An older adult patient was hospitalized for 2 weeks before having abdominal surgery 3 days ago. The nurse notes the patient’s hair is broken and dull. Which intervention is indicated?
- Increase vigilance for dehiscence.
- Talk to the family about trimming the patient’s hair.
- Use a protein-based shampoo.
- Increase the patient’s oral fluid intake.
Correct Answer: 1
Rationale 1: Broken and dull hair may indicate protein-calorie malnutrition. If this condition exists it increases risk for dehiscence of the patient’s abdominal incision.
Rationale 2: Trimming the hair will not reverse the process that is likely occurring.
Rationale 3: External application of protein will not correct the probable source of this change in the patient’s hair.
Rationale 4: Increasing fluid will not change this situation.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-1
Question 2
Type: MCSA
A patient with a BMI of 32 is in the intensive care unit recovering from surgery to repair an abdominal aortic aneurysm. What should be the nurse’s focus regarding this patient’s nutritional needs?
- Support elevated nutrient needs.
- Maintain on intravenous fluids and clear liquids.
- Limit food and fluid intake to three mealtimes daily.
- Begin a weight-reduction program immediately.
Correct Answer: 1
Rationale 1: During acute illness it is crucial to meet the elevated nutrient needs of obese patients to optimize outcomes.
Rationale 2: Weight loss is not the focus of the patient’s current needs.
Rationale 3: There is no reason to limit food to three daily meals. Fluids should not be restricted unless there is a comorbid condition that requires decrease in fluid intake.
Rationale 4: Weight loss is not the focus of the postoperative period.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-1
Question 3
Type: MCSA
A patient admitted for a gunshot wound to the leg and multiple abdominal stab wounds is transferred to the intensive care unit after surgery. The nurse would evaluate which finding as expected but as requiring monitoring?
- Blood pressure 170/104 mm Hg
- Elevated blood glucose level
- Serum potassium of 5.4 mEq/L
- Increase in body temperature
Correct Answer: 2
Rationale 1: This blood pressure reading would not be expected with this patient’s mechanism of injury.
Rationale 2: The first 24 hours after a body injury, the body responds with an increase in mobilization of carbohydrates and lipids. Glucose production increases in efforts to support wound healing. The body also responds by decreasing the amount of insulin produced. Because of these bodily responses, the nurse will most likely observe an elevated blood glucose level that will impact the patient’s nutritional needs at this time. This finding is physiologically normal but will require monitoring as the patient heals.
Rationale 3: This potassium level is elevated and is not an expected finding.
Rationale 4: The first 24 hours after a body injury, the body responds with a drop in body temperature. Increased temperature is not an expected finding.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-1
Question 4
Type: MCSA
The nurse is planning a refeeding program for a patient diagnosed with cachexia from AIDS. Which nursing interventions are indicated?
- Encourage the patient to eat as much as possible during each meal.
- Plan to increase the patient’s calorie intake to goal in 2 or 3 days.
- Limit the patient’s intake of fluids so to encourage a normal appetite.
- Each day offer foods that provide 20kcal/kg of the patient’s actual body weight.
Correct Answer: 4
Rationale 1: If the patient ingests as much food as possible during each meal, the risk of refeeding syndrome will increase.
Rationale 2: The increase in calories to the established goal should be done slowly and may take as long as a week.
Rationale 3: Restriction of fluids is not indicated, will not necessarily stimulate a normal appetite, and may place the patient at risk for fluid volume deficit.
Rationale 4: The patient with cachexia from AIDS is at risk for developing refeeding syndrome. In efforts to reduce this risk, the patient’s daily calorie intake should equal 20 kcal/kg of body weight.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-5
Question 5
Type: MCSA
The nurse is caring for a patient with a history of hypercapnea. What should the nurse include when planning for this patient’s nutritional needs?
- Monitor carbohydrate intake to reduce body carbon dioxide levels.
- Encourage fat intake.
- Minimize vitamin supplements.
- Limit protein.
Correct Answer: 1
Rationale 1: Limiting the carbohydrate intake in a patient with a history of hypercapnea would be beneficial in efforts to reduce the body’s carbon dioxide load.
Rationale 2: Fat is calorie intense and patients with excessive overall calorie intake may have increased carbon dioxide levels.
Rationale 3: Vitamin supplements should be provided according to the patient’s needs and not minimized unless necessary.
Rationale 4: The patient’s protein should not be limited but rather calculated to meet the patient’s needs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-1
Question 6
Type: MCSA
The nurse is caring for a patient diagnosed with chronic renal failure and being treated with hemodialysis who weighs 100 kg. What would be an appropriate intake of protein for this patient?
- 120 g per day
- 75 g per day
- 240 g per day
- 60 g per day
Correct Answer: 1
Rationale 1: The patient with renal failure receiving maintenance hemodialysis would benefit from receiving a protein intake of 0.8 to 2.0 g/kg per day. The patient weighs 100 kg and therefore a daily intake of 120 g of protein per day would be appropriate.
Rationale 2: 75 g of protein is equal to 0.75 g/kg, which is too low for this patient.
Rationale 3: 240 g of protein is equal to 2.4 g/kg, which is too high for this patient.
Rationale 4: 60 g of protein is 0.6 g/kg and is too low for this patient.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-2
Question 7
Type: MCSA
A patient, being treated for multiple injuries in the intensive care unit, had been NPO for several days. Clear liquids are started today, but the patient only takes a few sips before refusing additional fluids and then vomiting. The patient’s temperature is also elevated. The nurse would assess for findings associated with which disorder?
- Gastric ulcer
- Gut failure
- Electrolyte imbalance
- Diabetes insipidus
Correct Answer: 2
Rationale 1: Inability to tolerate fluids after being NPO would not be a primary indicator of gastric ulcer.
Rationale 2: During periods of high stress, the body will shunt blood to the organs to maintain maximum functioning. When this occurs, the gastrointestinal tract could develop ischemia and atrophy. The introduction of food or fluids at this time could cause the patient to vomit and have complaints of early satiety. With an ischemic gut, the patient is prone to developing bacterial translocation, which means bacteria enter the general circulation from the gastrointestinal tract. This is a major cause of sepsis with the body response as an increase in temperature.
Rationale 3: Inability to tolerate fluids after being NPO would not indicate an electrolyte imbalance.
Rationale 4: Inability to tolerate fluids after being NPO would not indicate diabetes insipidus.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-2
Question 8
Type: MCSA
The nurse is caring for a patient who sustained burns of 40% of the total body surface area. What would the nurse plan to meet this patient’s nutritional needs?
- Supply with balanced nutrients to meet current body weight needs.
- Complete a nutritional assessment and supply with high-calorie, high-protein supplements.
- Provide high dose therapy of vitamins C and B.
- Supply with high-fat and high-carbohydrate supplements.
Correct Answer: 2
Rationale 1: Because of the hypermetabolic status of the patient, the patient needs more calories than those needed to meet current body weight needs.
Rationale 2: The patient recovering from a burn injury of 40% of the total body surface should have a complete nutritional assessment and then be supplied with high calorie, high protein supplements to meet the body’s hypermetabolic and healing needs.
Rationale 3: Standardized protocols for vitamin supplementation should be followed.
Rationale 4: High fat and high carbohydrate are not the primary needs for this patient.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-2
Question 9
Type: MCSA
The nurse is caring for a patient who is comatose after a traumatic brain injury. What is important for the nurse to include when planning for this patient’s nutritional needs?
- Provide adequate calories in the form of carbohydrates and fats.
- Ensure adequate protein intake to maintain a positive nitrogen balance.
- Plan to implement parenteral nutrition as soon as possible.
- Increase dietary supply of cortisol.
Correct Answer: 2
Rationale 1: Calories should be provided to support all nutritional needs and not focus on carbohydrates and fats.
Rationale 2: In the patient with a traumatic brain injury, providing adequate energy and protein for a positive nitrogen balance is paramount to successful treatment, and aggressive nutrition support is recommended.
Rationale 3: Because patients with traumatic brain injury often have poor cough or gag reflex they are at risk of pulmonary aspiration. Enteral nutrition is the preferred alternative to oral nutrition.
Rationale 4: Patients with traumatic brain injury have massive release of catecholamines and cortisol. Cortisol in not added by nutritional means.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-2
Question 10
Type: MCSA
A patient, in the intensive care unit, has been NPO for several days. The nurse is unable to assess bowel sounds. What should be included in to the plan to support this patient’s nutritional needs?
- Maintain NPO status.
- Prepare to assist with implementation of a large bore venous access device to support total parenteral nutrition.
- Determine best enteral feeding approach and plan implementation.
- Begin oral feeding with a diet as tolerated as soon as bowel sounds return.
Correct Answer: 3
Rationale 1: The patient should not be maintained on NPO status only because of the absence of bowel sounds.
Rationale 2: Total parenteral nutrition might expose the patient to unnecessary pathogens which could compromise the healing process.
Rationale 3: Readiness for enteral feeding should not be determined by the presence of bowel sounds. Active bowel sounds have been used as criteria to initiate feeding, but there is no scientific evidence to support this practice. Bowel sounds are a poor indicator of small bowel motility and nutrient absorption, as they are the result of air passing through the intestinal tract.
Rationale 4: The patient may or may not be able to tolerate oral feedings with a diet as tolerated. Nutritional support should not wait until the presence of bowel sounds.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-3
Question 11
Type: MCMA
The nurse is assessing a patient’s ability to receive enteral feedings. Which findings would the nurse evaluate as potential contraindications to this intervention?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- The patient has a history of Crohn’s disease.
- The patient has a gastric ulcer.
- There is a mechanical obstruction.
- The patient has developed hemorrhagic pancreatitis.
- The patient has had severe intractable diarrhea for 3 days.
Correct Answer: 3,4,5
Rationale 1: History of Crohn’s disease is not a contraindication for enteral therapy.
Rationale 2: Presence of gastric ulcer is not a contraindication to enteral feeding but may be a determinant of type of feeding tube chosen.
Rationale 3: Contraindications to enteral nutrition have diminished as its safety and efficacy has been demonstrated in many types of high-acuity patients. Mechanical obstruction is the only absolute contraindication to enteral feedings.
Rationale 4: Severe hemorrhagic pancreatitis is a relative contraindication to enteral feeding.
Rationale 5: Severe intractable diarrhea is a relative contraindication to enteral feeding.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-3
Question 12
Type: MCSA
A patient, with a history of aspiration pneumonia, is going to receive enteral feedings. What should be considered regarding the tube and placement for this patient?
- Postpyloric feedings need to be interrupted and would not support the patient’s nutritional needs.
- Postpyloric feedings have less incidence of pneumonia in some groups and would be preferred for this patient.
- Gastric feedings provide more calories and better tolerance.
- Gastric feedings are ideal as long as the patient is receiving a proton pump inhibitor.
Correct Answer: 2
Rationale 1: Postpyloric feedings do not need to be interrupted as much as gastric feedings.
Rationale 2: Because it is documented that postpyloric feedings can be provided with less interruption and a higher nutritional intake and there is a lower incidence of pneumonia in some patients this technique should be considered for the patient.
Rationale 3: Gastric feedings are usually interrupted and would not necessarily provide more calories for the patient.
Rationale 4: The use of a proton pump inhibitor does not decrease the risk of gastric feeding related pneumonia.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5-3
Question 13
Type: MCSA
A patient receiving nasogastric tube feedings has a gastric residual volume of 450 mL. Which nursing intervention is indicated?
- Hold the tube feeding until the gastric aspirate is less than 100 mL.
- Provide the tube feeding as a bolus.
- Hold the tube feeding until the gastric aspirate is less than 250 mL.
- Provide the tube feeding as a continuous infusion.
Correct Answer: 3
Rationale 1: It is not necessary to wait until the gastric residual volume is less than 100 mL since this is a nasogastric tube and not a gastrostomy tube.
Rationale 2: Introducing a bolus feeding would quickly increase the amount of feeding in the stomach and is not indicated.
Rationale 3: A common intervention for high gastric residual volume is to hold the enteral feeding for 1 to 2 hours until the residual volume is less than 200 to 250 mL from a nasogastric tube.
Rationale 4: Additional tube feeding should not be introduced at this time.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-3
Question 14
Type: MCSA
A patient has a clogged postpyloric feeding tube. Which nursing intervention is indicated?
- Irrigate the tube with a large amount of pressure to break the clog.
- Pull the tube and insert another.
- Slowly attempt to irrigate the tube with warm water.
- Use a stylet to break through the clog.
Correct Answer: 3
Rationale 1: The nurse should not irrigate the tube with large amounts of pressure.
Rationale 2: Efforts should be undertaken to dislodge the clog before pulling the tube and inserting another.
Rationale 3: To dislodge a clogged tube, irrigate the tube with warm water, cola, or juice. Also, using a syringe with alternating positive and negative pressure can dislodge a clog.
Rationale 4: Using a stylet to break up a clog can cause an esophageal or gastric mucosa tear.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-3
Question 15
Type: MCMA
The nurse is caring for a patient with a large bore catheter for total parenteral nutrition. Which findings would indicate to the nurse that the patient might be experiencing catheter related sepsis?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Sudden glucose intolerance
- Leukocytosis
- Sudden onset of chills
- Sudden onset chest pain
- Tenderness at the insertion site
Correct Answer: 1,2,3,5
Rationale 1: Sudden glucose intolerance may occur up to 12 hours before a temperature elevation occurs and is an indicator of catheter-related sepsis.
Rationale 2: Leukocytosis will occur as the patient’s immune system begins to fight the infection.
Rationale 3: The patient may be experiencing chills for a number of reasons, but the nurse should consider the possibility of catheter-related sepsis.
Rationale 4: Sudden onset chest pain may occur if a pneumothorax develops but is not associated with catheter related sepsis.
Rationale 5: Infection at the site of insertion can be manifested by tenderness or erythema. Infection at this site is considered a catheter-related infection and can lead to sepsis.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-4
Question 16
Type: MCSA
A patient receiving total parenteral nutrition has elevated serum blood urea nitrogen and serum sodium levels. The nurse would conduct additional assessment for which complication?
- Prerenal azotemia
- Hyperglycemia
- Catheter related sepsis
- Hepatic dysfunction
Correct Answer: 1
Rationale 1: Prerenal azotemia is caused by overaggressive protein administration and is aggravated by underlying dehydration. Presenting signs and symptoms include an elevated serum BUN, serum sodium, and clinical signs of dehydration.
Rationale 2: Hyperglycemia is indicated by blood glucose level of greater than 220 mg/dL while receiving total parenteral nutrition.
Rationale 3: Signs and symptoms of catheter related sepsis include sudden onset of fever, rigors, or chills that coincide with parenteral infusion; erythema, swelling, tenderness, or purulent drainage from the catheter site; sudden temperature elevation that resolves on catheter removal; leukocytosis; sudden glucose intolerance that may occur up to 12 hours before temperature elevation; and bacteremia/septicemia/septic shock.
Rationale 4: Hepatic dysfunction would be assessed with serum liver function tests and bilirubin levels.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-4
Question 17
Type: MCSA
After the insertion of a central venous catheter for total parenteral nutrition, the patient demonstrates dyspnea. The nurse is concerned that pneumothorax may be occurring. Which assessment findings would support this concern?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
- Restlessness
- Chest pain
- Decrease in pulse oximetry reading
- Severe headache
- Combativeness
Correct Answer: 2
Rationale 1: Restlessness may occur as pneumothorax increases in size.
Rationale 2: Chest pain is a common finding during pneumothorax.
Rationale 3: Hypoxia will occur as pneumothorax size increases.
Rationale 4: Headache is not associated with development of pneumothorax.
Rationale 5: Combativeness is not a common result of pneumothorax.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-4
Question 18
Type: MCMA
A patient is suspected of having an air emboli from a central venous line inserted for total parenteral nutrition. What nursing interventions are indicated?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Place the patient on the left side.
- Place the patient in Trendelenburg position.
- Occlude the catheter nearest to the entry site of the skin.
- Notify the physician and prepare to take the patient to surgery.
- Prepare to assist with chest tube insertion.
Correct Answer: 1,2,3
Rationale 1: When air embolus is suspected, immediate action is required. The patient should be placed on the left side. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.
Rationale 2: When air embolus is suspected, immediate action is required. The patient should be placed in the Trendelenburg position. This allows an air embolus to float into the right ventricle of the heart, away from the pulmonary artery.
Rationale 3: The nurse should prevent additional air from entering the circulatory system by occluding the catheter as close as possible to where it enters the skin.
Rationale 4: Surgical intervention is not necessary.
Rationale 5: Chest tubes are not used in the treatment of air embolism.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-4
Question 19
Type: MCMA
The nurse is concerned that refeeding syndrome may be occurring in a patient receiving enteral nutrition. Which laboratory values would support this concern?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Serum potassium is 3.4 mEq/L
- Fasting blood glucose is 98mg/dL
- Hemoglobin is 10.8 g/100mL
- Serum sodium of 138 mEq/L
- Chloride of 98 mmol/L
Correct Answer: 1,3
Rationale 1: Hypokalemia is one of the electrolyte imbalances associated with refeeding syndrome.
Rationale 2: Hyperglycemia is more likely to occur with refeeding syndrome.
Rationale 3: Anemia can occur as a result of refeeding syndrome.
Rationale 4: This is a normal serum sodium level.
Rationale 5: This is a normal chloride level.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 5-5
Question 20
Type: MCSA
A patient has been started on tube feeding by nasogastric tube. When his wife visits she says, “I need to tell you that my husband is lactose intolerant so that feeding will make him sick.” What nursing response is indicated?
- “Even though the tube feeding fluid looks like milk it is lactose-free.”
- “We did not know that. I will contact his physician immediately.”
- “Since he is being fed by tube, the fact that he is lactose intolerant is not an issue.”
- “We will watch to see if he has any symptoms of lactose intolerance.”
Correct Answer: 1
Rationale 1: Commonly used tube feedings are lactose-free.
Rationale 2: There is no need to contact the physician.
Rationale 3: The process of tube feeding does not change the concern over the patient being lactose intolerant.
Rationale 4: The nurse should educate the wife about tube feeding.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5-3
Wagner, High Acuity Nursing, 6e
Chapter 7
Question 1
Type: MCSA
The nurse is preparing to use a patient’s pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated?
- Zero the transducer at the phlebostatic axis.
- Place the patient in Trendelenburg position.
- Warm cardiac output injectate fluid to body temperature.
- Prepare 20 mL of injectate.
Correct Answer: 1
Rationale 1: The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip.
Rationale 2: Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings.
Rationale 3: Injectate should be iced or room temperature but not warmed.
Rationale 4: The traditional method of thermodilution cardiac output uses a 10mL bolus of injectate.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-4
Question 2
Type: MCSA
The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?
- Inflating the pressure bag to 300 mm Hg
- Infusing a vasoactive drug through the proximal injectate port
- Obtaining a pulmonary artery wedge pressure reading through the distal port
- Using iced normal saline to obtain a cardiac output
Correct Answer: 2
Rationale 1: In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg.
Rationale 2: The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port.
Rationale 3: The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure.
Rationale 4: Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 7-3
Question 3
Type: MCSA
While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patient’s cardiac output remains at 6.0 liters per minute. What would the nurse expect the patient’s blood pressure to be?
- Increased
- Unchanged
- Decreased
- Initially decreased, and then increased
Correct Answer: 1
Rationale 1: Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume, measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up.
Rationale 2: Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure.
Rationale 3: Since the heart is working harder, blood pressure will not decrease immediately.
Rationale 4: The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-7
Question 4
Type: MCSA
The nurse is reviewing the results of a patient’s cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate?
- A low cardiac output
- Poor injection technique
- Incorrect placement of the catheter
- A high cardiac output
Correct Answer: 4
Rationale 1: A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output.
Rationale 2: The size of the curve does not indicate poor injection technique.
Rationale 3: A small cardiac output curve does not indicate incorrect placement of the catheter.
Rationale 4: A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-3
Question 5
Type: MCMA
The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Jugular vein distention
- Weak, thready pulse
- Presence of rales and rhonchi
- Poor skin turgor
- Hepatomegaly
Correct Answer: 1,5
Rationale 1: Elevation of right arterial pressure indicates high right ventricular preload which results in fluid back up into the venous system. Jugular vein distention is a sign of increased right ventricular preload.
Rationale 2: The pulse is usually full and bounding when right atrial pressure is increased.
Rationale 3: Rales and rhonchi are signs of left-sided heart failure.
Rationale 4: Skin turgor is a manifestation of hydration status.
Rationale 5: Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid back up into the venous system. Hepatomegaly is a sign of increased right ventricular preload.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-5
Question 6
Type: MCMA
A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patient’s right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of which conditions?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Internal hemorrhage
- Fluid loss during surgery
- Vasodilation from drugs administered during surgery
- Left heart failure
- Cardiac tamponade
Correct Answer: 1,2,3
Rationale 1: Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure.
Rationale 2: If the patient lost a significant amount of blood or other fluids during surgery the right atrial pressure could drop.
Rationale 3: Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure.
Rationale 4: Left heart failure results in an increased volume in the pulmonary circulation which increases right atrial pressure.
Rationale 5: Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-5
Question 7
Type: MCSA
While evaluating a patient’s pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated?
- Assist the patient to a left side-lying position.
- Notify the physician for repositioning.
- Increase intravenous fluids.
- Nothing, since this is an expected occurrence.
Correct Answer: 2
Rationale 1: Assisting the patient to a left side-lying position is not going to reposition the catheter.
Rationale 2: The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning.
Rationale 3: There is nothing to indicate that the patient needs an increase in intravenous fluids.
Rationale 4: This is not an expected occurrence and should not be ignored.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-4
Question 8
Type: MCSA
A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?
- A pulmonary artery wedge pressure of 16 mm Hg
- Pulmonary artery pressure of 34/16 mm Hg
- Systemic vascular resistance of 1,400 dynes/sec/cm-5
- A right atrial pressure of 5 mm Hg
Correct Answer: 4
Rationale 1: Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload.
Rationale 2: Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration.
Rationale 3: Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize.
Rationale 4: A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-6
Question 9
Type: MCSA
The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?
- Systemic vascular resistance of 900 dynes/sec/cm5
- Appearance of an “a” wave on the pulmonary artery waveform
- Pulmonary artery wedge pressure of 10 mm Hg
- Spontaneous development of a pulmonary artery wedge pressure waveform
Correct Answer: 4
Rationale 1: A systemic vascular resistance of 900 is normal.
Rationale 2: The “a” wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal.
Rationale 3: A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits.
Rationale 4: A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-6
Question 10
Type: MCSA
A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention?
- Pulmonary artery wedge pressure of 2 mm Hg
- Heart rate of 112
- Urine output of 25 mL/hr
- Presence of rales at both lung bases
Correct Answer: 1
Rationale 1: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Additional assessment is critical.
Rationale 2: Although a heart rate of 112 is abnormal it is not the most significant of the findings provided.
Rationale 3: Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided.
Rationale 4: Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6-3
Question 11
Type: MCMA
Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Use no more than 1.25 mL of air to inflate the balloon.
- Pull back on the syringe to deflate the balloon.
- Leave the balloon slightly inflated to maintain integrity.
- Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading.
- If there is any resistance during inflation do not continue.
Correct Answer: 1,5
Rationale 1: Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture.
Rationale 2: Passive deflation should be used to avoid damage to the balloon.
Rationale 3: The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction.
Rationale 4: The balloon should be inflated only long enough to obtain a stable reading.
Rationale 5: Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-6
Question 12
Type: MCSA
The nurse is caring for a patient whose pulmonary artery wedge pressure is 16 mm Hg. The patient’s neck veins are flat, lungs are clear, and the pulse pressure is low. Which intervention would the nurse anticipate?
- Administer a 500 mL normal saline fluid bolus.
- Repeat the reading after recalibrating the system.
- Repeat the reading after repositioning the patient.
- Administer a diuretic and a vasodilator.
Correct Answer: 4
Rationale 1: Administering a 500 mL normal saline fluid bolus would be expected if preload were low.
Rationale 2: The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary.
Rationale 3: The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading.
Rationale 4: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A reading of 16 mm Hg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-6
Question 13
Type: MCSA
A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurse’s priority assessment?
- Is there a palpable pulse?
- Is blood is easily obtained from the catheter?
- Does the patient have a fever?
- Does the waveform have a characteristic appearance?
Correct Answer: 1
Rationale 1: Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented.
Rationale 2: It is important to be able to easily access blood from the catheter, but this is not the priority assessment.
Rationale 3: Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority.
Rationale 4: An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patient’s safety and prevention of complications.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-2
Question 14
Type: MCMA
The nurse is assessing a patient’s arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Closure of the aortic valve
- The highest systolic pressure
- Systolic ejection of blood
- The diastolic pressure
- Beginning of ventricular diastole
Correct Answer: 1,5
Rationale 1: This “dicrotic” notch represents closure of the aortic valve.
Rationale 2: When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure.
Rationale 3: After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force.
Rationale 4: The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor.
Rationale 5: This “dicrotic notch” represents the beginning of ventricular diastole.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-2
Question 15
Type: MCSA
A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drug’s effectiveness?
- Decreased systemic vascular resistance
- Decreased cardiac output
- Increased right atrial pressure
- Increased pulmonary artery wedge pressure
Correct Answer: 1
Rationale 1: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance.
Rationale 2: Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output.
Rationale 3: Nitroprusside administration should result in right atrial pressure decrease.
Rationale 4: Pulmonary artery wedge pressure should decrease.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-7
Question 16
Type: MCSA
The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patient’s afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?
- Decreased circulating volume
- Reaction to antibiotics used to treat sepsis
- Marked vasodilation
- Decreased ventricular contractility
Correct Answer: 3
Rationale 1: Hemodynamic changes associated with sepsis are not caused by low circulating volume.
Rationale 2: The primary reason for decreased vascular resistance is not related to reaction to medications.
Rationale 3: Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance.
Rationale 4: Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-7
Question 17
Type: MCSA
A patient is being prepared for impedance cardiography. Which information will the nurse provide?
- “This technology will use ultrasound to measure your heart rate and blood flow.”
- “We are preparing to measure the oxygenation of your peripheral tissues.”
- “A catheter will be inserted into a vein in your neck.”
- “Electrodes will be placed on your neck and your lateral chest.”
Correct Answer: 4
Rationale 1: Doppler technology uses ultrasound through a probe to measure heart rate and blood flow.
Rationale 2: Pulse oximetry is used to measure peripheral oxygenation of tissues.
Rationale 3: Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter.
Rationale 4: Impedance cardiography is used to assess cardiac function through the use of a high-frequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-2
Question 18
Type: MCSA
A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patient’s skin is cool to the touch. Which nursing diagnosis (NDX) is priority?
- Risk for Falls
- Fluid Volume Deficient
- Decreased Cardiac Output
- Impaired Gas Exchange
Correct Answer: 3
Rationale 1: This patient does have risk for injury from falling, but this NDX is not the current priority. Interventions to reverse the primary NDX will help to reduce this risk.
Rationale 2: Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient.
Rationale 3: Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole.
Rationale 4: The scenario does not present arterial blood gases, so a diagnosis of impaired gas exchange is not supported.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7-1
Question 19
Type: MCMA
Which nursing actions are necessary to collect information needed to figure the patient’s cardiac index?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Weigh the patient.
- Take the patient’s temperature.
- Measure the patient’s blood pressure.
- Measure the patient’s height.
- Determine the patient’s age.
Correct Answer: 1,4
Rationale 1: Calculating cardiac index requires knowledge of the patient’s weight.
Rationale 2: Body temperature is not used to figure cardiac index.
Rationale 3: Blood pressure is not used to figure cardiac index.
Rationale 4: In order to figure the cardiac index, the nurse must know that patient’s height.
Rationale 5: It is not necessary to know the patient’s age in order to determine cardiac index.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 7-1
Question 20
Type: MCSA
A patient requires insertion of a pulmonary artery catheter. Which nursing action is indicated?
- Instill air in all stopcocks.
- Prime the pressure monitoring system.
- Call for the rapid response team.
- Obtain sterile gowns, gloves, caps, and masks for all persons who will be present during the insertion.
Correct Answer: 2
Rationale 1: Air should be removed from all stopcocks.
Rationale 2: The pressure monitoring system should be primed to remove all air.
Rationale 3: There is no need for rapid response team intervention.
Rationale 4: The people inserting the catheter will wear sterile gowns, gloves, caps, and masks. Others in the room should wear a cap and mask.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 7-4
Wagner, High Acuity Nursing, 6e
Chapter 11
Question 1
Type: MCSA
A patient is being admitted for treatment of pneumothorax. The nurse would anticipate providing care for a patient with which pathophysiology?
- Prolonged expiratory time
- Increased lung compliance
- Reduced tidal volume
- Hyper-inflated lungs
Correct Answer: 3
Rationale 1: Expiratory time is dependent upon airflow with remains normal in the patient with a restrictive lung disorder such as pneumothorax.
Rationale 2: With restrictive lung disorders such as pneumothorax the air cannot move into the alveoli because of decreased lung compliance.
Rationale 3: Restrictive disorders such as pneumothorax are problems of volume rather than airflow. The patient’s tidal volume will be reduced.
Rationale 4: Restrictive lung disorders such as pneumothorax result in decrease in the air capacity of the lungs.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1
Question 2
Type: MCSA
A patient is diagnosed with cystic fibrosis. The nurse will anticipate providing care for a patient with which change in lung function?
- Decreased total lung capacity
- Progressive respiratory alkalosis
- Increased PaCO2
- Increased forced expiratory volume (FEV)
Correct Answer: 3
Rationale 1: The air trapping associated with obstructive lung disorders such as cystic fibrosis results in increase in total lung capacity.
Rationale 2: Obstructive pulmonary disorders such as cystic fibrosis tends to produce progressive respiratory acidosis.
Rationale 3: In obstructive lung disorders such as cystic fibrosis PaCO2 levels increase as a result of air trapping.
Rationale 4: Obstructive disorders such as cystic fibrosis cause inability to exhale trapped air. This results in a decreased FEV.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1
Question 3
Type: MCSA
A patient tells the nurse that when he is exposed to cigarette smoke he begins to get short of breath, starts coughing, and gets a “high pitched noise” in his lungs when he breathes. The nurse would ask additional assessment questions about which pulmonary disorder?
- COPD
- Asthma
- Emphysema
- Pneumonia
Correct Answer: 2
Rationale 1: COPD also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
Rationale 2: The classic triad of asthma symptoms includes paroxysmal episodes of dyspnea, wheeze, and cough triggered by a stimulus. The stimulus, or trigger, for the patient is cigarette smoke. This patient most likely is describing the symptoms of asthma.
Rationale 3: Emphysema also is an obstructive disorder but does not typically become exacerbated with a trigger to cause the onset of symptoms.
Rationale 4: Pneumonia will not “suddenly appear” after exposure to cigarette smoke to cause the onset of the patient’s symptoms.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-1
Question 4
Type: MCSA
The nurse is caring for a patient with obstructive pulmonary disease who had tachycardia, tachypnea, and restlessness. The patient has become very lethargic, but has a normal respiratory rate. The nurse should evaluate this change as indicating which condition?
- The patient is now able to rest and sleep.
- The patient’s condition has significantly deteriorated.
- The patient’s condition shows some slight improvement.
- The patient’s condition has stabilized significantly.
Correct Answer: 2
Rationale 1: These findings do not indicate that the patient is resting and now able to sleep.
Rationale 2: The patient’s condition has deteriorated as evidenced by lethargy and decreased respiratory rate. The elevated carbon dioxide levels have affected the central nervous system causing lethargy, which may progress to coma. The patient has become exhausted and is unable to maintain the compensatory mechanisms needed to maintain acid–base balance.
Rationale 3: These findings do not indicate that the patient’s condition is improving.
Rationale 4: These findings do not indicate significant stabilization of the patient’s condition.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-2
Question 5
Type: MCMA
A patient with pneumonia is restless and confused with increased blood pressure and respiratory rate. PaO2 is less than 60 mm Hg with a normal PaCO2. What conclusion can the nurse draw regarding this patient?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- The patient has ventilation failure.
- Without treatment the patient’s oxygen saturation is likely to drop rapidly.
- The patient has decreased airflow.
- The patient is at risk for respiratory muscle fatigue.
- Acute respiratory failure is present.
Correct Answer: 2,4
Rationale 1: Ventilation failure is reflected by an increased PaCO2.
Rationale 2: Once the PaO2 drops below 60 mm Hg oxygen’s affinity to hemoglobin drops.
Rationale 3: When the patient has ventilatory failure (decreased airflow) carbon dioxide levels increase. This patient has a normal PaCO2.
Rationale 4: As respiratory rate increases the risk of respiratory muscle fatigue also increases.
Rationale 5: Currently the patient does not have acute respiratory failure because the PaCO2 is normal.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-2
Question 6
Type: MCMA
The nurse working in an intensive care unit is alert to the development of ALI/ARDS. The nurse would monitor which patients most closely for this complication?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- A patient who sustained a severe chest contusion.
- A patient hospitalized for treatment of drug overdose.
- A patient who sustained severe head trauma.
- A patient hospitalized for treatment of pneumonia.
- A patient diagnosed with sepsis.
Correct Answer: 4,5
Rationale 1: Chest contusion can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 2: Drug overdose can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 3: Head trauma can result in ALI/ARDS, but this is not the patient of most concern.
Rationale 4: Pneumonia is one of the most common predisposing disorders in the development of ALI/ARDS.
Rationale 5: Sepsis is one of the most common predisposing disorders in the development of ALI/ARDS.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3
Question 7
Type: MCSA
The nurse is caring for a patient with ARDS. Which finding would indicate that the disease is progressing?
- Increased lung compliance
- Decrease in heart rate
- Hypoxemia refractory to oxygen therapy
- Respiratory acidosis
Correct Answer: 3
Rationale 1: Pulmonary function tests would indicate decreased lung compliance because of the restrictive component of the disease.
Rationale 2: The heart rate increases as the work of breathing increases.
Rationale 3: In progressive ARDS there is a pattern of increasing hypoxemia that is refractory to increasing concentrations of oxygen because of collapsed alveoli, decreased lung compliance, and significant shunting.
Rationale 4: In the early onset of ARDS, respiratory alkalosis, and not acidosis, predominates as a result of compensatory mechanisms.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3
Question 8
Type: MCSA
A patient diagnosed with ARDS is being mechanically ventilated with 12 cm of PEEP. On assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. The nurse intervenes immediately due to the presence of which most likely complication?
- Obstructed endotracheal tube
- Increased severity of ARDS
- Decreased cardiac output
- Pneumothorax
Correct Answer: 4
Rationale 1: An obstructed endotracheal tube would affect both lung fields.
Rationale 2: If the disease process was worsening it would be likely that both lung fields would be involved.
Rationale 3: Decreased cardiac output would affect vital signs but not breath sounds.
Rationale 4: A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. Pneumothorax could be manifested by deterioration of vital signs and loss of air movement in the affected lung.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-3
Question 9
Type: MCSA
The nurse is caring for a patient who sustained a fractured femur from a motor vehicle accident 1 day ago. The patient is anxious, restless, appears short of breath, and requests pain medication for chest discomfort. Which nursing intervention is priority?
- Administer pain medication as ordered.
- Increase intravenous fluids.
- Evaluate the patient’s oxygen saturation.
- Help the patient assume a more comfortable position.
Correct Answer: 3
Rationale 1: The patient’s pain should be treated but this is not the priority intervention.
Rationale 2: Intravenous fluids may be increased, but this is not the priority intervention.
Rationale 3: The patient may be experiencing a fat embolism from the previous long bone fracture. The nurse should do a thorough assessment noting lung sounds, conjunctivae and pulse oximetry before calling the physician. Anticipate orders for supplemental oxygen, arterial blood gases, serum laboratory values, chest x-rays, electrocardiogram, a V/Q scan, and angiography.
Rationale 4: Positioning 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: 11-4
Question 10
Type: MCMA
The patient’s Wells Score indicate intermediate risk for the development of pulmonary embolism. Which nursing interventions would help reduce this risk?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Monitor daily D-dimer levels.
- Strictly measure all intake and output.
- Encourage ambulation.
- Instruct the patient on use of antiembolism stockings.
- Prevention of leg injury
Correct Answer: 3,4,5
Rationale 1: D-dimer elevation indicates presence of thrombolytic activity, but will not help to prevent occurrence of thrombus.
Rationale 2: Measuring intake and output will not prevent development of thrombus.
Rationale 3: Ambulation will help to support circulation and prevent clot development.
Rationale 4: Proper use of antiembolism stocking is helpful in decreasing development of thrombus.
Rationale 5: One of the risk factors for development of deep vein thrombosis in the leg is injury. This injury can occur from trauma from striking the bed or other objects in the room. The nurse should intervene to prevent this trauma.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-4
Question 11
Type: MCSA
The emergency department has treated two patients in the last day with symptoms that may be SARS. The nurse manager is updating staff on the pathophysiology of this disease. Which information would the nurse include?
- It is thought that SARS is a nonhuman virus that has crossed species.
- SARS is more common in patients also infected with HIV.
- SARS is a form of influenza virus, so additional cases are probable.
- SARS is related to RSV, so young children will be the most likely patients.
Correct Answer: 1
Rationale 1: Although the origin of SARS-CoV is unknown, it is suspected to be a nonhuman virus that jumped to humans.
Rationale 2: SARS is not associated with HIV.
Rationale 3: SARS is not a form on influenza virus.
Rationale 4: SARS is not related to RSV.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-5
Question 12
Type: MCMA
The nurse is preparing to participate in evaluation of the severity of a patient’s community acquired pneumonia using the CURB-65 criteria. Which information will the nurse collect for this evaluation?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- The patient’s respiratory rates for the last several hours
- BUN results
- If the patient has a history of smoking
- The patient’s gender.
- The patient’s age
Correct Answer: 1,2,5
Rationale 1: CURB-65 evaluates the patient’s respiratory rate. Rate of 30 or over is scored as a 1.
Rationale 2: CURB-65 evaluates that patient’s BUN level. BUN greater than 19.6 mg/dL is scored as a 1.
Rationale 3: Tobacco use history is not considered in CURB-65 scoring.
Rationale 4: Gender is not considered in CURB-65 scoring.
Rationale 5: The patient’s age is considered in CURB-65 scoring. If the patient is 65 or older, a score of 1 is assigned.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 11-5
Question 13
Type: MCSA
The nurse is caring for a patient with a chest tube and a three-chamber disposable drainage system. The physician orders an AP chest x-ray to be done in the x-ray department. How would the nurse transport the patient?
- Do a portable film in the patient’s room.
- Clamp the chest tube after full exhalation and call the department so they can be ready when you arrive.
- Disconnect the drainage system from the wall suction and transport.
- Clamp the chest tube after full inspiration and call the department so they can be ready when you arrive.
Correct Answer: 3
Rationale 1: Changing of a physician’s order is not within the scope of practice of the nurse.
Rationale 2: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.
Rationale 3: The nurse would disconnect the drainage system from wall suction and transport with the drainage system in an upright position, placed below the level of the heart. The suction chamber does not require attachment to an external suction source, although it does make the system more effective. As long as the water seal chamber is intact, air is not permitted to reenter the chest cavity.
Rationale 4: Clamping a chest tube for any length of time will obstruct the exit of air, causing pressure to build up in the pleural space, resulting in a tension pneumothorax.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-6
Question 14
Type: MCSA
A patient has been uncooperative with pulmonary hygiene following thoracic surgery because “it hurts more than I can bear.” Which intervention should the nurse employ?
- Instruct the patient to cough 3 to 4 times with each exhalation.
- Assist the patient to a sitting position to lean over the bedside table while coughing.
- Provide the patient with a pillow to splint the incision while coughing.
- Guide the patient to cough with the glottis open.
Correct Answer: 4
Rationale 1: The “cascade” cough is a series of 3 to 4 coughs on one exhalation. This type of cough could cause the patient more discomfort.
Rationale 2: Positioning the patient over the bedside table might cause injury during coughing.
Rationale 3: A pillow is too soft to effectively splint the incision for best pain relief.
Rationale 4: Pulmonary hygiene is an integral part of post-thoracic surgery care. Patients must be able to take a deep breath and generate an exhalation sufficiently strong to clear secretions. There are two types of coughs however the “huff” cough or coughing with the glottis open is a gentle maneuver, and is effective. This is the type of cough the nurse should assist the patient with performing.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-6
Question 15
Type: MCSA
The nurse is caring for a patient who has recently undergone major abdominal surgery. The patient is exhibiting shallow breathing and is hesitant to cough and deep breathe. Which nursing diagnosis (NDX) should the nurse choose for this patient?
- Ineffective Breathing Pattern
- Ineffective Airway Clearance
- Potential for Pneumonia
- Impaired Gas Exchange
Correct Answer: 1
Rationale 1: The patient has documented shallow breathing, indicative of an ineffective breathing pattern.
Rationale 2: Since there is no evidence of inability to clear secretions, this is not the best NDX choice for this patient.
Rationale 3: Potential for pneumonia is not a nursing diagnosis.
Rationale 4: In order to support the NDX Impaired Gas Exchange, the patient must exhibit cyanosis or have arterial blood gas evidence of poor oxygenation or carbon dioxide retention.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 11-7
Question 16
Type: MCMA
A patient has a diagnosis of Ineffective Airway Clearance as evidenced by the inability to clear thick secretions effectively. Which nursing interventions are appropriate to address this nursing diagnosis?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
- Encourage bedrest to conserve energy.
- Administer pain medications as needed.
- Position the patient on the unaffected side.
- Encourage the patient to provide as much self-care as possible.
- Encourage slow, deep breaths
Correct Answer: 2,4
Rationale 1: Bedrest will impair the patient’s ability to mobilize secretions. Activity as tolerated will help mobilize secretions.
Rationale 2: The nurse should treat the patient’s pain but avoid oversedation.
Rationale 3: Positioning the patient on the unaffected side is an intervention to improve gas exchange. Ineffective airway clearance generally involved both lungs and the trachea.
Rationale 4: Providing care for self encourages the patient to move within the environment even if it is limited to the bed or bedside. Movement encourages mobilization of secretions.
Rationale 5: Slow, deep breaths will support a healthier breathing pattern, but is not necessarily indicated for impaired gas exchange.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-7
Question 17
Type: MCSA
A patient recovering from thoracic surgery is demonstrating evidence of Impaired Gas exchange with a dropping oxygen saturation level. Which nursing intervention is most suited to addressing this nursing diagnosis?
- Teach the patient to use the incentive spirometer every 1 to 2 hours.
- Suction as necessary.
- Splint the chest when coughing.
- Encourage fluids up to 2.5 liters per day.
Correct Answer: 1
Rationale 1: Using the incentive spirometer correctly every 1 to 2 hours will help to improve gas exchange.
Rationale 2: Suctioning is related more to Ineffective Airway Clearance.
Rationale 3: Using a splint with coughing will help reduce pain so that the airway can be cleared. This intervention is most related to Ineffective Airway Clearance.
Rationale 4: Increasing fluids will help to thin secretions so that they are more easily mobilized. This intervention is most related to Ineffective Airway Clearance.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-7
Question 18
Type: MCSA
An older adult presents to the emergency department with cough, fever, and elevated temperature. A diagnosis of pneumonia is made, antibiotics are prescribed, and the patient will be admitted to the acute care unit. When should the nurse start the prescribed intravenous antibiotic?
- Whenever the drug is received from the pharmacy
- After the preliminary results of the sputum specimen are obtained
- Within 30 minutes of the order being received
- Within 4 hours of diagnosis
Correct Answer: 4
Rationale 1: There is a standard by which this drug should be started. If the drug is delayed from the pharmacy this standard might not be met. The nurse should advise pharmacy of the patient’s diagnosis and need to start the antibiotic quickly.
Rationale 2: The nurse should not wait for sputum specimen results.
Rationale 3: There is no standard by which the antibiotic must be started within 30 minutes of the order being received.
Rationale 4: Standards indicate that antibiotic therapy for pneumonia should be started within 4 hours of diagnosis or while the patient is in the setting where the diagnosis is made.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-5
Question 19
Type: MCSA
A patient had chest tube insertion for a pneumothorax. External suction was discontinued yesterday. This morning the nurse assesses cessation of tidling in the water-seal chamber. What nursing action is indicated?
- Collaborate with the health care provide regarding need to reinstitute the external suction.
- Check the connections between the chest tube and the drainage system.
- No action is necessary as this is an expected occurrence.
- Have the patient cough forcefully.
Correct Answer: 3
Rationale 1: There is no need for external suction.
Rationale 2: The nurse should always check these connections, but there is no special need for that action related to this assessment.
Rationale 3: The cessation of tidling in this patient likely indicates successful reinflation of the lung which is the desired outcome.
Rationale 4: This assessment does not indicate that coughing is necessary.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-6
Question 20
Type: MCSA
A patient presents to the emergency department after falling from a ladder at home. He has multiple contusions and abrasion on his right side and is holding his right arm tightly across his chest. On inspection the nurse notes that the patient’s trachea is slight displaced toward the left. Which nursing intervention is priority?
- Have the patient release his arm and sit up straight for reassessment.
- Notify the emergency room physician immediately.
- Auscultate the patient’s lung fields.
- Position the patient flat in bed without a pillow.
Correct Answer: 2
Rationale 1: Reassessment is not the priority in this situation.
Rationale 2: Deviation of the trachea away from the injured side indicates pressure on the affected side which may be from a developing pneumothorax or hemothorax. If so the patient may require immediate placement of a chest tube. Delay could be detrimental to the patient’s condition.
Rationale 3: The nurse will auscultate the lungs, but another intervention is the priority.
Rationale 4: This position is not indicated for this patient. Positioning is not the immediate priority.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 11-6
