clapgeek logo
A patient who experienced a blunt chest trauma in an automobile crash is admitted with multiple rib fractures. The patient is dyspneic and hypotensive and is reporting left shoulder pain. On auscultation, a nurse notes that bowel sounds can be heard over the lower left thorax. These findings are consistent with
A patient with a history of COPD is admitted with increasing dyspnea and fatigue. O2 is initiated via nasal cannula at 4 L/min with an O2 saturation of 99%. One hour later, the patient becomes lethargic. Which of the following is the most likely cause for the change in the patient's mental status?
While recording hourly ventilator checks on a patient who is being mechanically ventilated, the nurse notes that the PIP has gradually increased by 5 cm H2O over the past 4 hours. This increase indicates
There is an increase in catheter-associated urinary tract infections (CAUTIs) following a change in urinary catheter insertion trays. After conducting a literature review of evidence-based practices regarding indwelling catheter insertion and care, the nurse should
Potentially life-threatening consequences of diabetic ketoacidosis (DKA) include
A patient reported to have smoked crack cocaine is brought to the hospital by paramedics and admitted in an agitated state. On the way to the hospital, the patient had a generalized seizure. The toxicology screen is positive for cocaine. Which of the following is most appropriate to administer?
A unit council is requesting to change a documentation screen of the electronic health record (EHR) at a large health system. The change was not discussed with the department prior to the request and was denied by the EHR committee. Which of the following strategies will most likely lead to accomplishing the team's goals?
After observing an increase in the occurrence of oral pressure injuries in intubated patients on the unit, the nurse should
A patient is admitted for sepsis secondary to pneumonia. The patient has received 2000 mL of plasmalyte and their BP remains 80/50. What should the nurse anticipate next for the patient?
A patient who was admitted after an open aortofemoral bypass for claudication at rest has a hemoglobin A1C of 8.9. The patient admits having poor control of blood glucose levels and is scared to use insulin as directed because of a few episodes of hypoglycemia. Which of the following should the nurse initially request to be consulted?
Which of the following is most indicative of successful treatment for salicylate poisoning?
A patient has a linear skull fracture with multisystem trauma. The patient's vital signs are as follows:
BP 80/50
HR120
CVP2 mm Hg
Which of the following is the most appropriate explanation for this patient's condition?
Which of the following assessment findings would be found in a patient with pulmonary hypertension?
A patient is admitted with an acute anterior wall MI. Initial hemodynamic readings are:
The nurse anticipates initiating a plan of care for
A patient is admitted with anaphylactic shock secondary to a blood transfusion. The patient's spouse asks the nurse to explain how blood can cause a low blood pressure. The nurse responds that with anaphylactic shock the
A patient post-surgical externalized ventricular drain placement has treatment orders that include continuous cerebrospinal fluid (CSF) drainage at 10 mm
Hg. Which of the following should the nurse anticipate with an increase in the ICP above 25 mm Hg?
Which of the following is most often associated with damage to the alveolar capillary membrane secondary to aspiration?
Which of the following diagnostic procedures best pinpoints the location, size, and origin of a cerebral aneurysm?
A patient who is post repair of an abdominal aortic aneurysm should be monitored for which of the following complications?
A nurse is precepting an experienced critical care nurse who is new to the facility. To develop the orientation plan, which of the following should the preceptor do first?
A patient with unilateral facial droop and slurred speech has a history of hyperlipidemia and hypertension. The nurse should anticipate an order for a
To maintain adequate pain control in a post-surgical patient addicted to heroin, a nurse should plan to
A terminally ill patient is deteriorating. The patient's family states, "We don't want him to suffer any more." The most appropriate response is
A patient's blood culture report notes the presence of vancomycin resistant enterococcus. The nurse should place the patient in which type of isolation?
Family members have been complaining about limited visiting hours. To facilitate a potential change in practice, a nurse should first
Laboratory values diagnostic for disseminated intravascular coagulation (DIC) include
For a patient who sustained blunt renal trauma and a crush injury to the leg, monitoring should include observing for
Which of the following intubated patients is most at risk for developing ventilator-associated pneumonia (VAP)?
A patient presents with fever and chills, is diaphoretic, and reports experiencing abdominal and intermittent left shoulder pain for the past week. An
ultrasound shows an enlarged spleen. Vital signs are:
BP 106/59
HR 118
RR 23
T101.2° F (38.4° C)
When reviewing the lab report, which of the following findings is most significant to this presentation?
A patient has experienced significant brain damage from an anoxic episode and has been unable to be weaned from ventilator support. The patient's spouse expresses ambivalence about stopping the ventilator now that it has been started. Which of the following statements is the nurse's most appropriate response?
A patient is admitted following a motor vehicle crash. A fluid challenge is initiated immediately after assessing a BP of 80/palpable. Fifteen minutes later,
vital signs are as follows:
BP 86/50
HR 150
RR 36
The most appropriate action should be to
An unconscious patient in hepatic failure secondary to alcoholism becomes acutely hypoglycemic. Glucagon administration is contraindicated for this patient because glucagon
Assessment of a patient with a head injury reveals increased muscle tone and contractured positioning of the upper extremities. A nurse should
After consultation with the interdisciplinary team, a nurse implements progressive mobility by having the patient sit at the side of the bed. The patient's HR increases by 10, RR increases by 6, SpO2 remains at 94%, and BP remains stable. The patient states he is tired. Which of the following should be the nurse's next action?
Patients in end-stage cardiomyopathy often exhibit which of the following symptoms of right-sided heart failure?
The nurse who is caring for a patient following an esophagectomy notes new subcutaneous emphysema in the upper chest and neck. The nurse should expect an order for
An older adult patient reports an inability to sleep due to staff waking the patient for frequent neurological assessments. In order to minimize sleep disruptions, the nurse should
TESTED 07 Jul 2024
A bag of food on a hook
Description automatically generated
Salicylate poisoning
A screenshot of a computer
Description automatically generated
Abdominal aortic aneurysm
An x-ray of a human body
Description automatically generated
Meningitis
Splenomegaly
An x-ray of a person's body
Description automatically generated
Hyponatremia
A pink squares with black text
Description automatically generated