the following should be included in this plan for stimulation?

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systolic blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be:

Upon assessment, you are concerned that the patient is experiencing herniation.  Which of the following would be expected findings of Cushing’s triad?

A 72 year old female is admitted with a large frontal subdural hematoma due to a fall at home on blood thinners.  Frontal head injury behaviors and expected assessment findings may include which of the following?

A patient is admitted following a traumatic brain injury.  Upon assessment, the patient’s MAP is 75, ICP 27, and CPP 48.  According to the findings, what should the nurse do first? 

A 32-year-old male presents with battle signs and racoon's eyes, nausea, vomiting, and rhinorrhea.  His blood pressure is 130/72, heart rate 98, oxygen saturation 98% on room air, respirations of 26, and temperature of 99⁰ F.  Which intervention is most appropriate at this time?

A 24-year-old patient presents to the emergency department following an MVA. His blood pressure is 88/62 and heart rate is 125.  The physician performs a FAST exam to rule out which potential complication from the MVA?

A 33 year old male was brought to the ED after sustaining a gunshot wound to the leg.  A massive transfusion protocol was completed, and the patient regained hemodynamic stability once the bleeding was stopped.  What assessment finding indicates a need for further immediate intervention?

The nurse is caring for a patient that experienced a traumatic brain injury while performing at a concert. When the nurse asks the patient his name, he responds with: "Back to the rhythm of the funky jam, DJ Kool is who I am."

When the nurse asks the patient where he is at, he responds with:

"Rockin' to the beat in the place to be"

When the nurse asks the patient what year it is, he responds with:

"Check out the flavor of the rhythm I wrote! While I got a chance here, let me clear my throat!"

How will the nurse document the orientation status for this patient?

The nurse is assessing a patient admitted with a spinal cord injury that occurred while tailgating. During the assessment the nurse discovers that the patient has only visible contraction from the hip down. The patient has no sensation of light touch or pin prick from hip and mid-thigh down. The patient has also been incontinent of stool and did not have any anal contraction, anal pressure or anal sensation during incontinent episode. After completing the assessment the nurse suspects the patient has what type of spinal cord injury?

The nurse in the Emergency Department is preparing to administer methylprednisolone to a client with a spinal cord injury. What effect will this medication have on the client?

The nurse is caring for a patient with a spinal cord injury. During the assessment the patient is able to extend and flex against gravity and resistance at the elbows, but has no contraction from hip flexors down. The patient has decreased sensation at the nipple line and below. The patient is incontinent of bowel and bladder. The patient was able to verbalize anal and perineal sensation, but was unable to produce motor function of the anus. Use the ASIA protocol to determine the type of spinal cord injury for this patient.

The nurse is using the ASIA Impairment Scale to assess a patient presenting with a spinal cord injury post MVA. The patient has only palpable contraction in knee extensors and flaccid below, has impaired pin prick and light touch sensation bilateral knees down. The patient also has active muscle contraction of anus but unable to determine sensation or light touch of anus. Please use the attached scale to determine the level and type of spinal cord injury.

The nurse is caring for a patient with a spinal cord injury. During the assessment the patient has full strength of the elbows and wrists, but has no movement or muscle contraction of fingers. The patient has no sensation to pin prick or light touch from the axilla and down, the patient is incontinent of bowel and bladder and has no anal sensation. Use the ASIA protocol to determine the type of spinal cord injury for this patient.

The nurse is caring for a patient with a spinal cord injury. During the assessment the patient is able to extend and flex at the elbows and the third finger, but only has visible contraction of the fifth finger. The patient has no sensation starting at the medial antebrachium, but has sporadic contraction and relaxation of the anal sphincter. Use the ASIA protocol to determine the type of spinal cord injury for this patient.

The nurse is caring for a 24-year-old trauma patient that was admitted to the ED following a penetrating injury by an old metal pole, to the spleen, after miscalculating a dive off of a boat and into the lake. The nurse anticipates that the patient will receive which vaccines in relation to this injury?

What level of TBI is this?

GCS score is less than 8 and the patient is being referred for potential organ doantion after apnea testing

What level TBI is this?

Patient hit in head with a shoe, and loss conciousness for 15 minutes, GCS 15 and CT scan negative.

What level TBI is this?

Patient was lip syncing and miscalculated her "death drop" dance move. Upon assessment the patient had a GCS of 10 and lost conciousness for 3 hours.

What level TBI is this?

Student "passes" out during first day of cadaver work in physiology lab. The student hits head on floor and loses conciousness for 2 hours, has a GCS of 11 upon assessment and cannot remember anything that has happenned in the past 2 days.

What level TBI is this?

The patient tripped over flat ground and hit her head, upon assessment GCS 14, loss of counciousness for 5 minutes and has mild headache.

What level TBI is this?

Patient is on mechanical ventilation with minimal chance of breathing on own, because of damage to brainstem

The nurse is admitting a 30-year-old male patient dressed as a chicken, who was hit by a car while attempting to cross the street. Which is a priority assessment?

The nurse is conducting a primary assessment on a trauma client. Which of the following would demonstrate the client is having difficulty with ventilation?

The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question?

The nurse is caring for a patient born with spina bifida. The nurse positions the patient in the incubator in which position?

The health care provider has ordered mannitol (Osmitrol) for a child with a head injury. The best indicator that this medication has been effective is:

The nurse prepares medications for a patient with status epilepticus. What should the nurse identify as the medication of choice for this patient?

The nurse is caring for a patient who suffered a pneumothorax related to a penetrating chest wound after performing own stunts while filming an action movie. The nurse anticipates what assessment findings while assessing the chest tube drainage system? Select all that apply.

The nurse is instructing a new graduate nurse to monitor for signs and symptoms of increased intracranial pressure. Teaching has been successful when the new graduate states "I will anticipate _________________________ signs and symptoms of increased intracranial pressure."

The nurse is completing a neurovascular assessment on an unresponsive patient admitted with a traumatic brain injury after falling off a pole. The nurse is assessing response to painful stimuli, which is the most appropriate method?

The nurse is caring for a patient with a complete L2 spinal cord injury. The nurse is providing education to the patient and family about signs and symptoms of autonomic dysreflexia, what symptoms should be included? Select all that apply.

The nurse is caring for a patient with a complete T4 spinal cord injury, the patient becomes diaphoretic and complains of a severe headache. What is the next nursing action?

The nurse is evaluating patient admitted to the emergency department for a cervical fracture after falling from the top of a moving ice cream truck. Which assessment finding indicates the patient is still in spinal shock?

What is the purpose of hypertonic saline related to TBI patients?

What is the purpose of midazolam related to TBI patients?

What is the purpose of Fentanyl related to TBI patients?

What is the purpose of Dopamine related to TBI patients?

What is the purpose of Acetaminophen related to TBI patients?

What is the purpose of Pentobarbital related to TBI patients?

What is the purpose of Mannitol related to TBI patients?

The nurse is evaluating a patient that was admitted to the ICU ten days ago after traumatic injury while riding a mechanical bull. The patient was diagnosed with a diffuse axonal injury and has had transient neurologic deficits. The patient displays signs and symptoms of aggressive behavior and is easily agitated during the evaluation. These signs and symptoms are used to evaluate the effectiveness of which medication?   

The nurse is evaluating a patient admitted for a crushing injury to right lower extremity after jumping off top of a streetlight, while celebrating final exams. Which assessment findings may indicate the patient is developing compartment syndrome in the right lower extremity? Select all that apply.

The nurse is completing a neurological assessment on a patient admitted for traumatic injury riding on a unicycle while playing a harmonica. During the assessment the patient only opens eyes when nailbed pressure is applied, unable to form words only making sounds, and extends extremities outward for motor response. The nurse documents the Glascow Coma scale as? 

A client in the ICU has a MAP of 90 mm Hg and an ICP reading of 45 mm Hg. The nurse interprets these figures to mean:

You are providing care to a patient experiencing diabetic ketoacidosis. The patient is on an insulin drip and their current glucose level is 300. In addition to this, the patient also has 5% Dextrose 0.45% NS infusing in the right antecubital vein. Which of the following patient signs/symptoms causes concern?

Which of the following is not a sign or symptom of Diabetic Ketoacidosis?

Which of the following statements about metformin are true? Select all that apply.

A nurse is precepting a new graduate nurse and discussing diabetes and DKA education. Which of the following statements by the graduate nurse demonstrate an understanding of diabetes and DKA (select all that apply)?

What type of insulin do you expect the doctor to order for treatment of DKA?

A patient is admitted with Diabetic Ketoacidosis. The physician orders intravenous fluids of 0.9% Normal Saline and 10 units of intravenous regular insulin IV bolus and then to start an insulin drip per protocol. The patient’s labs are the following: pH 7.25, Glucose 455, potassium 2.5. Which of the following is the most appropriate nursing intervention to perform next?

The nurse monitors the blood glucose levels of a patient being treated with insulin for diabetic ketoacidosis. Why should the nurse ensure glucose levels decline no more than a rate of 50-70 mg/dL/hour?

The nurse is providing discharge instructions to a patient with a mild brain injury. Which of the following should be included in these instructions?

The nurse is caring for a patient who lost control while dressed as a unicorn frolicking on a treadmill and landed against the wall. The patient is lethargic and complaining of a headache. During the neuro assessment the patient's right pupil is fixed and dilated. The nurse knows that this patient has what type of hematoma?

The nurse is caring for a patient that was admitted for a traumatic brain injury. The patient is 47 years old and has a history of high impact sports. Upon admission the patient's spouse admits that the patient has been confused and impulsive the past few months. The nurse understands that this CT and the history from the spouse suggest that the patient has what type of brain injury?

The nurse is assisting the neurologist during a cold caloric stimulation test on a 25 year old male patient who sustained a traumatic brain injury from the below situation. The patient is the person laying on the table.

During instillation of cold water into the patient's right ear the patient's right eye slowly deviated toward the right and the left eye did not deviate from center. The nurse understands that this suggests what type of prognosis for this patient?