Chapter 37 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 37

Question 1

Type: MCSA

A patient admitted with an infected wound is demonstrating signs of improvement. The nurse would attribute this improvement to which physiologic process?

1. Cortisol released from the adrenal glands

2. Hypothalamus activating white blood cells

3. Endothelial cells releasing mediators to contain the infection

4. Mediators that decrease permeability of vessel walls

Correct Answer: 3

Rationale 1: The wound infection was not contained because of the release of cortisol by the adrenal glands.

Rationale 2: The hypothalamus does not activate white blood cells.

Rationale 3: Mediators, bioactive substances that stimulate physiologic changes in cells, are released from endothelial cells. It is these mediators that control inflammation, activate coagulation, deposit fibrin, and inhibit fibrinolysis to contain the inflammatory activity to the site of the infection.

Rationale 4: Permeability of the vessel walls is increased in order to contain infection.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 2

Type: MCSA

A patient tells the nurse that he is upset because his surgical wound is infected and everyone else that he knows who had the same surgery did not have the same problem. How should the nurse respond to this concern?

1. There really is nothing that could be done to prevent it.

2. You should talk to your surgeon about your concerns.

3. At least you are in the hospital when the infection started and not at home.

4. Developing an infection depends on many factors, even things like age and gender.

Correct Answer: 4

Rationale 1: The nurse has no way of knowing if there was a way to prevent this patients infection.

Rationale 2: The nurse can offer some explanation about the development of infection instead of referring the patient to the surgeon.

Rationale 3: Commenting about being in the hospital instead of home when the infection developed does not address the patients concerns.

Rationale 4: How endothelial cells respond to alterations in the environment differ, according to the host genetics, age, gender, nature of the pathogen, and location of the vascular bed. The nurse should explain to the patient that the development of a wound infection depends upon these variables.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 3

Type: MCSA

A patient who underwent transurethral resection of the prostate 5 days ago returns to the emergency department. After assessing the patient and obtaining laboratory results the nurse notes a temperature of 96.8F, a respiratory rate of 26, and a white blood cell (WBC) count of 3,000 mm3. The nurse anticipates additional treatment for which disorder?

1. Systemic inflammatory response syndrome

2. Homeostasis

3. Localized inflammation

4. Multiple organ dysfunction syndrome

Correct Answer: 1

Rationale 1: Systemic inflammatory response syndrome is correct because the clinical manifestations include a respiratory rate of greater than 20 breaths per minute and a white blood cell count below 4,000/mm3. These findings meet the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference criteria of sepsis.

Rationale 2: Homeostasis is incorrect because the clinical manifestations are not compatible with the state of equilibrium found in homeostasis.

Rationale 3: Localized inflammation may exist and contribute to the patients condition, but is not the specific problem of concern.

Rationale 4: There is no indication of the failure of organ systems.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 37-2

Question 4

Type: MCSA

The nurse is admitting a patient into the intensive care unit and is planning preventative measures to avoid the onset of the systemic inflammatory response syndrome. Which assessment findings would increase the patients risk of developing this syndrome?

1. Age 36

2. Body mass index of 23

3. Asian ancestry

4. 15 pack-year smoking history

Correct Answer: 4

Rationale 1: Patient-related risk factors for developing systemic inflammatory response syndrome include older age.

Rationale 2: A normal body mass index does not increase risk for SIRS.

Rationale 3: There is no indication that those of Asian ancestry are at higher risk of developing SIRS.

Rationale 4: Smoking is a risk factor for developing SIRS.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-2

Question 5

Type: MCSA

A patient involved in a motor vehicle accident was admitted to the intensive care unit with a closed head injury. Which clinical manifestation would warn the nurse that the patients condition was progressing to multiple organ dysfunction syndrome?

1. Urine output less than 400 mL/day

2. Decreased PaO2 with an increase in FiO2

3. Alteration in level of consciousness

4. Hypotension that responds to fluids

Correct Answer: 2

Rationale 1: Urine output less than 400 mL/day develops later in the course of multiple organ dysfunction syndrome.

Rationale 2: Decreased PaO2 with an increase in FiO2 is correct because the lungs are usually the first organs to show signs of dysfunction and is the main organ affected in multiple organ dysfunction syndrome.

Rationale 3: Alteration in level of consciousness is probably already present with the closed head injury, and it also can occur with hypoperfusion, microvascular coagulopathy, or cerebral ischemia and not necessarily progress to multiple organ dysfunction syndrome.

Rationale 4: The hypotension and dysrhythmias common in MODS do not respond to fluid therapy.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 6

Type: MCMA

The nurse will calculate the pressure-adjusted heart rate for a patient with cardiovascular dysfunction associated with MODS. Which information must the nurse obtain before this measurement can be calculated?

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

2. Central venous pressure

3. Mean arterial pressure

4. Temperature

5. PaFiO2

Correct Answer: 1,2,3

Rationale 1: Heart rate is a part of this calculation.

Rationale 2: Central venous pressure is used in this calculation.

Rationale 3: Mean arterial pressure is used in this calculation.

Rationale 4: Temperature is not part of this calculation.

Rationale 5: PaFiO2 is not part of this calculation.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 7

Type: MCSA

A patient with a history of alcoholism and esophageal varices was admitted to the intensive care unit and developed multiple organ dysfunction syndrome. Which laboratory results would confirm the nurses suspicion of hepatic involvement?

1. Increased fibrinogen level

2. Decreased blood urea nitrogen

3. Increased serum bilirubin

4. Increased serum albumin

Correct Answer: 3

Rationale 1: Abnormalities in the liver would be likely to result in decreased fibrinogen levels.

Rationale 2: Blood urea nitrogen changes for several reasons and would generally increase in metabolic disorders.

Rationale 3: Liver dysfunction typically manifests as high levels of serum bilirubin. An increased serum bilirubin level would confirm the suspicion of hepatic involvement.

Rationale 4: Low serum albumin levels would indicate liver involvement.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 8

Type: MCSA

A patient diagnosed with sepsis and multiple organ dysfunction syndrome has developed acute renal failure. Which arterial blood gas (ABG) result would the nurse expect to find?

1. pH = 7.30, PaCO2= 38, HCO3 = 16, PaO2 = 60

2. pH = 7.50, PaCO2 = 30, HCO3 = 26, PaO2 = 90

3. pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70

4. pH = 7.46, PaCO2 = 42, HCO3= 28, PaO2 = 80

Correct Answer: 1

Rationale 1: The choice pH = 7.30, PaCO2 = 38, HCO3 = 16, and PaO2 = 60 metabolic acidosis is correct because of anaerobic metabolism due to hypoxia and an increase in lactic acid and the kidneys inability to excrete hydrogen ions. In acute renal failure metabolic acidosis can be caused by loss of bicarbonate.

Rationale 2: The choice pH = 7.50, PaCO2= 30, HCO3 = 26, PaO2 = 90 is incorrect because respiratory alkalosis can be found initially when a patient is hyperventilating or adjustments to the ventilator need to be made but not in an acute renal failure.

Rationale 3: The choice pH = 7.35, PaCO2 = 45, HCO3 = 24, PaO2 = 70 is incorrect; it is a normal ABG.

Rationale 4: The choice pH = 7.46, PaCO2 = 42, HCO3 = 28, PaO2 = 80 is incorrect because it is metabolic alkalosis and acute kidney failure would likely result in metabolic acidosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 9

Type: MCSA

A patient is in the intensive care unit with multiple organ dysfunction syndrome. Which assessment finding would suggest to the nurse that the patient is experiencing failure of the gastrointestinal system?

1. Increased flatus

2. Abdominal cramps

3. Absent bowel sounds

4. Complaint of epigastric burning

Correct Answer: 3

Rationale 1: Increased flatus would indicate some degree of gastrointestinal functioning.

Rationale 2: Abdominal cramps would indicate some degree of gastrointestinal functioning.

Rationale 3: Because there is no objective measure of gastrointestinal function in the patient, the one assessment finding that could indicate dysfunction in this system would be the absence of normal bowel sounds.

Rationale 4: Complaint of epigastric burning is not specific to gastrointestinal dysfunction.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-4

Question 10

Type: MCMA

Which nursing interventions should be implemented to help prevent the development of multiple organ dysfunction in a critically ill patient who is being mechanically ventilated?

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

Standard Text: Select all that apply.

1. Enforcing hand washing before and after touching a patient

2. Following an evidence-based ventilator bundle

3. Using urinary catheters to prevent perineal skin breakdown

4. Complying with turning and repositioning schedules

5. Restricting visitors to immediate family only

Correct Answer: 1,2,4

Rationale 1: Enforcing hand washing before and after touching a patient is correct because hand washing may prevent infections.

Rationale 2: An evidence-based ventilator bundle should be implemented to help avoid ventilator-associated pneumonias.

Rationale 3: Use of urinary catheters increases risk for infection and risk for multiple organ dysfunction.

Rationale 4: Minimizing the risk for pressure ulcers by relieving pressure and shear points can help prevent development of MODS.

Rationale 5: Restricting visitors is not necessary as long as universal precautions are followed.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 11

Type: MCSA

A critically ill patient who is being mechanically ventilated has a temperature of 97.8F. What nursing intervention is priority?

1. Cover the patient with a warming blanket.

2. Communicate with the provider.

3. Increase frequency of turning and repositioning the patient.

4. Increase the amount of humidification given via the ventilator.

Correct Answer: 2

Rationale 1: The patient may be more comfortable with a warming blanket, but this is not the priority intervention.

Rationale 2: Communicating a low temperature to the provider and discussing alteration in the plan of care is an essential intervention.

Rationale 3: This intervention may be indicated, but is not the priority.

Rationale 4: Increasing the amount of humidification may be indicated, but this is not the priority intervention.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 12

Type: MCSA

Which blood glucose reading would the nurse evaluate as supporting the outcome measure of maintaining glycemic control in a patient at risk for multiple organ dysfunction?

1. 100 mg/dL

2. 120 mg/dL

3. 156 mg/dL

4. 184 mg/dL

Correct Answer: 3

Rationale 1: The normal fasting blood sugar level is not a goal for this patient and may result in hypoglycemia.

Rationale 2: A high normal level of blood glucose is not the goal for this patient and may result in hypoglycemia.

Rationale 3: The goal for glucose control in this patient is approximately 150 mg/dL.

Rationale 4: This blood glucose level indicates inadequate glycemic control.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 13

Type: MCMA

The nurse is caring for a patient with multiple organ dysfunction syndrome. Which interventions would help optimize tissue perfusion for this patient?

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

Standard Text: Select all that apply.

1. Assess pulse oximetry.

2. Maintain patency of the endotracheal tube.

3. Administer pain medications as scheduled.

4. Keep the environment calm and quiet.

5. Maintain a darkened environment

Correct Answer: 2,3,4

Rationale 1: Simply assessing pulse oximetry will not affect tissue perfusion but may provide information about gas exchange.

Rationale 2: Maintaining the integrity of the endotracheal tube is part of managing the care of a patient being mechanically ventilated. Mechanical ventilation helps to provide oxygen for perfusion.

Rationale 3: Managing pain helps to decrease oxygen consumption so that more oxygen is available for tissue perfusion.

Rationale 4: A calm environment decreases oxygen consumption.

Rationale 5: A darkened environment can be frightening and stressful for the patient which would increase oxygen consumption.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

Question 14

Type: MCSA

A patient develops systemic inflammatory response syndrome (SIRS) after acute pancreatitis. The patients wife says, I thought he didnt have any infection. How should the nurse respond?

1. He probably had an infection that we did not recognize.

2. He developed SIRS after getting MODS.

3. Infection isnt necessary to develop SIRS, only a severe inflammation.

4. Your husbands body is working against itself.

Correct Answer: 3

Rationale 1: SIRS can occur in the absence of infection.

Rationale 2: Multiple organ dysfunction syndrome follows SIRS.

Rationale 3: Pancreatitis is a severe inflammatory illness. SIRS can develop without infection.

Rationale 4: The wife is not likely to understand this explanation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 15

Type: MCMA

A patient with a foot infection says, I can hardly walk on my foot because it is stiff and swollen. What nursing response is indicated?

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

Standard Text: Select all that apply.

1. Infections in the foot always swell because of gravity.

2. The swelling and pain help remind you not to overuse your foot.

3. That is a sign of infection that would not have occurred if the area was only inflamed.

4. Swelling indicates that your infection is getting worse.

5. Inflammation often causes pain and tissue swelling.

Correct Answer: 2,5

Rationale 1: The swelling is a normal part of the inflammatory process.

Rationale 2: Loss of function due to local swelling and pain is a physiologic change to help protect the site of injury.

Rationale 3: Inflammation also results in localized swelling and pain.

Rationale 4: Swelling may or may not indicate worsening of the infection.

Rationale 5: Pain and swelling are normal parts of the inflammatory response.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-1

Question 16

Type: MCMA

A hospitalized patient develops multiple organ dysfunction syndrome. Which assessment findings would be the best indication of oxygenation status?

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

Standard Text: Select all that apply.

1. Absence of central cyanosis

2. Decreased bowel sounds

3. Unlabored respirations

4. Mental slowing

5. Normal pulse amplitude

Correct Answer: 2,4

Rationale 1: Patients with MODS may appear clinically to have adequate oxygenation. It is not possible to determine that the patient is oxygenating all tissues on the basis of absence of central cyanosis.

Rationale 2: Regional tissue hypoxia, particularly in the intestinal tract, is a complication of MODS. Decreased bowel motility, evidenced by decrease in bowel sounds, is a result of that hypoxia.

Rationale 3: The patient with MODS may appear clinically to have adequate oxygenation, so respiratory effort may also appear to be normal.

Rationale 4: Regional tissue hypoxia occurs in MODS, particularly in the brain. Slowing of mental processes results from that hypoxia.

Rationale 5: Increasing cardiac contractility is compensatory for decreased tissue perfusion. This change will result in normal pulse amplitude in many cases, so the presence of normal pulses does not rule out regional tissue hypoxia.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-3

Question 17

Type: MCSA

A patient has developed MODS. The nurse would monitor for development of which classic coagulation system findings?

1. Large pulmonary emboli

2. Deep vein thrombosis

3. Clots in microcirculation

4. Clot occlusion of coronary arteries

Correct Answer: 3

Rationale 1: Large pulmonary emboli are not the most common effect of coagulation changes in MODS.

Rationale 2: Development of deep vein thrombosis is not the most common effect of coagulation changes in MODS.

Rationale 3: MODS causes abnormal clotting in the small blood vessels (microcirculation) that results in microthrombosis that obstructs blood flow.

Rationale 4: This is not the most common result of coagulation changes in MODS.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-3

Question 18

Type: MCSA

The health care team is working to prevent the development of MODS in a critically injured patient. The nurse would evaluate that these efforts have failed when which findings develop?

1. SIRS is confirmed.

2. Transfusion is required.

3. Laboratory findings over the last 24 hours indicated renal failure.

4. Respiratory distress and gastrointestinal bleeding have persisted for 36 hours.

Correct Answer: 4

Rationale 1: SIRS is a risk factor, but not all persons with SIRS develop MODS.

Rationale 2: Transfusion is a risk factor, but not all those who receive transfusions develop MODS.

Rationale 3: Failure of one organ system does not indicate MODS.

Rationale 4: MODS is the failure of two or more organ systems that persists beyond 24 hours.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 37-3

Question 19

Type: MCSA

Which information will the nurse gather to figure a patients Sequential Organ Failure Assessment (SOFA) score?

1. Hemoglobin

2. Blood glucose

3. Platelets

4. Urine pH

Correct Answer: 3

Rationale 1: Hemoglobin is not considered in this scoring.

Rationale 2: Blood glucose is not considered in this scoring.

Rationale 3: Platelet measurement is considered in SOFA scoring as an indicator or hematological function.

Rationale 4: Urine pH is not considered in SOFA scoring.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-4

Question 20

Type: MCSA

A patient has developed MODS. Which information should the nurse provide to the patients family?

1. Treatment will require intubation and placement on mechanical ventilation.

2. Treatment will focus on supporting all organ systems.

3. MODS can be corrected with antibiotic therapy and rest.

4. MODS patients require dialysis.

Correct Answer: 2

Rationale 1: Not all MODS patients require this level of respiratory support.

Rationale 2: Treatment must focus on supporting those organ systems that are failing and protecting the organ systems that have not failed.

Rationale 3: There is no definitive treatment for MODS.

Rationale 4: Not all patients require this level of renal support.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 37-5

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