Chapter 36 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 36

Question 1

Type: MCSA

A patient is admitted to the emergency department with severe burn injuries. The nurses priority actions are to prevent development of which type of shock?

1. Cardiogenic

2. Hypovolemic

3. Distributive

4. Obstructive

Correct Answer: 2

Rationale 1: Cardiogenic shock may develop in this patient if injury stress results in myocardial infarction. However, immediate actions are focused on a different type of shock.

Rationale 2: Hypovolemic shock states are a result of a decrease in vascular volume, which leads to a decrease in cardiac output. Severe burns will cause loss of intravascular fluids from the skin and may lead to this shock state. This is a critical issue in the emergent care of the patient with burn injury and is the priority.

Rationale 3: Distributive shock, particularly septic shock, is a potential complication for patients with burn injury and the nurse will take measures to prevent wound contamination. However, this is not the highest priority in emergent burn care.

Rationale 4: Depending upon other injuries the patient with burns may develop obstructive shock, but this is not the nurses highest priority in emergent care.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-1

Question 2

Type: MCSA

A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient?

1. Ineffective Airway Clearance

2. Ineffective Tissue Perfusion

3. Stress Overload

4. Impaired Skin Integrity

Correct Answer: 2

Rationale 1: Without additional assessment findings, it is not possible to determine if this patient has ineffective airway clearance.

Rationale 2: Shock occurs when oxygen delivery does not support tissue oxygen demands. This is a state of ineffective tissue perfusion and is the priority nursing diagnosis for all patients in shock.

Rationale 3: Undoubtedly this patient is experiencing stress, but this is not the highest priority nursing diagnosis.

Rationale 4: This patient may have impaired skin integrity, but not enough assessment data is provided to make that determination.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 36-1

Question 3

Type: MCSA

A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurses concern that this patient may be developing shock?

1. Hot, dry skin

2. Respiratory rate 11

3. Pulse rate 118 and weak

4. Anxiety

Correct Answer: 3

Rationale 1: Hot, dry skin is the expected assessment when a patient is febrile, which may be the case with severe infection.

Rationale 2: Typically rapid breathing occurs in the presence of shock. This response is an attempt to add oxygen to the system.

Rationale 3: Rapid pulse occurs in an attempt to increase blood flow, thereby increasing oxygenation to tissues. Weak pulses occur as the contractility of the heart decreases.

Rationale 4: Anxiety can occur for a variety of reasons and would not immediately be associated with a shock state.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 4

Type: MCMA

A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurses concern that shock is developing?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Serum lactate level is 5.4 mmol/L.

2. Base deficit is -12 mmol/L.

3. SvO2 is 68%.

4. pHi is 6.9.

5. Arterial pH of 7.38.

Correct Answer: 1,2,4

Rationale 1: Lactate is the metabolic byproduct of pyruvate, which is formed as the result of anaerobic metabolism. Elevated levels mean that the body is depending, at least to some part, on anaerobic metabolism rather than the normal aerobic metabolism.

Rationale 2: This is a moderate base deficit and indicates buildup of lactic acidosis resulting from impaired tissue oxygenation.

Rationale 3: Normally, when oxygen supply and demand are in balance, hemoglobin is about 60% to 80% saturated after leaving the tissues.

Rationale 4: Low mucosal pH indicates development of acidosis.

Rationale 5: This is a normal arterial pH.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-2

Question 5

Type: MCSA

A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patients mental status?

1. Temporarily discontinue the drip and assess mental status within a few minutes.

2. Temporarily discontinue the drug and plan to assess mental status in an hour.

3. Use train of four testing while the medication is still infusing.

4. This assessment will have to wait until the sedating drug is no longer needed.

Correct Answer: 1

Rationale 1: Propofol has a very short half-life, so assessment of mental status can occur within a few minutes of the drugs discontinuation.

Rationale 2: Benzodiazepines used for sedation require discontinuation of the drug for a longer time in order for mental status assessment to be valid.

Rationale 3: Train of four testing is used when the patient is receiving neuromuscular blocking agents.

Rationale 4: Mental status should be assessed frequently and cannot be safely deferred until sedation is no longer needed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-3

Question 6

Type: MCSA

A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive?

1. The patient complains of a severe headache.

2. The patients urine output has dropped.

3. The patient begins to shiver.

4. The patient develops a cough.

Correct Answer: 3

Rationale 1: Development of a severe headache should be evaluated, but is not associated with treatment for hyperthermia.

Rationale 2: Decreased urine output is not associated with treatment for hyperthermia.

Rationale 3: Shivering increases metabolism and oxygen consumption and should be avoided. It may indicate that efforts at decreasing hyperthermia have been too aggressive and should be modified.

Rationale 4: Development of a cough is not associated with treatment for hyperthermia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-3

Question 7

Type: MCSA

The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement?

1. Temperature of 97.8F

2. Heart rate of 70 bmp

3. Resistance to ventilator-assisted breaths.

4. Pink skin tone

Correct Answer: 2

Rationale 1: Hypothermia is one of the triad of expected signs of neurogenic shock. This patient remains hypothermic.

Rationale 2: Bradycardia is one of the triad of expected signs of neurogenic shock. Return to a normal heart rate is a sign of improvement.

Rationale 3: Respiratory rate is not one of the triad of expected findings associated with neurogenic shock. The patient may be mechanically ventilated, but a change in acceptance of this assistance is not indicative of an improved shock status.

Rationale 4: Peripheral vasodilation produces a pink skin tone so this finding does not indicate improvement.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-8

Question 8

Type: MCSA

An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurses priority intervention?

1. Benadryl (diphenhydramine) 50 mg intravenously

2. Oxygen at 3 liters via nasal cannula

3. Epinephrine 1:1000 0.5 mg sq

4. Normal saline at 150 mL/hr

Correct Answer: 3

Rationale 1: Administration of diphenhydramine is appropriate but is not the initial therapy.

Rationale 2: Oxygen should be administered, but is not the priority intervention.

Rationale 3: The patient in anaphylaxis experiences bronchial spasm and constriction. The administration of epinephrine is necessary to reverse this process and facilitate an open airway. This is the priority intervention.

Rationale 4: After experiencing anaphylaxis the patient will likely be hospitalized and given IV fluids. This is not the immediate priority.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-8

Question 9

Type: MCSA

A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention?

1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open.

2. Stop the infusion and place an intermittent infusion cap on the IV access device.

3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion.

4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patients response

Correct Answer: 4

Rationale 1: Abrupt withdrawal of this medication is not indicated.

Rationale 2: Abrupt withdrawal of this drug is not indicated.

Rationale 3: The infusion rate should not be abruptly lowered.

Rationale 4: The nurse should decrease the infusion slowly, while monitoring the patients response. This is the only response that does not result in abrupt withdrawal of the medication.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-4

Question 10

Type: MCMA

A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Persistent hypotension

2. Heart rate 118

3. Development of a bundle branch block

4. Drop in urine output

5. Mottling of extremities

Correct Answer: 2,3,4,5

Rationale 1: The rate of infusion of dopamine can be increased above that which is being given if hypotension is not resolved. This is not an adverse effect but may be a case of not getting enough drug. If the patient remains hypotensive at higher infusion rates (50 mcg/kg/min), an adverse effect may be occurring.

Rationale 2: Tachycardia can be an adverse effect of dopamine.

Rationale 3: Aberrant cardiac conduction may indicate an adverse drug effect is occurring.

Rationale 4: Tissue ischemia is an adverse effect of dopamine. Decreased blood flow to the kidney will cause decrease in urine output.

Rationale 5: Mottling of extremities indicates peripheral ischemia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 36-4

Question 11

Type: MCSA

A patient with cardiac decompensation is started on dobutamine at 1 mcg/kg/min with an order to titrate to effect. After receiving this dose for several minutes the patient develops tachycardia and occasional premature ventricular contractions. What nursing intervention is indicated?

1. Increase the dose to 1.5 mcg/kg/min.

2. Discontinue the infusion.

3. Decrease the infusion to 0.5 mcg/kg/min.

4. Contact the prescriber immediately.

Correct Answer: 3

Rationale 1: There is no indication to increase the dose.

Rationale 2: Discontinuing the infusion is not the first intervention.

Rationale 3: Decreasing the infusion rate may reverse these adverse cardiac effects.

Rationale 4: The order is given to titrate the drug to effect. There is no reason to contact the prescriber at this point.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-4

Question 12

Type: MCMA

The nurse is monitoring a patient at risk for development of left ventricular failure and cardiogenic shock. Which findings would the nurse immediately discuss with the primary health care provider?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Development of an S3 heart sound

2. Sustained systolic hypertension

3. Development of bilateral crackles

4. Decrease in PAWP

5. Decrease in cardiac index

Correct Answer: 1,3,5

Rationale 1: Development of third or fourth heart sounds may indicate development of left ventricular failure.

Rationale 2: Sustained systolic hypotension would indicate development of left ventricular failure.

Rationale 3: Increased pulmonary congestion, as manifested by development of bilateral crackles, may indicate that left ventricular failure is developing.

Rationale 4: Left ventricular failure would be manifested by elevation of PAWP.

Rationale 5: Low cardiac index can indicate development of left ventricular failure.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-5

Question 13

Type: MCSA

A patient who had a myocardial infarction this morning is now developing cardiogenic shock. Which nursing intervention is indicated?

1. Increase IV fluids.

2. Administer vasoconstricting drugs.

3. Provide care in a calm, reassuring manner.

4. Withhold oral fluids and nutrition.

Correct Answer: 3

Rationale 1: Increasing IV fluids is not indicated when the patients heart is already damaged. The physiological issue is not lack of fluid, but inability to pump fluid efficiently.

Rationale 2: It is more likely that vasodilating drugs like nitroglycerin will be administered.

Rationale 3: Providing care in a calm and quiet manner helps to decrease the patients anxiety, thereby reducing oxygen consumption.

Rationale 4: There is no reason to withhold oral fluids and nutrition that is evidenced by this scenario. If the patient appears to be deteriorating rapidly, withholding food may be indicated.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-5

Question 14

Type: MCMA

A patient has been admitted to the emergency department with bleeding from a traumatic amputation of the leg. Which findings would the nurse interpret as indicating this patients blood loss is severe?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Heart rate is 120.

2. Blood has soaked the dressing applied by first responders.

3. Blood pressure is 78/50.

4. Mild anxiety is present.

5. Heart rate is 50.

Correct Answer: 1,3

Rationale 1: Marked tachycardia, greater than 110 bpm, indicates severe volume loss.

Rationale 2: It is not possible to characterize blood loss by the appearance of a bandage. Blood may have been lost prior to the application of the bandage.

Rationale 3: Marked hypotension indicates severe blood loss.

Rationale 4: Presence of mild anxiety indicates moderate hypovolemia.

Rationale 5: As exsanguination occurs, heart rate will drop and the condition becomes life-threatening. This indicates massive blood loss.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-6

Question 15

Type: MCMA

A patient who sustained a gunshot wound walks into the emergency department and collapses. Which priority directions should the nurse who assumes this patients care give to those coming to assist?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Check the airway.

2. Bring a wheelchair.

3. Put direct pressure on the leg wound.

4. Check for identification.

5. Check the pulse.

Correct Answer: 1,3,5

Rationale 1: Airway patency is the most important intervention for this patient.

Rationale 2: This patient will likely need to be transported by stretcher.

Rationale 3: Controlling the source of the fluid loss is imperative.

Rationale 4: Checking for identification can wait until more pertinent interventions are performed.

Rationale 5: The patient may have collapsed due to cardiac arrest from hypovolemia. Checking the pulse is part of the immediate assessment.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 36-6

Question 16

Type: MCSA

A patient hospitalized for treatment of a severe urinary tract infection may be developing septic shock. The nurse would monitor for the development of which finding associated with early septic shock?

1. Cold extremities

2. Increase in serum lactate levels

3. Decreased SCVO2

4. Widening of pulse pressure

Correct Answer: 4

Rationale 1: Cold and mottled extremities are associated with later stages of septic shock.

Rationale 2: Increased serum lactate levels indicate a later stage of shock.

Rationale 3: Decreased SCVO2 indicates a later stage of shock.

Rationale 4: Since the patients diastolic blood pressure decreases, the pulse pressure increases. This finding is associated with early stages of septic shock.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-7

Question 17

Type: MCSA

A patient being evaluated for septic shock has a serum lactate level of 5 mmol/L. What intervention does the nurse anticipate?

1. Decreasing the amount of oxygen being given

2. Immediate initiation of fluid resuscitation

3. Repeat of the testing in 4 hours

4. Bedside fingerstick level of blood glucose

Correct Answer: 2

Rationale 1: An increased serum lactate calls for increased oxygenation.

Rationale 2: A lactate level of 4 mmol/L is suspicious of significant tissue hypoperfusion and requires immediate fluid resuscitation.

Rationale 3: There is no need to repeat this test before intervening.

Rationale 4: Measuring blood glucose is not indicated by this lab result.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-7

Question 18

Type: MCSA

A patient being treated for a severe infection has a temperature of 35.8C. Which additional finding would indicate to the nurse that initiation of treatment for sepsis is likely?

1. A shift to the left on the white blood cell differential

2. Heart rate 88

3. Respiratory rate 10

4. Acute alteration in mental status

Correct Answer: 1

Rationale 1: Greater than 10% bands on the white blood cell differential, or a shift to the left, along with this temperature would indicate sepsis has developed.

Rationale 2: Heart rate over 90, along with this temperature, indicates sepsis is present.

Rationale 3: Respiratory rate greater than 20, along with this temperature, indicate sepsis is present.

Rationale 4: Acute alteration in mental status is related to development of septic shock.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-7

Question 19

Type: MCSA

A patient admitted to the emergency department following chest trauma has tracheal deviation to the left. The nurse would prepare for which emergency medical intervention?

1. Open thoracotomy

2. Placement of a chest tube

3. Open excision of the pericardial sac

4. Immediate cardiopulmonary resuscitation

Correct Answer: 2

Rationale 1: Open thoracotomy is not indicated for this complication.

Rationale 2: Tracheal deviation can result from mediastinal shifting due to a tension pneumothorax. Treatment is placement of a chest tube or a needle thoracotomy.

Rationale 3: Excision of the pericardial sac may be indicated when cardiac tamponade exists. There is no indication that this complication has developed.

Rationale 4: There is no indication that cardiopulmonary resuscitation is needed at this point.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 36-9

Question 20

Type: MCSA

Which finding would cause the nurse to be concerned that a patient who sustained chest trauma is experiencing cardiac tamponade?

1. Distant heart sounds

2. Decrease of right arterial pressure

3. Sudden development of hypertension

4. Development of an S3 heart sound

Correct Answer: 1

Rationale 1: The presence of blood in the pericardial space makes the heart tones sound muffled or distant.

Rationale 2: Right arterial pressure increases with cardiac tamponade.

Rationale 3: Hypotension is associated with cardiac tamponade due to the hearts inability to fill.

Rationale 4: S3 heart sounds are not associated with cardiac tamponade.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 36-9

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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