Introduction Critical Care Nursing 7th Edition Sole Klein-Test Bank

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Introduction Critical Care Nursing 7th Edition Sole Klein-Test Bank

Chapter 02: Patient and Family Response to the Critical Care Experience

Sole: Introduction to Critical Care Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. Family members have a need for information. Which interventions best assist in meeting this need?
a. Handing family members a pamphlet that explains all of the critical care equipment
b. Providing a daily update of the patient’s progress and facilitating communication with the intensivist
c. Telling them that you are not permitted to give them a status report but that they can be present at 4:00 PM for family rounds with the intensivist
d. Writing down a list of all new medications and doses and giving the list to family members during visitation

 

 

ANS:  B

The nurse can give a status report related to the patient’s condition and current treatment plan as well as ensure that the family has daily meeting time with the intensivist for an update on diagnoses, prognoses, and the like. Pamphlets are helpful; however, the nurse should also explain the equipment that is at this patient’s bedside and not assume that everyone can read and understand written material. Limiting the information to that provided by the physician is unnecessary and will not meet the family’s information needs. Most family members are concerned about the patient’s general condition and treatment plan. They do not want or need a detailed list of medications, doses, or other treatments.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 23

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The nurse is a member of a committee to design a critical care unit in a new building. Which design trend would best facilitate family-centered care?
a. Ensure that the patient’s room is large enough and has adequate space for a sleeper sofa and storage for family members’ personal belongings.
b. Include a diagnostic suite in close proximity to the unit so that the patient does not have to travel far for testing.
c. Incorporate a large waiting room on the top floor of the hospital with a scenic view and amenities such as coffee and tea.
d. Provide access to a scenic garden for meditation.

 

 

ANS:  A

New unit design trends to promote family-centered care include patient rooms that provide a larger family space and comfortable furniture and storage to promote open visitation, including overnight stays in the patient’s room. Ready access to diagnostic testing, including portable equipment, is an important trend; however, the purpose for this is to prevent the need for transport, not to foster family-centered care. A waiting room in close proximity to the unit with amenities is a nice feature; however, it does not need to be large if adequate space is incorporated into the patient’s room. A scenic garden for meditation may assist in reducing family members’ stress, but proximity to the patient is the greatest need.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 19

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The nurse is caring for a patient who sustained a head injury and is unresponsive to painful stimuli. Which intervention is most appropriate while bathing the patient?
a. Ask a family member to help you bathe the patient, and discuss the family structure with the family member during the procedure.
b. Because the patient is unconscious, complete care as quickly and quietly as possible.
c. Tell the patient the day and time, and that you are providing a bath. Reassure the patient that you are there.
d. Turn the television on to the evening news so that you and the patient can be updated to current events.

 

 

ANS:  C

Although unconscious, many patients can hear, understand, and respond to stimuli. Therefore, it is important to converse with the patient and reorient her to the environment. Some, but not all, family members may want to get involved in direct care; it is not known if this individual is a willing participant, and talking about who’s who in the family is inappropriate while providing direct care to the patient. Although the patient is unconscious, communication and simple conversations remain important interventions. Use of the television to provide sensory input that the patient regularly enjoys is a nursing intervention, but turning on the news for the sake of the nurse is not appropriate.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 20

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Sleep often is disrupted for critically ill patients. Which nursing intervention is most appropriate to promote sleep and rest?
a. Consult with the pharmacist to adjust medication times to allow periods of sleep or rest between intervals.
b. Encourage family members to talk with the patient whenever they are present in the room.
c. Keep the television on to provide white noise and distraction.
d. Leave the lights on in the room so that the patient is not frightened of his or her surroundings.

 

 

ANS:  A

Planning care to promote periods of uninterrupted rest is important. Consulting with the pharmacist to adjust a medication schedule is an excellent example of this intervention. It is important for family members to communicate with the patient; however, rest periods must be scheduled. Family members can be present in the room while remaining quiet during these scheduled times. The television may be useful if it is part of the patient’s normal routine for sleep; however, it does not consistently provide white noise or distraction. Lights should be dimmed during scheduled rest periods and at night to facilitate sleep and rest.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 20

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity—Basic Care and Comfort

 

  1. Family assessment is essential to meet family needs. Which of the following must be assessed first to assist the nurse in providing family-centered care?
a. Assessment of patient and family’s developmental stages and needs
b. Description of the patient’s home environment
c. Identification of immediate family, extended family, and decision makers
d. Observation and assessment of how family members function with each other

 

 

ANS:  C

Assessment of the family structure is the first step and is essential before specific interventions can be designed. It identifies immediate family, extended family, and decision makers in the family. Structural assessment also includes ethnicity and religion. The developmental assessment is done after the structural assessment and includes the developmental stages of the patient and family. Functional assessment is also important to assess how family members function with each other; however, it is not done first. Assessment of the home environment is important when identifying discharge planning needs.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 21

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Critical illness often results in family conflicts. Which scenario is most likely to result in the greatest conflict?
a. A 21-year-old college student of divorced parents hospitalized with multiple trauma. She resides with her mother. The parents are amicable with each other and have similar values. The father blames the daughter’s boyfriend for causing the accident.
b. A 36-year-old male admitted for a ruptured cerebral aneurysm. He has been living with his 34-year-old girlfriend for 8 years, and they have a 4-year-old daughter. He does not have a written advance directive. His parents arrive from out-of-state and are asked to make decisions about his health care. He has not seen them in over a year.
c. A 58-year-old male admitted for coronary artery bypass surgery. He has been living with his same-sex partner for 20 years in a committed relationship. He has designated his sister, a registered nurse, as his health care proxy in a written advance directive.
d. A 78-year-old female admitted with gastrointestinal bleeding. Her hemoglobin is decreasing to a critical level. She is a Jehovah’s Witness and refuses the treatment of a blood transfusion. She is capable of making her own decisions and has a clearly written advance directive declining any transfusions. Her son is upset with her and tells her she is “committing suicide.”

 

 

ANS:  B

Each of these situations may result in family conflict. The situation with the unmarried 36-year-old male without a written advance directive results in his distant parents being legally responsible for his health care decisions. Because of his long-standing commitment with his partner and lack of recent contact with his parents, this scenario is likely to cause the most conflict. The parents may make decisions based on their wishes, as they may not be knowledgeable of the patient’s wishes. The supportive parents of the college student may create conflict with the boyfriend, but the parents’ ongoing friendship and shared values will assist in reducing conflict. The male admitted for bypass surgery, although in a same-sex relationship, has clearly identified whom he wants to make health care decisions for him. The elderly female may have conflict with her son; however, she is capable of making her own decisions and has a written advance directive to support her decisions.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 22

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Which nursing interventions would best support the family of a critically ill patient?
a. Encourage family members to stay all night in case the patient needs them.
b. Give a condition update each morning and whenever changes occur.
c. Limit visitation from children into the critical care unit.
d. Provide beverages and snacks in the waiting room.

 

 

ANS:  B

The need for information is one of the highest identified by family members of critically ill patients. A planned condition update helps the family know what to expect. New room designs provide space for family members to spend the night if desired; however, if the patient is stable, family members should be encouraged to sleep at home to ensure that they are well rested and can support the patient. Restriction of children in the critical care unit is not supported by research evidence. Child visitation should be individualized based on the needs and wishes of the patient and family. Beverages and snacks are important but not as important as information.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 23

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Which intervention is appropriate to assist the patient in coping with admission to the critical care unit?
a. Allowing unrestricted visiting by several family members at one time
b. Explaining all procedures in easy-to-understand terms
c. Providing back massage and mouth care
d. Turning down the alarm volume on the cardiac monitor

 

 

ANS:  B

Communication and explanations of procedures are priority interventions to help patients cope with admission. Comfort is an important intervention but not the priority. Noise control is an important intervention but not the priority. Open visitation is recommended; however, the number of family members may need to be limited to promote rest and sleep.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 20

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The constant noise of a ventilator, monitor alarms, and infusion pumps predisposes the patient to:
a. anxiety.
b. pain.
c. powerlessness.
d. sensory overload.

 

 

ANS:  D

Constant noise is a source of sensory overload. Pain and lack of information contribute to anxiety. Noise does not cause physical pain. Lack of involvement in care causes powerlessness.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 18

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Which of the following statements about family assessment is false?
a. Assessment of structure (who comprises the family) is the last step in assessment.
b. Interaction among family members is assessed.
c. It is important to assess communication among family members to understand roles.
d. Ongoing assessment is important, because family functioning may change during the course of illness.

 

 

ANS:  A

Assessment of structure should be done first so that the nurse can identify such things as who comprises the family and who assumes leadership and decision-making responsibilities. This assessment also assists in identifying which individuals are most important to the patient and how many people may be seeking information. Family member interaction must be assessed, so this answer is true. Family member communication must be assessed, so this answer is true. Ongoing assessment of family is necessary as functions may change, so this answer is true.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 21

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Which intervention about visitation in the critical care unit is true?
a. The majority of critical care nurses implement restricted visiting hours to allow the patient to rest.
b. Children should never be permitted to visit a critically ill family member.
c. Visitation that is individualized to the needs of patients and family members is ideal.
d. Visiting hours should always be unrestricted.

 

 

ANS:  C

Visiting should be based on the needs of patients and their families. There may be times when visiting needs to be limited (e.g., to allow the patient to rest); however, it is important to individualize visitation. Sometimes it is appropriate for children to visit; research has not found child visitation to be harmful to either the patient or the child. Visiting should be adjusted to patient needs.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 24

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Elderly patients who require critical care treatment are at risk for increased mortality, functional decline, or decreased quality of life after hospitalization. Assuming each of these patients was discharged from the hospital, which of the following patients is at greatest risk for decreased functional status and quality of life?
a. A 70-year-old man who had coronary artery bypass surgery. He developed complications after surgery and had difficulty being weaned from mechanical ventilation. He required a tracheostomy and gastrostomy. He is being discharged to a long-term acute care hospital. He is a widower.
b. A 79-year-old woman admitted for exacerbation of heart failure. She manages her care independently but needed diuretic medications adjusted. She states that she is compliant with her medications but sometimes forgets to take them. She lives with her 82-year-old spouse. Both consider themselves to be independent and support each other.
c. A 90-year-old man admitted for a carotid endarterectomy. He lives in an assisted living facility (ALF) but is cognitively intact. He is the “social butterfly” at all of the events at the ALF. He is hospitalized for 4 days and discharged to the ALF.
d. An 84-year-old woman who had stents placed to treat coronary artery occlusion. She has diabetes that has been managed, lives alone, and was driving prior to hospitalization. She was discharged home within 3 days of the procedure.

 

 

ANS:  A

Although he is younger, the 70-year-old with the complicated critical care course, limited social support, and a transfer to a long-term acute care facility is at greatest risk for decreased quality of life and functional decline. He will continue to need high-level nursing care and support for rehabilitation. The other cases are examples of individuals with shorter hospital stays, uncomplicated courses, and social support systems.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 21

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Health Promotion and Maintenance

 

  1. Patients often have recollections of the critical care experience. Which is likely to be the most common recollection of patients who required endotracheal intubation and mechanical ventilation?
a. Difficulty in communicating
b. Inability to get comfortable
c. Pain
d. Sleep disruption

 

 

ANS:  A

Although the patient may recall all of these potential experiences, recollection of difficult communication is most likely secondary to the endotracheal tube placement.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 20

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach?
a. Ask family members to limit their visitation to 2-hour periods in morning, afternoon, and evening.
b. Explain the unit routine.
c. Explain procedures before and while you are doing them.
d. Suction Mr. J.’s endotracheal tube immediately when he starts to cough.

 

 

ANS:  C

Anxiety is reduced when procedures are explained before completing them and when the nurse continues to talk to the patient during them. Limiting visitation has not been demonstrated by research to benefit patients. Explaining the unit routine is important but is not as specific to the patient as explaining a procedure right before doing it. Providing physical care is vital to critically ill patients, but may or may not reduce anxiety.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 20

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The intensive care nurse is working on a committee to reduce noise in the unit. Which recommendation should the nurse propose first?
a. Change telephones to blinking lights instead of audible ringtones.
b. Invest in call lights that page the nursing staff instead of beeping.
c. Recommend that nurses turn off cardiac monitors on stable patients.
d. Soundproof the pneumatic tube system.

 

 

ANS:  D

The pneumatic tube system is extremely loud at 88dB[A] and should be the first proposal as it will have the biggest impact on noise on the unit. Call light systems typically ring at the 48–63 dB[A] range and are also a significant cause of noise, but not as much as the pneumatic tube system. Telephones are also noisy, ringing at 60–67 dB[A]. Nurses should never shut off monitor alarms as this is a patient safety issue.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 19

OBJ:   Discuss how to safely reduce the noise level on the unit floor.

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment—Management of Care

 

  1. The nurse is assigned to care for a patient who is a non–native English speaker. What is the best way to communicate with the patient and family to provide updates and explain procedures?
a. Conduct a Google search on the computer to identify resources for the patient and family in their native language. Print these for their use.
b. Contact the hospital’s interpreter service for someone to translate.
c. Get in touch with one of the residents who you know is fluent in the native language and ask him if he can come up to the unit.
d. Use the patient’s 8-year-old child who is fluent in both English and the native language to translate for you.

 

 

ANS:  B

The best approach when communicating with someone whose primary language is not English is to use the interpreter services of the agency. These individuals are trained and knowledgeable. If the nurse conducted a search on the computer, he or she would not know if the information retrieved was valid, nor would the nurse know if the patient or family can read in their native language. Although one of the residents might be fluent in the language, you do not know his or her abilities to translate. In addition, the resident’s availability is likely to be limited. Although the child might be able to translate, the nurse cannot ensure that the child is translating health care concepts correctly.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 22

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Family assessment can be challenging, and each nurse may obtain additional information regarding family structure and dynamics. What is the best way to share this information from shift to shift?
a. Create an informal family information sheet that is kept on the bedside clipboard. That way, everyone can review it quickly when needed.
b. Develop a standardized reporting form for family information that is incorporated into the patient’s medical record and updated as needed.
c. Require that the charge nurse have a detailed list of information about each patient and family member. Thus, someone on the unit is always knowledgeable about potential issues.
d. Try to remember to discuss family structure and dynamics as part of the change-of-shift report.

 

 

ANS:  B

A standardized method for gathering data about family structure and function and recording it in an official document is the best approach. This strategy ensures that data are collected and kept in the medical record. Data are also easily retrievable by anyone who needs to know this information. Informal documentation is often kept to assist in follow-up and change-of-shift reporting; however, this strategy is not recommended, as data collected are likely to vary and not be part of a permanent record. Although the charge nurse often has some information regarding families, the primary responsibility for assessment and follow-up belongs to the bedside nurse. Family information should be shared at change of shift using a standardized format, not “try to remember to discuss….”

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 22

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The spouse of a patient who is hospitalized in the critical care unit following resuscitation for a sudden cardiac arrest at work demands to meet with the nursing manager. The spouse demands, “I want you to reassign us to another nurse. His current nurse is not in the room enough to make sure everything is okay.” The nurse recognizes that this response most likely is due to the spouse’s
a. desire to pursue a lawsuit if the assignment is not changed.
b. inability to participate in the husband’s care.
c. lack of prior experience in a critical care setting.
d. sense of loss of control of the situation.

 

 

ANS:  D

Demanding behaviors often occur when the family member has a sense of loss of control or has had adverse outcomes in a previous hospitalization. Prevention of a lawsuit is not relevant to this scenario. No information is provided regarding whether the family member is participating in care or not. It is unknown whether the spouse had a prior negative experience.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 22

OBJ:   Discuss the impact of critical care hospitalization on the patient and family.

TOP:   Integrated Process: Communication and Documentation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Open visitation policies are expected by many professional organizations. Which statement reflects adherence to current recommendations?
a. Allow animals on the unit; however, these can only be “therapy” animals through the hospital’s pet therapy program.
b. Allow family visitation throughout the day except at change of shift and during rounds.
c. Determine, in collaboration with the patient and family, who can visit and when. Facilitate open visitation policies.
d. Permit open visitation by adults 18 years of age and older; limit visits of children to 1 hour.

 

 

ANS:  C

Open visitation is considered best practice. Limiting visitation is not supported by research. Facilities should develop visitation schedules in collaboration with the patient and family. Animals do not need to be limited to therapy animals. Many patients benefit from the presence of personal pets brought to the unit according to hospital policy. Although many units restrict visitation during report and rounds for confidentiality, family-centered facilities will encourage family participation during report and rounds. Children should not be banned arbitrarily from the unit or have hours limited.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 24

OBJ:   Identify strategies for promoting visitation and family presence in the critical care setting.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The VALUE mnemonic is a helpful strategy to enhance communication with family members of critically ill patients. Which of the following statements describes a VALUE strategy?
a. View the family as guests on the unit.
b. Acknowledge family emotions.
c. Learn as much as you can about family structure and function.
d. Use a trained interpreter if the family does not speak English.

 

 

ANS:  B

The VALUE mnemonic includes the following:

V—Value what the family tells you.

A—Acknowledge family emotions.

L—Listen to the family members.

U—Understand the patient as a person.

E—Elicit (ask) questions of family members.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 25

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Changing visitation policies can be challenging. The nurse manager recognizes which of the following as an effective strategy for promoting changes in practice?
a. Ask the clinical nurse specialist to lead a journal club on open visitation after each nurse is tasked to read one research article about visitation.
b. Discuss the pros and cons of open visitation at the next staff meeting.
c. Invite the nurses with the most experience to develop a revised policy.
d. Task the unit-based nurse practice council to invite volunteers to serve on the council to revise the current policy toward more liberal visitation.

 

 

ANS:  D

Changes in policy are most effective through willing champions as part of a unit-based, staff-led practice council. Discussion of evidence-based findings is important, but it is not logical to expect every nurse to read a research article and share findings. Discussion of pros and cons at a staff meeting is likely to be prolonged and based on opinion rather than evidence. Nurses with the most experience are not necessarily the ones to develop a new policy. They may be the least likely to change; therefore, it is important to solicit volunteers from all staff members, not just the experienced ones.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 25

OBJ:   Identify strategies for promoting visitation and family presence in the critical care setting.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Nursing strategies to help families cope with the stress of critical illness include: (Select all that apply.)
a. asking the family to leave during the morning bath to promote the patient’s privacy.
b. encouraging family members to make notes of questions they have for the physician during family rounds.
c. if possible, providing continuity of nursing care.
d. providing a daily update of the patient’s condition to the family spokesperson.
e. ensuring that a waiting room stocked with snacks is nearby.

 

 

ANS:  B, C, D

Encouraging families to formulate questions assists in family care. Continuity of nursing care with consistent staff members assists in reducing stress. Communicating daily updates of the patient’s condition meets the family’s need for information. Family members often want to assist with simple activities of patient care, so limiting participation is the exception to this list. A comfortable waiting room is necessary; however, it may or may not impact the family’s stress level.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    pp. 23-24

OBJ:   Describe common family needs and family-centered nursing interventions.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Family presence is encouraged during resuscitation and invasive procedures. Which findings about this practice have been reported in the literature? (Select all that apply.)
a. Families benefit by witnessing that everything possible was done.
b. Families report reduced anxiety and fear about what is being done to the patient.
c. Presence encourages family members to seek litigation for improper care.
d. Presence reduces nurses’ involvement in explaining things to the family.
e. Families report that staff conversations during this time were distressing.

 

 

ANS:  A, B

Families benefit from witnessing procedures and resuscitation. The presence of family members removes doubt about the patient’s condition, allows them to witness that everything was done, and decreases anxiety about what is occurring. Increased litigation has not been associated with family presence. Policies and procedures are needed to facilitate family presence. A facilitator is needed, and it may initially require more nursing involvement. It does not eliminate nurses’ responsibility for communicating with the family. The literature does not report that families have reported feelings of distress over staff conversations during these times.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 26

OBJ:   Identify strategies for promoting visitation and family presence in the critical care setting.

TOP:   Integrated Process: Caring

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Noise in the critical care unit can have negative effects on the patient. Which of the following interventions assists in reducing noise levels in the critical care setting? (Select all that apply.)
a. Ask the family to bring in the patient’s iPod or other device with favorite music.
b. Invite a volunteer harpist to play on the unit on a regular basis.
c. Remodel the unit to have two-patient rooms to facilitate nursing care.
d. Remodel the unit to install acoustical ceiling tiles.
e. Turn the volume of equipment alarms as low as they can be adjusted, and “off” if possible.

 

 

ANS:  A, B, D

A personal device with favorite music and headphones can be helpful in reducing ambient unit noise. Music therapy programs, such as harpists, can provide soothing sedative music that is often comforting to both patients and family members. Acoustical tiles help to reduce noise in the critical care setting and should be included in remodeling plans as well as new unit construction. Multiple patients in a single room would increase noise levels and contribute to an increased risk of infection. Alarms on critical equipment must never be turned off. The volume should be loud enough that the alarm can be heard by the nurse if outside the room. The lowest setting may not be loud enough, depending on the unit layout and patient assignment.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 19

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. It is important for critically ill patients to feel safe. Which nursing strategies help the patient to feel safe in the critical care setting? (Select all that apply.)
a. Allow family members to remain at the bedside.
b. Consult with the charge nurse before making any patient care decisions.
c. Provide informal conversation by discussing your plans for after work.
d. Respond promptly to call bells or other communication for assistance.
e. Inform the patient that you have cared for many similar patients.

 

 

ANS:  A, D

Patients feel safe when nurses exhibit technical competence, meet their needs, and provide reorientation. Family member presence may also contribute to feeling safe. Consulting with the charge nurse before making decisions may be interpreted as incompetence or insecurity. The nurse’s personal activities should never be discussed with patients. Simply informing the patient that you have cared for many similar patients may or may not cause the patient to feel safer; the patient may feel this is condescending.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 23

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The critical care environment is often stressful to a critically ill patient. Identify stressors that are common. (Select all that apply.)
a. Alarms that sound from various devices
b. Bright fluorescent lighting
c. Lack of day-night cues
d. Sounds from the mechanical ventilator
e. Visiting hours tailored to meet individual needs

 

 

ANS:  A, B, C, D

Adjustment of visiting hours to meet the needs of patients and families assists in reducing the stress of critical illness. All other responses are environmental stressors that may increase anxiety or affect sleep.

 

DIF:    Cognitive Level: Understand/Comprehension                 REF:   pp. 19-20

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. To reduce relocation stress in patients transferring out of the intensive care unit, the nurse can (Select all that apply.)
a. ask the nurses on the intermediate care unit to give the family a tour of the new unit.
b. contact the intensivist to see if the patient can stay one additional day in the critical care unit so that he and his family can adjust better to the idea of a transfer.
c. ensure that the patient will be located near the nurses’ station in the new unit.
d. invite the nurse who will be assuming the patient’s care to meet with the patient and family in the critical care unit prior to transfer.
e. help the patient and family focus on the positive meaning of a transfer.

 

 

ANS:  A, D, E

Patients often have stress when they are moved from the safety of the critical care unit. Introducing the patient and his family to the nurse who will assume care and to the new environment are strategies to reduce relocation stress. Encouraging the patient and family to see the transfer as a positive sign of healing might lessen the stress they feel. Although the patient and his family may feel safer in a room near the nurses’ station, bed placement is determined by a variety of factors and cannot be guaranteed. Beds in the critical care unit are at a premium, and once the physician has determined that the patient no longer meets critical care admission requirements, it is essential that transfers be made as soon as a bed on the intermediate care unit is available.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 20

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

 

  1. The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
a. Adjust lighting to promote normal sleep-wake cycles.
b. Provide clocks, calendars, and personal photos in the patient’s room.
c. Talk to the patient about other patients you are caring for on the unit.
d. Tell the patient the day and time when you are providing routine nursing interventions.
e. Allow unlimited visitation tailored to the patient’s individual needs.

 

 

ANS:  A, B, E

Manipulation of the environment, such as the adjustment of lighting, is helpful in promoting sleep and rest. Clocks, calendars, photos, and other personal items promote orientation and personalize the environment; telling the patient the day and time and other current events assists in maintaining the patient’s orientation. Allowing visitation that best meets the patient’s needs will reduce stress as the patient’s support systems are present. Conversations about other patients are private and should take place away from other patients.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    pp. 22-24

OBJ:   Describe stressors in the critical care environment and strategies to reduce them.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Psychosocial Integrity

Chapter 10: Rapid Response Teams and Code Management

Sole: Introduction to Critical Care Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. The nurse chooses which method and concentration of oxygen administration until intubation is established in a patient who has sustained a cardiopulmonary arrest?
a. Bag-valve-mask at FiO2 of 100%
b. Bag-valve-mask at FiO2 of 50%
c. Mouth-to-mask ventilation with supplemental oxygen
d. Non-rebreather mask at FiO2 of 100%

 

 

ANS:  A

Oxygen can be delivered via mouth to mask or with a bag-valve device connected to a mask or endotracheal tube. During resuscitation efforts, 100% oxygen is administered.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 212 | Table 10-3

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Laypersons should use which device to treat lethal ventricular dysrhythmias that occur outside a hospital setting?
a. Automatic external defibrillator
b. Carbon dioxide detector
c. Pocket mask
d. Transcutaneous pacemaker

 

 

ANS:  A

Because of the ease of use and efficacy in treating lethal ventricular dysrhythmias, automatic external defibrillators are recommended to be placed in a variety of public settings where they may be used by laypersons.

 

DIF:    Cognitive Level: Understand/Comprehension                 REF:   p. 218

OBJ:   Identify equipment used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. When doing manual ventilations during a code, the nurse would administer ventilations following which guideline?
a. Approximately 8 to 10 breaths per minute
b. During the fifth chest compression
c. Every 3 seconds or 20 times per minute
d. While compressions are stopped

 

 

ANS:  A

Manual ventilations are delivered one breath every 6 to 8 seconds or approximately 8 to 10 breaths per minute.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 212 | Table 10-3

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The patient has been admitted to a critical care unit with a diagnosis of acute myocardial infarction. Suddenly the monitor alarms and the screen shows a flat line. What action should the nurse take first?
a. Administer epinephrine by intravenous push.
b. Begin chest compressions.
c. Check patient for unresponsiveness.
d. Defibrillate at 360 J.

 

 

ANS:  C

The first intervention is to assess unresponsiveness.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 214

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. During a code, the nurse would place paddles for anterior defibrillation in what locations?
a. Second intercostal space, left sternal border and fourth intercostal space, left midclavicular line
b. Second intercostal space, right sternal border and fourth intercostal space, left midaxillary line
c. Second intercostal space, right sternal border and fifth intercostal space, left midclavicular line
d. Fourth intercostal space, right sternal border and fifth intercostal space, left midclavicular line

 

 

ANS:  C

Anterior paddle placement is used most often for defibrillation. In the anterior method, one paddle or adhesive electrode pad is placed at the second intercostal space to the right of the sternum, and the other paddle or adhesive electrode pad is placed at the fifth intercostal space, midaxillary line, to the left of the sternum.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 216 | Figure 10-8

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. During cardioversion, the nurse would synchronize the electrical charge to coincide with which wave of the ECG complex?
a. P
b. R
c. S
d. T

 

 

ANS:  B

During cardioversion, the electrical shock is synchronized to deliver shock on the R wave. This is to prevent the shock from being delivered during repolarization (T wave). Ventricular fibrillation may occur if the shock is delivered on the T wave.

 

DIF:    Cognitive Level: Understand/Comprehension                 REF:   p. 218

OBJ:   Identify equipment used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The nurse knows that in advanced cardiac life support, the secondary survey includes steps A-B-C-D, in which “D” refers to:
a. defibrillate.
b. differential diagnosis.
c. diltiazem intravenous push.
d. do not resuscitate.

 

 

ANS:  B

The A-B-C-D (airway, breathing, circulation, differential diagnosis) in the Advanced Cardiac Life Support (ACLS) secondary survey involves the performance of more in-depth assessments and interventions. Differential diagnosis involves investigation into the cause of the arrest. If a reversible cause is identified, a specific therapy can be initiated.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 213

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The patient is diagnosed with abrupt onset of supraventricular tachycardia (SVT). The nurse prepares which medication to administer to the patient?
a. Adenosine
b. Amiodarone
c. Diltiazem
d. Procainamide

 

 

ANS:  A

Adenosine is the initial drug of choice for the diagnosis and treatment of supraventricular dysrhythmias. Adenosine has an onset of action of 10 to 40 seconds and duration of 1 to 2 minutes; therefore, it is administered rapidly.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 215 | Table 10-4

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The code team has just defibrillated a patient in ventricular fibrillation. Following CPR for 2 minutes, what is the next action to take?
a. Administer amiodarone.
b. Administer lidocaine.
c. Assess rhythm and pulse.
d. Prepare for transcutaneous pacing.

 

 

ANS:  C

Reassess the patient frequently. Check for return of pulse, spontaneous respirations, and blood pressure.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 214

OBJ:   Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.           TOP:              Nursing Process Step: Evaluation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The patient’s monitor shows bradycardia (heart rate of 40 beats/min) and frequent premature ventricular contractions (PVCs) with a measured blood pressure of 85/50 mm Hg. The nurse anticipates the use of which drug?
a. Atropine 0.5 to 1 mg intravenous push
b. Dopamine drip—continuous infusion
c. Lidocaine 1 mg/kg intravenous push
d. Transcutaneous pacemaker

 

 

ANS:  A

This patient is having PVCs secondary to bradycardia. Atropine is a first-line drug for bradycardia. Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg. Atropine is not indicated in second-degree atrioventricular (AV) block type II or third-degree AV block.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   pp. 214-214 | Table 10-4

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. The monitor technician notifies the nurse “stat” that the patient has a rapid, chaotic rhythm that looks like ventricular tachycardia. What is the nurse’s first action?
a. Call a code overhead.
b. Check the patient immediately.
c. Go to the nurses’ station and look at the rhythm strip.
d. Take the crash cart to the room.

 

 

ANS:  B

The first intervention in this situation is to assess unresponsiveness by checking the patient.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 211

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Which rhythm would be an emergency indication for the application of a transcutaneous pacemaker?
a. Asystole
b. Bradycardia (heart rate 40 beats/min), normotensive and alert
c. Bradycardia (heart rate 50 beats/min) with hypotension and syncope
d. Supraventricular tachycardia (heart rate 150 beats/min), hypotensive

 

 

ANS:  C

Transcutaneous (external noninvasive) cardiac pacing is used during emergencies to treat symptomatic bradycardia (hypotension, altered mental status, angina, pulmonary edema) that has not responded to atropine. This patient is symptomatic.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 215 | Table 10-4

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. A patient is admitted to the coronary care unit with an inferior wall myocardial infarction and develops symptomatic bradycardia with premature ventricular contractions every third beat (trigeminy). The nurse knows to prepare to administer which drug?
a. Amiodarone
b. Atropine
c. Lidocaine
d. Magnesium

 

 

ANS:  B

Atropine is used to increase the heart rate by decreasing the vagal tone. It is indicated for patients with symptomatic bradycardia.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 215 | Table 10-4

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. A patient develops frequent ventricular ectopy. The nurse prepares to administer which drug?
a. Adenosine
b. Atropine
c. Lidocaine
d. Magnesium

 

 

ANS:  C

Lidocaine is an antidysrhythmic drug that suppresses ventricular ectopic activity.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 223 | Table 10-4

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. It is determined that the patient needs a transcutaneous pacemaker until a transvenous pacemaker can be inserted. What is the most appropriate nursing intervention?
a. Apply conductive gel to the skin.
b. Provide adequate sedation and analgesia.
c. Recheck leads to make sure that the rhythm is asystole.
d. Set the milliamperes to 2 mA below the capture level.

 

 

ANS:  B

The alert patient who requires transcutaneous pacing may experience some discomfort. Because the skeletal muscles are stimulated, as well as the heart muscle, the patient may experience a tingling, twitching, or thumping feeling that ranges from mildly uncomfortable to intolerable. Sedation, analgesia, or both may be indicated.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 220

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. The nurse needs to evaluate arterial blood gases before the administration of which drug?
a. Calcium chloride
b. Magnesium sulfate
c. Potassium
d. Sodium bicarbonate

 

 

ANS:  D

Bicarbonate therapy should be guided by the bicarbonate concentration or calculated base deficit from arterial blood gas analysis or laboratory measurement.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 224 | Table 10-4

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. During a code situation, the nurse would prepare to use which preferred intravenous fluid?
a. 5% dextrose in 0.45% normal saline
b. 5% dextrose in water
c. Dopamine infusion
d. Normal saline

 

 

ANS:  D

Normal saline is the preferred intravenous fluid during resuscitation efforts because it expands intravascular volume better than infusions containing dextrose.

 

DIF:    Cognitive Level: Understand/Comprehension                 REF:   p. 209

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. A nursing home patient is admitted to the critical care unit with a severe case of pneumonia. No living will or designation of health care surrogate is noted on the chart. In the event this patient needs intubation and/or cardiopulmonary resuscitation, what should be the nurse’s action?
a. Activate the code team, but initiate a “slow” code.
b. Call the nursing home to determine the patient’s or family’s wishes.
c. Code the patient for 5 minutes and then cease efforts.
d. Initiate intubation and/or cardiopulmonary resuscitation efforts.

 

 

ANS:  D

In the absence of a written order from a physician to withhold resuscitative measures, resuscitation efforts must be initiated if indicated.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 205

OBJ:   Identify psychosocial, legal, and ethical issues related to code management.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. A patient is brought to the critical care unit after a motor vehicle crash. On admission, the patient reports dyspnea and chest pain. Upon examination, the nurse notes a lack of breath sounds on the left side and a tracheal shift. The patient suddenly experiences cardiac arrest. What assessment by the nurse takes priority?
a. Heart tones
b. Lung sounds
c. Peripheral pulses
d. Neurological status

 

 

ANS:  B

The nurse should listen to lung sounds first. The signs and symptoms the patient experienced are consistent with a tension pneumothorax, which is a reversible cause of cardiac arrest. A tension pneumothorax occurs when air enters the pleural space but cannot escape. Pressure increases in the pleural space and causes the lung to collapse. Symptoms of a tension pneumothorax include dyspnea, chest pain, tachypnea, tachycardia, and jugular venous distension.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   Box 10-2

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. The patient has pulseless electrical activity (PEA). What action by the nurse takes priority?
a. Begin high-quality CPR.
b. Assist with chest tube placement.
c. Prepare equipment for a pericardiocentesis.
d. Attach the patient to a transcutaneous pacemaker.

 

 

ANS:  A

A patient in PEA does not have a pulse or blood pressure. The nurse initiates high-quality CPR. Chest tube insertion, pericardiocentesis, and transcutaneous pacing are not required.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 214

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. What is the major reason for using a treatment to lower body temperature after cardiac arrest to promote better neurological recovery?
a. Hypothermia decreases the metabolic rate by 7% for each decrease of 1° C.
b. Lower body temperatures are beneficial in patients with low blood pressure.
c. Temperatures of 40° C may reduce neurological impairment.
d. The lower body temperature leads to decreased oxygen delivery.

 

 

ANS:  A

Hypothermia decreases the metabolic rate by 6% to 7% for every decrease of 1° C in temperature; decreased metabolic rate may protect neurological function. Induced hypothermia to a core body temperature of 32° C to 34° C for 12 to 24 hours may be beneficial in reducing neurological impairment after cardiac arrest.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   pp. 227-228

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Assessment

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. The patient has a transcutaneous pacemaker in place. Pacemaker spikes followed by QRS complexes are noted on the cardiac rhythm strip. To determine if the pacemaker is working, the nurse must do which of the following?
a. Obtain a 12-lead electrocardiogram (ECG).
b. Call for a pacemaker interrogation.
c. Palpate the pulse.
d. Run a 2-minute monitor strip for analysis.

 

 

ANS:  C

The electrical and mechanical effectiveness of pacing is assessed. The electrical activity is noted by a pacemaker “spike” that indicates that the pacemaker is initiating electrical activity. The spike is followed by a broad QRS complex. Mechanical activity is noted by palpating a pulse during electrical activity.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 220

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. A patient has been successfully converted from ventricular tachycardia with a pulse to a sinus rhythm. Upon further assessment, it is noted that the patient is hypotensive. The appropriate treatment for her hypotension may include (Select all that apply)
a. adenosine.
b. dopamine infusion.
c. magnesium.
d. normal saline infusion.
e. sodium bicarbonate.

 

 

ANS:  B, D

The patient may need fluid resuscitation; dopamine is indicated for hypotension once hypovolemia has been corrected. Adenosine, magnesium, and sodium bicarbonate are not indicated in this situation.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 213 | Table 10-4

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. A patient is admitted to the critical care unit with bradycardia at a heart rate of 39 beats/min and frequent premature ventricular contractions. The nurse notes that the patient is lethargic and reports dizziness for the past 12 hours. Which of the following are acceptable initial treatments for this patient? (Select all that apply.)
a. Atropine
b. Epinephrine
c. Lidocaine
d. Transcutaneous pacemaker
e. Magnesium sulfate infusion

 

 

ANS:  A, D

Administer atropine, 0.5 mg IV every 3 to 5 minutes to a total dose of 3 mg for symptomatic bradycardia. Transcutaneous pacing is also indicated for symptomatic bradycardia unresponsive to atropine. Epinephrine infusion can be used if atropine is not effective but it is not a first-line choice. Lidocaine is contraindicated in bradycardia because it can depress conduction, which would be detrimental with a heart rate of 39 beats/min. Magnesium is not indicated for bradycardia.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   pp. 214-215 | Box 10-3

OBJ:   Identify medications used in code management, including use, action, side effects, and nursing implications.           TOP:              Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Ventricular fibrillation should initially be treated by which of the following? (Select all that apply)
a. Administration of amiodarone, followed by defibrillation at 360 J
b. Atropine 1 mg, followed by defibrillation at 200 J
c. Defibrillation at 200 J with biphasic defibrillation
d. Defibrillation at 360 J with monophasic defibrillation
e. Dopamine continuous infusion.

 

 

ANS:  C, D

If a biphasic defibrillator is available, use the dose at which that defibrillator has been shown to be effective for terminating VF (typically 120 to 200 J). If the dose is not known, use 200 J. If a monophasic defibrillator is available, use an initial shock of 360 J and use 360 J for subsequent shocks. Dobutamine is used for hypotension not related to hypovolemia.  Amiodarone can be used for ventricular fibrillation not responsive to CPR, defibrillation, and vasopressors.  Atropine is not used in this situation.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   pp. 213-214

OBJ:   Discuss treatment of special problems that can occur during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Which code drugs can be given safely through an endotracheal tube? (Select all that apply)
a. Adenosine
b. Atropine
c. Epinephrine
d. Vasopressin
e. Amiodarone

 

 

ANS:  B, C, D

Medications that can be administered through the endotracheal tube until IV access is established are atropine, epinephrine, lidocaine, and vasopressin.

 

DIF:    Cognitive Level: Understand/Comprehension                 REF:   Table 10-4

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following statements about defibrillation are correct? (Select all that apply)
a. Early defibrillation (if warranted) is recommended before other actions.
b. It is not necessary to ensure that personnel are clear of the patient if hands-off defibrillation is used.
c. It is not necessary to synchronize the defibrillation shocks.
d. Paddles/patches can be placed anteriorly and posteriorly on the chest.
e. All models of defibrillators are the same for standardization.

 

 

ANS:  A, C, D

Defibrillation is indicated as soon as possible because early defibrillation and CPR increase the chance of survival. Regardless of the method of defibrillation, all personnel must avoid contact with the patient or bed during the shock delivery. Shocks are delivered without synchronization. Anterior paddle placement is used most often; however, the alternative method is anteroposterior placement. Defibrillators come in many models, and nurses must ensure they are familiar with the model in use on their unit.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    pp. 215-216

OBJ:   Differentiate basic and advanced life-support measures used during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Postresuscitation goals include which of the following? (Select all that apply)
a. Control dysrhythmias
b. Maintain airway
c. Maintain blood pressure
d. Wean off oxygen
e. Early ambulation

 

 

ANS:  A, B, C

Postresuscitation goals include optimizing tissue perfusion by airway, blood pressure maintenance, oxygenation, and control of dysrhythmias. Weaning off oxygen and early ambulation are good actions when possible but are not goals of postresuscitation care.

 

DIF:    Cognitive Level: Apply/Application                                          REF:    p. 225 |p. 227

OBJ:   Describe care of patients after resuscitation.

TOP:   Nursing Process Step: Planning

MSC:  NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following are documented as part of the cardiopulmonary arrest record? (Select all that apply)
a. Medication administration times
b. Defibrillation times, joules, outcomes
c. Rhythm strips of cardiac rhythm(s) noted
d. Signatures of recorder and other personnel
e. Model of defibrillator used.

 

 

ANS:  A, B, C, D

Documentation includes the time the code is called, the time CPR is started, any actions that are taken, and the patient’s response (e.g., presence or absence of a pulse, heart rate, blood pressure, cardiac rhythm). Intubation and defibrillation (and the energy used) must be documented, along with the patient’s response. The time and sites of IV initiations, types and amounts of fluids administered, and medications given to the patient must be accurately recorded. Rhythm strips are recorded to document events and response to treatment. Signatures of those involved in the code effort, including the recorder, are essential.

 

DIF:    Cognitive Level: Remember/Knowledge                         REF:   p. 225 | Figure 10-15

OBJ:   Identify information to be documented during a code.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. Benefits of having the family present during resuscitation include which of the following? (Select all that apply)
a. Facilitates the grief process
b. Lets the family see that everything is being done
c. Sustains patient-family relationships
d. Allows the staff easy access to ask for organ transplant
e. Provides a sense of closure

 

 

ANS:  A, B, C, E

Families who have been present during a code describe the benefits as knowing that everything possible was being done for their loved one, feeling supportive and helpful to the patient and staff, sustaining patient-family relationships, providing a sense of closure on a life shared together, and facilitating the grief process.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 227

OBJ:   Identify psychosocial, legal, and ethical issues related to code management.

TOP:   Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. The nurse should call the rapid response team for which patients? (Select all that apply)
a. 53-year-old with pneumonia and severe respiratory distress
b. 17-year-old with apnea following a severe head injury
c. 24-year-old experiencing a severe asthmatic attack with stridor
d. 73-year-old patient with bradycardia of 40 beats per minute
e. 52-year-old patient with no palpable pulse

 

 

ANS:  A, C, D

Rapid response teams (RRTs) or medical emergency teams focus on addressing changes in a patient’s clinical condition before a cardiopulmonary arrest occurs. The patient without a pulse and the patient with apnea needs the code team activated.

 

DIF:    Cognitive Level: Analyze/Analysis                                 REF:   p. 205

OBJ:   Compare roles of caregivers in rapid response teams and managing cardiopulmonary arrest situations.           TOP:              Nursing Process Step: Implementation

MSC:  NCLEX Client Needs Category: Safe and Effective Care Environment

Chapter 20: Trauma and Surgical Management

Sole: Introduction to Critical Care Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. Which of the following best defines the term traumatic injury?
a. All trauma patients can be successfully rehabilitated.
b. Traumatic injuries cause more deaths than heart disease and cancer.
c. Alcohol consumption, drug abuse, or other substance abuse contribute to traumatic events.
d. Trauma mainly affects the older adult population.

 

 

ANS:   C

Many patients who sustain traumatic injury are under the influence of alcohol, drugs, or other substances. Rehabilitation potential depends on multiple factors, including severity of injury, patient age, and comorbidities. Heart disease and cancer claim more lives than trauma, but trauma claims lives of predominantly young individuals.

 

DIF:    Cognitive Level: Understand/Comprehension                      REF:    p. 556

OBJ:    Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP:    Nursing Process Step: Planning

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. When providing information on trauma prevention, it is important to realize that individuals age 35 to 54 years are most likely to experience which type of trauma incident?
a. High-speed motor vehicle crashes
b. Poisonings from prescription or illegal drugs
c. Violent or domestic traumatic altercations
d. Work-related falls

 

 

ANS:   B

People age 35 to 54 years are at greater risk of experiencing poisonings from prescription and/or illegal drugs resulting in unintentional injury, followed by motor vehicle crashes (MVCs). MVCs and homicide are the leading causes of death for individuals age 16 to 24 years, and falls are responsible for traumatic injuries in those 65 years and older. Domestic violence is not well defined as an age-related trauma incident.

 

DIF:    Cognitive Level: Understand/Comprehension                      REF:    p. 556

OBJ:    Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. An 18-year-old unrestrained passenger who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. This patient should be treated at which level trauma center?
a. Level I
b. Level II
c. Level III
d. Level IV

 

 

ANS:   A

Because the patient is hypotensive and was unrestrained, the patient is at higher risk for more severe injuries related to the mechanism of injury; thus, treatment should occur at a level I trauma center. Patients with less severe injuries can be treated at lower-level trauma centers.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 558 | Table 20-1

OBJ:    Discuss prehospital care, emergency care, and resuscitation of the trauma patient.

TOP:    Nursing Process Step: Evaluation

MSC:   NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. Which of the following injuries would result in a greater likelihood of internal organ damage and risk for infection?
a. A fall from a 6-foot ladder onto the grass
b. A shotgun wound to the abdomen
c. A knife wound to the right chest
d. A motor vehicle crash in which the driver hits the steering wheel

 

 

ANS:   B

The penetrating injury of the gunshot wound would cause the greatest amount of injury because of the kinetic energy and dispersion pattern of the shotgun ammunition once it penetrated the body. A fall would cause a compression injury from the blunt force of the fall. The knife wound would cause a penetrating injury in which the magnitude of the injury would depend on damage to the vessels and lung. Blunt chest trauma that may include a cardiac contusion is possible following an injury in which the patient hits the steering column.

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    p. 563

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Evaluation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. A 24-year-old unrestrained driver who sustained multiple traumatic injuries from a motor vehicle crash has a blood pressure of 80/60 mm Hg at the scene. The primary survey of this patient upon arrival to the ED
a. includes a cervical spine x-ray study to determine the presence of a fracture.
b. involves turning the patient from side to side to get a look at his back.
c. is done quickly in the first few minutes to get a baseline assessment and establish priorities.
d. is a methodical head-to-toe assessment identifying injuries and treatment priorities.

 

 

ANS:   C

The primary survey is a systematic rapid assessment of the patient’s airway with cervical spine immobilization, breathing and ventilation, circulation with hemorrhage control, disability or neurological status, and exposure/environmental considerations. The secondary survey is more methodical and involves identifying injuries and specific treatment priorities.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 563

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The nurse has admitted a patient to the ED following a fall from a first-floor hotel balcony. The patient smells of alcohol and begins to vomit in the ED. Which of the following interventions is most appropriate?
a. Insert an oral airway to prevent aspiration and to protect the airway.
b. Offer the patient an emesis basin so that you can measure the amount of emesis.
c. Prepare to suction the oropharynx while maintaining cervical spine immobilization.
d. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

 

 

ANS:   C

Stabilization of the cervical spine, preventing aspiration, and maintaining a patent airway are essential elements of trauma management. An oral airway may increase the risk of aspiration related to the emesis, and offering an emesis basin would contradict spine precautions. Alcohol level is best determined by serum analysis.

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    p. 566 | Table 20-2

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following interventions would not be appropriate for a patient who is admitted with a suspected basilar skull fracture?
a. Insertion of a nasotracheal tube
b. Insertion of an indwelling urinary catheter
c. Endotracheal intubation
d. Placement of an oral airway

 

 

ANS:   A

Nasotracheal tubes are contraindicated in basilar skull fractures because insertion may result in penetration of the meninges. An indwelling urinary catheter may be necessary to monitor fluid balance. Protection of the airway to include placement of an oral airway or endotracheal tube may be indicated.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 566 | Table 20-2

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Evaluation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The nurse is having difficulty inserting a large caliber intravenous catheter to facilitate fluid resuscitation to a hypotensive trauma patient. The nurse recommends which of the following emergency procedures to facilitate rapid fluid administration?
a. Placement of an intraosseous catheter
b. Placement of a central line
c. Insertion of a femoral catheter by a trauma surgeon
d. Rapid transfer to the operating room

 

 

ANS:   A

Infusion of volume is required for optimal fluid resuscitation and may be achieved through large caliber venous cannulation or intraosseous access. A central line or femoral vein access may be obtained by the physician, but the procedure requires time. Transport to the operating room is not a priority in the goal to obtain intravenous access for fluid resuscitation.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 568

OBJ:    Describe prehospital care, emergency care, and resuscitation of the trauma patient.

TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. In the trauma patient, symptoms of decreased cardiac output are most commonly caused by
a. cardiac contusion.
b. cardiogenic shock.
c. hypovolemia.
d. pericardial tamponade.

 

 

ANS:   C

Hypovolemia is commonly associated with traumatic injury resulting from acute blood loss. Cardiac contusion may decrease cardiac output, but hypovolemia occurs more often. Cardiogenic shock is not typically associated with trauma. Pericardial tamponade would decrease cardiac output but is not as common as hypovolemia.

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    p. 567

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. A community-based external disaster is initiated after a tornado moved through the city. A nurse from the medical records review department arrives at the emergency department asking how to assist. The best response by a nurse working for the trauma center would be to
a. assign the nurse administrative duties, such as obtaining patient demographic information.
b. assign the nurse to a triage room with another nurse from the emergency department.
c. thank the nurse but inform her to return to her department as her skill set is not a good match for patients’ needs.
d. have the nurse assist with transport of patients to procedural areas.

 

 

ANS:   A

A nurse in the medical records department is a knowledgeable health care provider who can help in a disaster by obtaining essential patient information. Assigning the nurse to provide direct care to patients, such as assisting in the triage room or transporting patients, may not be appropriate, as the direct care skills are not known. Asking the nurse to return to the medical records department also may not be appropriate because the nurse offers a skill set that can be used during the disaster.

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    pp. 560-561

OBJ:    Describe a system approach to trauma care.

TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. A patient has been admitted to the emergency department with a massive hemothorax. What action by the nurse takes priority?
a. Place the patient on a cardiac monitor
b. Prepare for rapid intubation
c. Seal the wound with occlusive dressings
d. Start 2 large bore IVs

 

 

ANS:   D

A patient with a hemothorax will need blood transfusions and a chest tube placement for treatment. The nurse should start 2 large bore IVs with crystalloid solution. A cardiac monitor is also necessary, but active measures to treat the patient should be done first. The patient may or may not need intubation and mechanical ventilation. An occlusive dressing is not necessary.

 

DIF:    Cognitive Level: Apply/Application

REF:    p. 572 | Table 20-4

OBJ:    Discuss prehospital care, emergency care, and resuscitation of the trauma patient.

TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The need for fluid resuscitation can be assessed best in the trauma patient by monitoring and trending which of the following tests?
a. Arterial oxygen saturation
b. Hourly urine output
c. Mean arterial pressure
d. Serum lactate levels

 

 

ANS:   D

Serum lactate levels are useful in assessing acidosis and the need for aggressive fluid resuscitation. Arterial oxygen saturation provides clinical information on oxygen delivery to cells. Hourly urine output and mean arterial pressure provide information on systemic perfusion and are monitored in the assessment of effective resuscitation; however, serum lactate is a better indicator of metabolic acidosis caused by underperfusion (under resuscitation).

 

DIF:    Cognitive Level: Understand/Comprehension

REF:    p. 569 Lab Alert Box

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The nurse is caring for a patient who sustained rib fractures after hitting the steering wheel of the car during a motor vehicle crash. The patient is spontaneously breathing and receiving oxygen via a face mask; the oxygen saturation is 95%. During the nurse’s assessment, the oxygen saturation drops to 80%. The patient’s blood pressure has dropped from 128/76 mm Hg to 84/60 mm Hg. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the provider and anticipates
a. administration of lactated Ringer’s solution (1 L) wide open.
b. chest x-ray study to determine the etiology of the symptoms.
c. endotracheal intubation and mechanical ventilation.
d. needle thoracostomy and chest tube insertion.

 

 

ANS:   D

These are classic symptoms of a tension pneumothorax in a patient at high risk related to mechanism of injury. Emergent decompression by a needle thoracostomy followed by a chest tube insertion is needed. A chest x-ray would delay treatment and is not needed before emergent intervention. Administration of IV fluids would not assist with blood pressure, as increased thoracic pressure from the tension pneumothorax needs to be relieved to restore cardiac output (and blood pressure). Endotracheal intubation and mechanical ventilation may be necessary after the tension pneumothorax is relieved to assist with the patient’s ventilation.

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    p. 572 | Table 20-4

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following patients have the greatest risk of developing acute respiratory distress syndrome (ARDS) after traumatic injury?
a. A patient who has a closed head injury with a decreased level of consciousness
b. A patient who has a fractured femur and is currently in traction
c. A patient who has received large volumes of fluid and/or blood replacement
d. A patient who has underlying chronic obstructive pulmonary disease

 

 

ANS:   C

During states of hypoperfusion and acidosis, inflammation occurs and vessels become more permeable to fluid and molecules. With aggressive fluid resuscitation, this change in permeability allows the movement of fluid from the intravascular space into the interstitial spaces (third-spacing). As more IV fluids are given to support systemic circulation, fluids continue to migrate into the interstitial space, causing excessive edema and predisposing the patient to additional complications such as abdominal compartment syndrome, ARDS, acute kidney injury, and MODS. A patient with a closed head injury, a patient with a fractured femur stabilized by traction, and a patient with chronic obstructive pulmonary disease may develop ARDS, but it would not be related to fluid resuscitation and excessive inflammation associated with traumatic injury.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 569 Lab Alert Box

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Patients with musculoskeletal injury are at increased risk for compartment syndrome. What is an initial symptom of a suspected compartment syndrome?
a. Absence of pulse in affected extremity
b. Pallor in the affected area
c. Paresthesia in the affected area
d. Severe, throbbing pain in the affected area

 

 

ANS:   D

Patients with compartment syndrome complain of increasing throbbing pain disproportionate to the injury. Narcotic administration does not relieve the pain. The pain is localized to the involved compartment and increases with passive muscle stretching. The area affected is firm. Paresthesia distal to the compartment, pulselessness, pallor, and paralysis are late signs and must be reported immediately to prevent loss of the extremity.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 576

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. During the treatment and management of the trauma patient, maintaining tissue perfusion, oxygenation, and nutritional support are strategies to prevent
a. disseminated intravascular coagulation.
b. multisystem organ dysfunction.
c. septic shock.
d. wound infection.

 

 

ANS:   B

Patients with multisystem injuries are at high risk of developing myriad complications associated with the overwhelming stressors of the injury, prolonged immobility, and consequences of inadequate tissue perfusion and oxygenation. Maintaining effective tissue perfusion, oxygenation, and nutritional support are all vital to prevent progression into multiple organ dysfunction syndrome. Disseminated intravascular coagulation, septic shock, and wound infections are best prevented by addressing infection early and aggressively with appropriate antibiotics and nursing interventions to reduce infection (e.g., hand hygiene).

 

DIF:    Cognitive Level: Apply/Application                                      REF:    p. 560

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Range-of-motion exercises, early ambulation, and adequate hydration are interventions to prevent
a. catheter-associated infection.
b. venous thromboembolism.
c. fat embolism.
d. nosocomial pneumonia.

 

 

ANS:   B

Prevention of venous thromboembolism is essential in the management of trauma patients. If not medically contraindicated, patients should receive pharmacological prophylaxis (e.g., heparin or heparin derivatives). Nurses should encourage ambulation, evaluate the patient’s overall hydration, and ensure sequential compression devices are used properly. Prevention of catheter-associated infections is also important through interventions that maintain the integrity of the catheter site and injection ports. Hydration and ambulation, along with pulmonary exercises, help prevent pneumonia. Fat embolism is associated with long bone fractures and early recognition of this complication is essential to treatment.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 576

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following interventions is a strategy to prevent fat embolism syndrome?
a. Administer lipid-lowering statin medications.
b. Intubate the patient early after the injury to provide mechanical ventilation.
c. Provide prophylaxis with low–molecular weight heparin.
d. Stabilize extremity fractures early.

 

 

ANS:   D

Stabilization of extremity fractures to minimize both bone movement and the release of fatty products from the bone marrow must be accomplished as early as possible. Administration of statin medications has no effect on prevention of fat embolism. Intubation and mechanical ventilation may be necessary to support the pulmonary system in the event the patient has a fat embolism, but it will not prevent this complication. Heparin will not prevent fat embolism; it is for venous thromboembolism prophylaxis.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 576

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Treatment and/or prevention of rhabdomyolysis in at-risk patients includes aggressive fluid resuscitation to achieve urine output of:
a. 30 mL/hr.
b. 50 mL/hr.
c. 100 mL/hr.
d. 300 mL/hr.

 

 

ANS:   C

Treatment of rhabdomyolysis consists of aggressive fluid resuscitation to flush the myoglobin from the renal tubules. A common protocol includes the titration of IV fluids to achieve a urine output of 100 to 200 mL/hr. Urine volumes less than 100 mL/hr are insufficient and a urine volume greater than 200mL/hr will not harm the patient but may create too aggressive a diuresis.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 576

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following statements about mass casualty triage during a disaster is true?
a. Priority treatments and interventions focus primarily on young victims.
b. Disaster victims with the greatest chances for survival receive priority for treatment.
c. Once interventions have been initiated, health care providers cannot stop the treatment of disaster victims.
d. Color-coded systems in which green indicates the patient of greatest need are used during disasters.

 

 

ANS:   B

Victims are triaged based on the severity of injury. Patients receive treatment based on the assessment of greatest chances for survival matched to resources available for medical intervention. Age is not a determination in rendering interventions. Patient survival and severity of injury are the priority assessment for triage. If interventions are initiated and found to be ineffective, treatment can be stopped according to principles of ethical care. Color-coded systems are frequently used during disasters to signify patients in greatest need of assistance, with red indicating worse severity of injury and green being most stable.

 

DIF:    Cognitive Level: Understand/Comprehension                      REF:    p. 561

OBJ:    Describe a system approach to trauma care.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Safe and Effective Care Environment

 

  1. A 36-year-old driver was pulled from a car after it collided with a tree and the gas tank exploded. What assessment data suggest the patient suffered tissue damage consistent with a blast injury?
a. Blood pressure 82/60 mm Hg, heart rate 122 beats/min, respiratory rate 28 breaths/min
b. Crackles (rales) on auscultation of bilateral lung fields
c. Responsive only to painful stimuli
d. Irregular heart rate and rhythm

 

 

ANS:   B

Explosive blast energy generates shock waves that create changes in air pressure, causing tissue damage. Initially after an explosion, there is a rapid increase in positive pressure for a short period, followed by a longer period of negative pressure. The increase in positive pressure injures gas-containing organs. The tympanic membrane ruptures, and the lungs may show evidence of contusion, acute edema, or rupture. A low blood pressure and corresponding tachycardia are more suggestive of hypovolemia. Lack of response to stimuli suggests a neurological injury. An irregular heart rate and rhythm may be associated with blunt trauma to the heart (e.g., cardiac contusion).

 

DIF:    Cognitive Level: Analyze/Analysis    REF:    p. 563

OBJ:    Identify mechanisms of traumatic injury commonly seen in the critical care setting.

TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which of the following statements are true regarding fluid resuscitation during the care of a trauma patient? (Select all that apply.)
a. 5% Dextrose is recommended for rapid crystalloid infusion.
b. IV fluids may need to be warmed to prevent hypothermia.
c. Massive transfusions should be avoided to improve patient outcomes.
d. Only fully crossmatched blood products are administered.
e. Hypertonic saline solutions are often used during initial resuscitation.

 

 

ANS:   B, C

Lactated Ringer’s and normal saline are the crystalloids of choice in trauma resuscitation. Because hypothermia is a concern, fluids should be warmed. Massive blood transfusions are associated with poor outcomes. Crossmatched blood is preferred, but blood type O, universal donor blood, can be administered in an emergency. Isotonic solutions are used predominantly during fluid resuscitation.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 571 | p. 576 | Table 20-2

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following statements apply to trauma patients and their potential complications? (Select all that apply.)
a. Indwelling urinary catheters are a source of infection.
b. Patients often develop infection and sepsis secondary to central line catheters.
c. Pneumonia is often an adverse outcome of mechanical ventilation.
d. Wounds require sterile dressings to prevent infection.

 

 

ANS:   A, B, C

Prevention of infection is essential in the care of trauma and postsurgical patients. Removing invasive devices when they are no longer needed for monitoring and ensuring aseptic care of devices are important nursing care considerations for management of indwelling urinary catheters, central lines, and airway adjuncts. Wounds, other than the immediate postoperative dressing, are not required to be sterile. Aseptic technique is used for wound care.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 579

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Planning

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. During the assessment of a patient after a high-speed motor vehicle crash, which of the following findings would increase the nurse’s suspicion of a pulmonary contusion? (Select all that apply.)
a. Chest wall ecchymosis
b. Diminished or absent breath sounds
c. Pink-tinged or blood secretions
d. Signs of hypoxia on room air
e. Paradoxical chest wall movement

 

 

ANS:   A, C, D

Pulmonary contusion is a serious injury associated with deceleration or blast forces and is a common cause of death after chest trauma. The clinical presentation includes chest wall abrasions, ecchymosis, bloody secretions, and a partial pressure of arterial oxygen (PaO2) of less than 60 mm Hg while breathing room air. The bruised lung tissue becomes edematous, resulting in hypoxia and respiratory distress. Absence of breath sounds is more suggestive of atelectasis or a collapsed lung. Paradoxical chest wall movement is indicative of flail chest.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    pp. 572-573

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. It is important to prevent hypothermia in the trauma patient because hypothermia is associated with which of the following? (Select all that apply.)
a. ARDS
b. Coagulopathies
c. Dysrhythmias
d. Myocardial dysfunction
e. Fat embolism

 

 

ANS:   B, C, D

Prolonged hypothermia is associated with the development of myocardial dysfunction, coagulopathies, reduced perfusion, and dysrhythmias (bradycardia and atrial or ventricular fibrillation). ARDS is a complication associated with excessive inflammation and overresuscitation. Fat embolism is often seen with long bone fractures.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    pp. 576-577

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which of the following patients would require greater amounts of fluid resuscitation to prevent acute kidney injury associated with rhabdomyolysis? (Select all that apply.)
a. Crush injury to right arm
b. Gunshot wound to the abdomen
c. Lightning strike of the left arm and chest
d. Pulmonary contusion and rib fracture
e. Penetrating wound to both legs

 

 

ANS:   A, C

Causes of rhabdomyolysis include crush injuries, compartment syndrome, burns, and injuries from being struck by lightning. Acute kidney injury may result from a gunshot wound related to prolonged hypotension. Acute kidney injury would not have a direct cause associated with a pulmonary contusion or penetrating wounds.

 

DIF:    Cognitive Level: Remember/Knowledge                              REF:    p. 576

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Which interventions can the nurse implement to assist the patient’s family in coping with the traumatic event? (Select all that apply.)
a. Establish a family spokesperson and communication system.
b. Ask the family about their normal coping mechanisms.
c. Limit visitation to set times throughout the day.
d. Coordinate a family conference.
e. Determine how the family perceives the event

 

 

ANS:   A, B, D, E

The trauma team can assist the patient and family in crisis by helping them establish a consistent communication process between the health care team and family. Other interventions include exploring the family’s perceptions of the event, support systems, and coping mechanisms. Family conferences early in the emergent phase and frequently during the critical care phase assist with communication and with understanding the patient’s and family’s expectations for care. Limiting visitation will not assist the patient or the family’s ability to cope with the traumatic event.

 

DIF:    Cognitive Level: Apply/Application                                      REF:    p. 580

OBJ:    Describe assessment and management of common traumatic injuries.

TOP:    Nursing Process Step: Assessment | Nursing Process Step: Evaluation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. Nursing priorities to prevent ineffective coagulation include which of the following? (Select all that apply.)
a. Prevention of hypothermia
b. Administration of fresh frozen plasma as ordered
c. Administration of potassium as ordered
d. Administration of calcium as ordered
e. Monitoring CBC and coagulation studies

 

 

ANS:   A, B, D

Ineffective coagulation is a serious complication for a trauma patient that can be prevented by maintaining normothermia, evaluating and treating for hypocalcemia, administering clotting factors found in fresh frozen plasma or platelets, and evaluating and treating metabolic acidosis. Evaluating and treating serum potassium levels is important for effective cardiac muscle function, not coagulation. Monitoring lab values does not prevent an event from occurring although it can allow the nurse to notice it sooner.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 569 Lab Alert Box

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.

TOP:    Nursing Process Step: Assessment | Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Psychosocial Integrity

 

  1. Which of the following findings require immediate nursing interventions in a patient with a traumatic brain injury? (Select all that apply.)
a. Mean arterial pressure 48 mm Hg
b. Elevated serum blood alcohol level
c. Nonreactive pupils
d. Respiratory rate of 10 breaths/min
e. Open skull fracture

 

 

ANS:   A, C, D, E

Rapid assessment of patients with neurological injury is vital to the treatment of patients with traumatic brain injury. Preventing hypotension (mean arterial pressure less than 50 mm Hg) is essential to maintain cerebral perfusion; nonreactive pupils are an abnormal finding and require immediate attention to evaluate the cause. Adequate oxygenation and ventilation are necessary to deliver oxygen to the brain; thus, a respiratory rate of 10 requires further evaluation. An open skull fracture leaves the patient extremely vulnerable to infection in the brain. An elevated blood alcohol level interferes with the ability to conduct a neurological examination but does not require immediate intervention.

 

DIF:    Cognitive Level: Apply/Application                                      REF:    p. 570

OBJ:    Formulate a plan of care for the trauma patient, including prevention of complications.      TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The nurse working in a trauma center administers blood products to a severely hemorrhaging trauma patient in a 1:1:1 ratio. Which blood products does the nurse include in this transfusion protocol? (Select all that apply.)
a. Whole blood
b. Universal donor blood only
c. Red blood cells
d. Platelets
e. Plasma

 

 

ANS:   C, D, E

The 1:1:1 transfusion protocol is an evidence-based practice consisting of transfusions of red blood cells, platelets, and plasma for optimal outcomes. Whole blood and universal donor blood exclusively are not included.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    Evidence Based Practice Box

OBJ:    Formulate a plan of care of the trauma patient, including prevention of complications.       TOP:    Nursing Process Step: Implementation

MSC:   NCLEX Client Needs Category: Physiological Integrity

 

  1. The trauma nurse understands which information related to the older trauma patient? (Select all that apply.)
a. Falls are the leading cause of death in the older population.
b. Physiologic capacity is an important predictor of outcome.
c. Hypotension in the elderly can appear as normotension.
d. Chronic diseases do not have much effect on the older trauma patient.
e. Fractures to bones other than hips are uncommon from trauma.

 

 

ANS:   A, B, C

Falls are the leading cause of death in the elderly and frequently result in fractures to many different bones, not just hips. Decreased physiologic reserve leads to poorer outcomes. Hypertension can mask hypotension by the blood pressure appearing to be normal. That is just one example of how chronic disease can complicate the picture of an older trauma patient.

 

DIF:    Cognitive Level: Remember/Knowledge

REF:    p. 578 Lifespan considerations          TOP:    Nursing Process Step: Assessment

MSC:   NCLEX Client Needs Category: Health Promotion and Maintenance

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