Test Bank for Priorities in Critical Care Nursing, 9th Edition, Linda D. Urden, Kathleen M. Stacy, Mary E. Lough
Priorities in Critical Care Nursing, 8th Edition By URDEN |Complete Guide Questions and Answers| REVISED EDITION| All Chapters And Rationales Included| 2024/2025 Brand New |Graded A+|
Test Bank for Priorities in Critical Care Nursing, 9th Edition, Linda D. Urden, Kathleen M. Stacy, Mary E. Lough
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Test Bank - Priorities in Critical Care Nursing, 8th Edition
(Lough, 9780323531993), Chapter 1-27 | Rationals Included
An acutely ill patient is receiving in the hospital's critical care unit. In addition to being delirious, the
patient is simultaneously exhibiting significant signs of anxiety. The critical care nurse should
recognize that this patient has a heightened risk of having what nursing diagnosis?
A) Risk for Aspiration
B) Risk for Impaired Skin Integrity
C) Risk for Injury
D) Risk for Imbalanced Body Temperature - ANSWER: Correct response:
Risk for Injury
Explanation:
A delirious patient who is also experiencing anxiety is at risk of injuring himself or herself;
interventions to prevent this are necessary. Risks of aspiration or impaired skin integrity are not
implausible, but these are less likely than injury. Anxiety and delirium do not normally contribute to
impaired temperature regulation.
A patient is being treated in the critical care unit for urosepsis. The patient's level of consciousness
has decreased over the past 12 hours, but the nurse is continuing to conduct regularly scheduled pain
assessments in the knowledge that:
A) Pain is associated with a consequent decrease in renal function.
B) Pain blunts the patient's awareness of other important signs and symptoms.
C) Pain contributes to hyperglycemia and hypoglycemia.
D) Pain increases the patient's cardiac workload. - ANSWER: Correct response:
Pain increases the patient's cardiac workload.
Explanation:
It is well known that pain elicits a stress response leading to a catabolic state with increased cardiac
workload and an impaired immune response. Care must be taken to ensure that all ICU patients are
assessed for any pain whether or not they are able to communicate their pain.
A patient who has been admitted to the intensive care unit (ICU) with extensive burns is conscious but
unable to speak due to upper airway trauma. When communicating with this patient, the ICU nurse
should adopt which of the following strategies?
A) Provide brief explanations and directions to the patient.
B) Ask the patient questions that can be answered with a nod or a shake of the head.
C) Defer to a friend or family member of the patient when information is needed.
D) Speak to the patient slowly and with increased volume. - ANSWER: Correct response:
Ask the patient questions that can be answered with a nod or a shake of the head.
Explanation:
Communication strategies for patients who cannot speak include asking yes or no questions to which
patients may nod their head. There is no indication that the patient has a deficit in cognition of
understanding, so speaking more slowly or loudly than normal is unnecessary. It would be
inappropriate to defer to the patient's friend or family member if the patient is conscious.
A 70-year-old woman was admitted to the medical unit with a diagnosis of pyelonephritis but failed to
respond appreciably to antibiotic therapy. Upon demonstrating warning signs and symptoms of septic
shock, the patient has transferred to the intensive care unit for treatment. Recent assessments
,suggest that the patient's infection is now beginning to resolve. What types of monitoring and
assessment are likely to be required in this patient's immediate care? Select all that apply.
A) Peripheral intravenous access
B) Arterial line access
C) Pulmonary artery catheterization
D) Ventricular assist device
E) Cardiac monitoring - ANSWER: A) Peripheral intravenous access
E) Cardiac monitoring
Reason:
Fluid replacement must be instituted to correct the hypovolemia that results from the incompetent
vasculature and the inflammatory response.
Fluid resuscitation should be initiated early and aggressively in patients with shock to maximize
intravascular volume. For example, in patients with septic shock, an intravenous fluid challenge (20 to
30 mL/kg) may be given rapidly of crystalloid IV fluid to improve intravascular volume.
Initially, two large-bore peripheral IVs (at least 16 gauge) are inserted to prepare for fluid
administration
Current treatment of septic shock involves identification and elimination of the cause of infection and
aggressive cardiopulmonary support to prevent or limit end-organ damage and death.
5. An arterial line has been ordered for a patient who is receiving treatment in the critical care unit.
The nurse on the unit should recognize that this patient will benefit from:
A) Bolus infusion of intravenous solution
B) Simultaneous administration of more than one antibiotic
C) Frequent blood pressure monitoring
D) Serial blood culture samples - ANSWER: Correct response:
Frequent blood pressure monitoring
Explanation:
An arterial line is a peripheral IV in the arterial system used for frequent blood pressure monitoring
when a patient requires vasoactive medications (such as nitroprusside) and frequent blood sampling.
It is not for administration of fluids or medications and blood is not drawn from the line.
An acutely ill patient has had a pulmonary artery catheter (PAC) placed and the critical care nurse is
closely monitoring the data that the PAC provides. When documenting the patient's mean arterial
pressure, the nurse understands that this value represents:
A) The midpoint between the patient's systolic arterial blood pressure and diastolic arterial blood
pressure
B) The average arterial blood pressure throughout the patient's cardiac cycle
C) The difference between the patient's systolic arterial blood pressure and diastolic arterial blood
pressure
D) The standard deviation of the patient's arterial blood pressure over a given time period - ANSWER:
B) The average arterial blood pressure throughout the patient's cardiac cycle
MAP is the Average arterial pressure throughout the cardiac cycle
Formula for MAP is ~ Systolic BP + 2(diastolic BP)/3
Normal MAP Values ~ 70 to 105
A patient in the intensive care unit has had blood work drawn several times over the past 24 hours
and the nurse notes that the patient's serum lactic acid level is trending upward. The most recent
level is elevated at 5.3 mEq/L. What interpretation should the nurse draw from this assessment
finding?
, A) The patient is experiencing increased intracranial pressure.
B) Intracellular contents are being released into the patient's vascular space.
C) The patient has developed a systemic infection.
D) The patient is experiencing a deficit in oxygen supply. - ANSWER: Correct response:
The patient is experiencing a deficit in oxygen supply.
Explanation:
The lactic acid level represents the end product of anaerobic metabolism used by the body during
times of insufficient oxygen supply. This level rises with larger and longer oxygen supply deficits. This
phenomenon does not denote increased intracranial pressure, infection, or cellular lysis.
A male patient who presented to the emergency department with severe headache and visual
disturbances has been found to be experiencing a hypertensive emergency and has been admitted to
the critical care unit. The critical care unit should anticipate the administration of which of the
following medications?
A) Epinephrine
B) Dopamine
C) Nitroprusside
D) Dobutamine - ANSWER: Correct response:
Nitroprusside
Explanation:
Decreased blood pressure is the major indication for the administration of nitroprusside. Dopamine,
dobutamine, and epinephrine would exacerbate this patient's hypertension.
A patient with class IV heart failure has been receiving care in the cardiac critical care unit and
attempts to wean the patient from inotropic support have been unsuccessful. The care team has
appraised the benefits and deficits of a ventricular assist device (VAD) and will present this option to
the patient's family. When teaching the patient's family about this intervention, what description
should the nurse provide?
A) "A VAD is inserted to supplement the heart's ability to pump blood from the heart to the rest of the
body."
B) "A VAD regulates the electrical activity in the heart and coordinates the pumping action to increase
efficiency."
C) "A VAD increases the size of the blood vessels downstream from the heart so that circulation is
easier and more efficient."
D) "A VAD involves the insertion of a balloon into a major blood vessel to improve the strength and
volume of circulation." - ANSWER: Correct response:
"A VAD is inserted to supplement the heart's ability to pump blood from the heart to the rest of the
body."
Explanation:
A ventricular assist device (VAD) is an implantable device in which cannulas are inserted into the atria
or ventricles to support the right heart, left heart, or both sides by taking over the work of delivering
blood to the pulmonary artery and/or aorta. It does not alter the electrical activity of the heart,
increase the size of the vascular space, or use a balloon to improve circulation.
Continuous positive airway pressure (CPAP) has been ordered for a patient in the intensive care unit
in an effort to defer intubation. The respiratory therapist has set up the patient's CPAP system and the
nurse is now responsible for maintaining the system. When assessing the function of the patient's
CPAP, the nurse should ensure that:
A) Suction is set between 30 and 45 mm Hg.
B) The patient receives nebulized bronchodilators every 2 to 3 hours.
C) A tight seal exists between the mask and the patient's mouth.
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