A patient who sustained acute head trauma exhibited intermittent unconsciousness prior to admission. The patient is disoriented initially and exhibits rapid deterioration in neurological status shortly after admission. X-rays reveal a right temporal bone fracture, and a diagnosis of epidural hematoma is made. The deterioration in the patient's condition is most likely associated with
A patient with a left ventricular assist device has been hospitalized for 5 days. A nurse notes anasarca and skin breakdown over multiple pressure points. When addressing the patient's nutritional needs, which of the following should the nurse consider?
Postoperatively, symptoms that may indicate hemothorax or internal bleeding in a video-assisted thoracic surgery (VATS) patient include
Which of the following intubated patients is most at risk for developing ventilator-associated pneumonia (VAP)?
A caloric irrigation test of the oculovestibular reflex is performed on a patient who is comatose following a hypoxic brain injury. When cold water is introduced into the left ear, nystagmus occurs with slow deviation of the eyes toward the left, followed by faster eye deviation to the right. This pattern is indicative of a
A terminally ill patient is deteriorating. The patient's family states, "We don't want him to suffer any more." The most appropriate response is
A family member asks permission to visit a patient after work at 12:30 AM. On previous visits, the family member has been disruptive. To address the situation, a nurse should
A patient is 2 days post MI. The patient was stable until this morning, when severe chest discomfort developed. Assessment reveals:
BP70/palpable
HR122
RR38
PAOP28 mm Hg, with large V waves
CI1.6 L/min/m2
Cool, clammy skin
Inspiratory crackles throughout the lung field
Loud blowing holosystolic murmur at the apex
The patient's present clinical status is most likely a result of
Which of the following serum laboratory results is most concerning to a nurse who is caring for a patient with a Stage Ill pressure ulcer on the coccyx?
In order to meet the spiritual needs of critically ill patients and their families, which of the following should the nurse understand regarding chaplain services?
Examination of a patient exhibiting Kernig's and Brudzinski's signs indicates which of the following?
Patients in end-stage cardiomyopathy often exhibit which of the following symptoms of right-sided heart failure?
A patient with a history of COPD is admitted with increasing dyspnea and fatigue. O2 is initiated via nasal cannula at 4 L/min with an O2 saturation of 99%. One hour later, the patient becomes lethargic. Which of the following is the most likely cause for the change in the patient's mental status?
After observing an increase in the occurrence of oral pressure injuries in intubated patients on the unit, the nurse should
A patient who recently lost their spouse is admitted following an emergent cardiac catheterization. The procedure report states chest pain and ST elevation, no significant coronary artery disease, left ventricular dysfunction with apical ballooning, and an EF of 35%. These findings are consistent for
A patient with a C5 spinal cord injury calls the nurse every 15 minutes with requests for juice, water, and repositioning. Which of the following is the nurse's best response?
A patient who experienced a blunt chest trauma in an automobile crash is admitted with multiple rib fractures. The patient is dyspneic and hypotensive and is reporting left shoulder pain. On auscultation, a nurse notes that bowel sounds can be heard over the lower left thorax. These findings are consistent with
A nurse who is providing care to a patient with a hemorrhagic stroke receives an order to administer 3% Normal Saline IV. The nurse should recognize the goal of therapy is to create an
A patient with acute renal failure has a serum potassium level of 7.2 mEq/L. The most appropriate immediate intervention for this patient is
The family member of a patient who is receiving mechanical ventilation is to be taught suctioning. When developing a teaching plan, the nurse should first
A nurse is caring for a patient who had a gastric bypass procedure 2 days ago. A physician has ordered a gastric tube to be placed due to increased abdominal distention. The nurse realizes that this procedure will most likely need to be done
A patient who is confused and dyspneic is admitted with ABG values that reveal hypoxemia. Results from insertion of a pulmonary artery catheter are:
PAP 38/18 mm Hg
PAOP10 mm Hg
CI 3.5 L/min/m2
These values are most indicative of
A patient underwent bariatric surgery for weight loss 3 days ago. The patient appears anxious, restless, and reports increased abdominal pain over the last 24 hours. The nurse palpates mild subcutaneous crepitus over the neck. Vital signs are:
BP 106/64
HR 128
RR 27
T 100.4° F (38°C)
Which action should the nurse anticipate?
A 22-year-old trauma patient sustained multiple fractures after a fall. The patient fell 50 feet from a cliff while rock climbing without a harness. The patient is intubated and sedated with casts to bilateral lower extremities. The nurse should recognize that young adults are
A patient with a history of six cardiac catheterizations relates that he has received differing instructions about the duration of required bedrest after the procedure. To further investigate this issue, which of the following is a nurse's most appropriate action?
A patient with cardiogenic shock for several days has been managed aggressively with vasopressor and inotrope therapies. Which of the following indicates organ dysfunction from hypoperfusion?
A patient has gained 8 kg in the past week. Serum sodium is 115 mEq/L, CVP is 20 mm Hg, and serum osmolality is decreased. The patient has just experienced a generalized tonic-clonic seizure. In this situation, which of the following IV solutions should a nurse be prepared to administer?
Which of the following assessment findings would be found in a patient with pulmonary hypertension?
A nurse is providing care to a patient diagnosed with abdominal compartment syndrome. The nurse should recognize the patient is most at risk for developing
An older adult patient is admitted with acute exacerbation of congestive heart failure. An echocardiogram indicates that EF is unchanged at 50%. The patient is most likely experiencing
Which of the following should the nurse expect in a patient with papillary muscle dysfunction?
Which of the following is the most common prerenal cause of acute tubular necrosis?
A patient with an acute anterior wall MI presents with an S3 gallop and the following values:
Which drug therapy would be most appropriate for this patient?
A patient admitted with a diagnosis of pneumonia has a temperature of 103.2° F (39.5° C) and copious pulmonary secretions. ABG results drawn on room air are:
The nurse should expect that hemoglobin's affinity for oxygen in this patient to be
Which of the following is most indicative of successful treatment for salicylate poisoning?
Laboratory values diagnostic for disseminated intravascular coagulation (DIC) include
A patient with history of hypothyroidism is admitted with severe confusion and nonpitting edema. The nurse should anticipate which order?
A patient has been declared brain dead. A nurse would like the family to consider organ donation but has never requested this from a family before. The best initial action by the nurse is to
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TESTED 21 Nov 2024
Epidural hematoma
Ventricular assist device
Hemothorax
Spinal cord injury
Hypovolemic shock
Salicylate poisoning