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Conquering the NUR 240 Final Exam: Your Ultimate Study Guide to Success A Comprehensive, Exams of Nursing

Conquering the NUR 240 Final Exam: Your Ultimate Study Guide to Success A Comprehensive Exam Study Guide Latest Updated 2025/2026.

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Conquering the NUR 240 Final Exam: Your
Ultimate Study Guide to Success
A Comprehensive Exam Study Guide Latest
Updated 2025/2026.
The nurse reviews assessment data on a group of patients. Which patient should the nurse
identify as experiencing a critical illness?
1. Chronic airflow limitation with VS: BP 110/72, P 110, R 16
2. Acute bronchospasm with VS: BP 100/60, P 124, R 32
3. Motor vehicle crash with VS: BP 124/74, P 74, R 18
4. Chronic renal failure on hemodialysis with no urine output with VS: BP 98/50, P 108, R 12
- 2
Which patient should the nurse expect to be transferred to a critical care unit? Select all that
apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Experiences an acetaminophen overdose
2. Diagnosed with an acute mental illness
3. Receiving treatment for chronic renal failure
4. New onset of acute decompensated heart failure
5. Treatment for bacteremia from an infected foot wound - 1,4,5
The nurse employed in a hospital in a small rural town would expect to provide which level
of care in the critical care unit?
1. Level I
2. Level II
3. Level III
4. It is unlikely that the hospital would have a critical care unit. - 3
With which individuals should the nurse expect to provide patient care in an "open" ICU?
1. Multidisciplinary team with physicians who are also responsible for patients on other units
2. Multidisciplinary team that includes a physician employed by the hospital
3. Physician in charge of patient care who is a specialist in critical care
4. Primary care physician who must consult a critical care specialist - 1
What should the nurse who provides care to patients in a critical care unit realize the role of
technology is on the amount of errors?
1. It relies heavily on human decision making.
2. Devices are programmed to function without double checks.
3. It makes the workload seem overwhelming to health care providers.
4. There is uniform equipment throughout each facility. - 2
What should the nurse identify as an example of an installed forcing function or a system-
level firewall to prevent errors when providing patient care?
1. Prior to administration of insulin, two nurses check the dose.
2. Prior to obtaining a medication, height, weight, and allergies are recorded.
3. All medications are checked by two nurses prior to administration.
4. Undiluted potassium chloride is not available on critical care units. - 4
The nurse realizes that the increased use of technology in critical care units has resulted in
which consequence for patient care?
1. Decreased risk of errors in patient care
2. Decreased therapeutic nurse-patient communication
3. Improved overall patient satisfaction with care
4. Improved patient safety across the entire spectrum - 2
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Ultimate Study Guide to Success

A Comprehensive Exam Study Guide Latest

Updated 2025/2026.

The nurse reviews assessment data on a group of patients. Which patient should the nurse identify as experiencing a critical illness?

  1. Chronic airflow limitation with VS: BP 110/72, P 110, R 16
  2. Acute bronchospasm with VS: BP 100/60, P 124, R 32
  3. Motor vehicle crash with VS: BP 124/74, P 74, R 18
  4. Chronic renal failure on hemodialysis with no urine output with VS: BP 98/50, P 108, R 12
  • 2 Which patient should the nurse expect to be transferred to a critical care unit? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  1. Experiences an acetaminophen overdose
  2. Diagnosed with an acute mental illness
  3. Receiving treatment for chronic renal failure
  4. New onset of acute decompensated heart failure
  5. Treatment for bacteremia from an infected foot wound - 1,4, The nurse employed in a hospital in a small rural town would expect to provide which level of care in the critical care unit?
  6. Level I
  7. Level II
  8. Level III
  9. It is unlikely that the hospital would have a critical care unit. - 3 With which individuals should the nurse expect to provide patient care in an "open" ICU?
  10. Multidisciplinary team with physicians who are also responsible for patients on other units
  11. Multidisciplinary team that includes a physician employed by the hospital
  12. Physician in charge of patient care who is a specialist in critical care
  13. Primary care physician who must consult a critical care specialist - 1 What should the nurse who provides care to patients in a critical care unit realize the role of technology is on the amount of errors?
  14. It relies heavily on human decision making.
  15. Devices are programmed to function without double checks.
  16. It makes the workload seem overwhelming to health care providers.
  17. There is uniform equipment throughout each facility. - 2 What should the nurse identify as an example of an installed forcing function or a system- level firewall to prevent errors when providing patient care?
  18. Prior to administration of insulin, two nurses check the dose.
  19. Prior to obtaining a medication, height, weight, and allergies are recorded.
  20. All medications are checked by two nurses prior to administration.
  21. Undiluted potassium chloride is not available on critical care units. - 4 The nurse realizes that the increased use of technology in critical care units has resulted in which consequence for patient care?
  22. Decreased risk of errors in patient care
  23. Decreased therapeutic nurse-patient communication
  24. Improved overall patient satisfaction with care
  25. Improved patient safety across the entire spectrum - 2

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The nurse in the critical care area is completing a preoperative checklist before sending a patient for surgery. This nurse's activity is an example of which recommendation issued by the Institute of Medicine?

  1. Utilizing constraints
  2. Simplifying key processes
  3. Avoiding reliance on vigilance
  4. Standardizing key processes - 3 Which actions should the nurse complete after realizing that an incorrect dose of medication has been administered to a patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  5. Notify the patient and family.
  6. Notify the physician.
  7. Document the error.
  8. Prepare for an analysis of the error.
  9. Keep the notification of the error silent. - 1,2,3, The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized when:
  10. Highly qualified nurses care for patients in highly technical settings.
  11. Nurses agree to work overtime to cover unit staffing needs.
  12. Staff nurse competency is matched with patient needs.
  13. Patient care is delivered within a "closed unit" model. - 3 Which actions by the critical care nurse demonstrate an understanding of patient advocacy? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  14. Maintaining attendance at the bedside with the patient during a physician visit
  15. Assisting and supporting the patient and family as they reveal their needs
  16. Alerting the physician to concerns about client placement after hospitalization
  17. Encouraging and supporting a patient's spouse in preparing for a family meeting
  18. Seeing the big picture when planning patient care - 1,2,3, A nurse is preparing to communicate an issue about patient care to a physician using the SBAR technique. Which phrase is an appropriate initial statement?
  19. "I am concerned about..."
  20. "The patient's immediate history is..."
  21. "I think the problem is..."
  22. "I would like you to..." - 1 Which statement should the nurse include for "A-Assessment" in the SBAR technique for communication?
  23. "I think the problem is..."
  24. "The patient's vital signs are..."
  25. "The patient's treatments are..."
  26. "I would like you to..." - 1 Which statement should the nurse use when concluding SBAR communication about a patient issue?
  27. "The patient's immediate history is..."
  28. "The patient's physical findings are..."
  29. "I am requesting that you..."

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What is associated with moral distress in critical care nurses? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.

  1. Having no voice in clinical decision making
  2. Providing aggressive care to patients who cannot benefit
  3. Realizing that nurses maintain power in bedside decision making
  4. Knowing the right thing to do but not being able to do it
  5. Leaving employment as a critical care nurse - 1 ,2,4, What might occur when a nurse employs conscientious refusal to participate? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  6. Dismissal from a nursing position
  7. Employer sanctions
  8. Support from nursing administrators
  9. Protection from the state boards of nursing
  10. Support by the patient - 1, Which symptoms indicate a nurse is experiencing compassion fatigue? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  11. Difficulty separating work from personal life
  12. Excessively high tolerance for frustration
  13. Having a completely laissez-faire attitude
  14. Decreased functioning in nonprofessional situations
  15. Dreads working with certain types of patients - 1,4, The nurse is providing care to patients in a Level II general critical care unit. For which types of patient problems will this nurse most likely provide care? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  16. Exacerbation of heart failure
  17. Wound infection
  18. Burns over 50% of total body surface
  19. Kidney transplant
  20. Reattachment of a traumatic amputation of the left leg - 1, A patient is admitted to an "open" intensive care unit. In addition to the nurse, which health care providers will assist in the care of this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  21. Pharmacist
  22. Respiratory therapist
  23. Attending physician
  24. Dietician
  25. Social worker - 1,2, The critical care nurse is identifying patients at risk for safety and medical errors. Which patients should the nurse identify as being at risk for these issues? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  26. Patient in isolation with MRSA
  27. Patient who does not understand English
  28. Patient with end stage renal disease and a respiratory rate of 8 per minute
  29. Patient recovering from pacemaker insertion
  30. Patient with pulmonary edema - 1,2,

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The nurse manager of a critical care unit is explaining the AACN Synergy Model to the critical care nurses. What should the manager include as basic parts of this model? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.

  1. Based on the patients' characteristics
  2. Based on the competencies of the nurses
  3. Patient outcomes will be measured
  4. The nurses' assessment of patient outcomes will be measured
  5. Reduction of cost to provide critical care services to patients - 1,2,3, While completing a self-evaluation, the critical care nurse compares personal practice to the competencies identified by the AACN Synergy Model. Which behaviors are consistent with those in the Synergy Model? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  6. Seeks out research studies to update protocols
  7. Approaches patient care by looking at the "big picture"
  8. Ensures family members are comfortable when visiting critical care patients
  9. Encourages patient families to discuss issues with the physician
  10. Telling the next shift that a patient needs help with understanding instructions - 1,2,3, What would be appropriate reasons for an intensive care unit intensivist to call a huddle? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  11. Make care providers aware of a change in a patient's situation.
  12. Communicate a critical issue about a patient.
  13. Make an assignment change.
  14. Discuss concerns about a patient's status or care.
  15. Plan care for the shift. - 1,2,3, The nurse manager, concerned that several staff nurses are experiencing moral distress, is planning to implement the 4 A's to Rise Above Moral Distress. Which steps will the manager take? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  16. Ask
  17. Affirm
  18. Assess
  19. Act
  20. Assert - 1,2,3, The critical care nurse is experiencing psychologic symptoms of compassion fatigue. What strategies should the nurse use to enhance psychological well-being? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  21. Make time for recreational activities.
  22. Practice yoga for relaxation.
  23. Plan to take a walk in the park at least once a week.
  24. Monitor food and beverage intake.
  25. Darken the room and limit activities before sleep. - 1,2, The nurse manager is planning the staffing budget for the next fiscal year. What action should the manager take to ensure that staffing is adequate?
  26. Study the results of the organization's staffing evaluation.

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The nurse realizes that which stressor is one of the primary concerns of critically ill patients and should be routinely included during assessments?

  1. Inability to control elimination
  2. Lack of family support
  3. Hunger
  4. Altered ability to communicate - 4 A patient has just completed a preoperative education session prior to undergoing coronary artery bypass surgery. Which patient statements indicate that teaching has been effective? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  5. "I understand that I will have to blink my eyes to respond after the breathing tube is in my throat."
  6. "I will be given frequent mouth care to help me when I am thirsty."
  7. "I will be able to move about freely in bed and into the chair without help while connected to the electronic equipment for monitoring."
  8. "I may need something to help me rest due to the unfamiliar lights and sounds of the ICU unit."
  9. "I might not behave like my usual self after the surgery, but it will be because of the medications and my illness." - 1,2,4, When providing care to critically ill patients, whether they are responsive or unresponsive, what should the nurse do?
  10. Clearly explain what care is to be done before starting the activity.
  11. Perform the activity and then let the patient rest without explaining the care.
  12. Make sure the patient always responds and is cooperative before giving care.
  13. Explain to the family that the patient will not understand or remember any of the discomfort associated with care. - 1 Which communication strategy should the critical care nurse use when communicating with a ventilated patient?
  14. Use professional terminology and provide the patient with detailed information.
  15. Use simple language and explain in other terms if the patient does not seem to understand.
  16. Provide minimal information so the patient is not overwhelmed.
  17. Discuss issues primarily with the family because the patient is unlikely to understand the information. - 2 During an assessment, a ventilated patient begins to frown and wiggle about in bed. Which assessment strategy would be most helpful for the nurse to validate these observations?
  18. Glasgow Scale
  19. Maslow's hierarchy levels
  20. Critical-Care Pain Observation Tool (CPOT)
  21. Vital signs trends - 3 Which parameter indicates that a patient in the intensive care unit being mechanically ventilated is ready for an interruption in sedation? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  22. MAP of 75 and heart rate of 76
  23. Awakens with verbal stimuli
  24. Frowns when turned but otherwise shows no muscular tension
  25. Activates the ventilator alarms, but the alarms stopped spontaneously

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  1. Receives neuromuscular blocking agents to ensure adequate ventilation - 1,2,3, A patient scores positive on the Confusion Assessment Method of the Intensive Care Unit (CAM-ICU). Which nursing diagnosis would have the highest priority based on this positive score?
  2. Injury, Risk for
  3. Family Processes, Altered
  4. Social Interaction, Impaired
  5. Memory Impaired Answer: 1 - 1 Which nursing action would be appropriate when the nurse initiates an infusion of morphine sulfate for a post-operative patient who is experiencing pain?
  6. Anticipate that the patient will begin to experience the effect of the morphine 15 minutes after the start of the infusion.
  7. Provide additional intermittent boluses of morphine sulfate if the patient experiences breakthrough pain.
  8. Complete the Critical-Care Pain Observation Tool scale 5 minutes after increasing the infusion rate each time.
  9. Begin the infusion at the lowest ordered dose, and increase the rate every 30 minutes if the patient continues to have pain. - 2 Which strategies should the nurse include in the plan of care when trying to minimize sleep disruptions for a patient in an ICU? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  10. Instituting a short course of therapy for sleeping agents
  11. Accurate scoring and vigilance in sedation and sedation scoring
  12. Managing the environment to reduce lighting and sound
  13. Minimizing staff interruptions during sleep periods
  14. Scheduling treatments only during the day or at least 4 hours apart at night - 1,2,3, The nurse confirms medication orders and the schedule to administer a sedative to a patient with delirium. Which dosing schedule maximizes the effectiveness of the drugs?
  15. Only in the early morning
  16. Only at bedtime (HS)
  17. Around the clock with higher dosages in the evening
  18. Only on an as-needed (PRN) basis - 3 The charge nurse reviews information about patients received during morning report. Which patient is at risk for nutritional imbalances? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  19. Client recovering from a myocardial infarction
  20. Client receiving hemodialysis treatments 3 times a week
  21. Client with slightly elevated liver enzymes
  22. Client who is intubated for respiratory failure
  23. Client recovering from extensive burns - 1,2,4, Members of the multidisciplinary care team review a patient's nutritional status and analyze assessment values. Which value would need additional investigation?
  24. A serum albumin of more than 3.5 g/dL or 35 g/L
  25. A weight increase of 1.5 kg in a day

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A physician suggests that a patient being mechanically ventilated, needing immediate transport to CT scan, and having severe pain be given IV fentanyl (Sublimaze) rather than morphine sulfate for pain management. Why is fentanyl (Sublimaze) preferred?

  1. Rapid administration does not have any hemodynamic consequences.
  2. It has a more rapid onset and a shorter duration of action.
  3. Weaning of a continuous infusion is never needed due to its short half-life.
  4. It is not likely to cause respiratory depression - 2 A patient being mechanically ventilated receives midazolam (Versed) for sedation. What findings indicate to the nurse that the patient is receiving an appropriate dose of this medication?
  5. Awake with a respiratory rate of 38 and a heart rate of 132
  6. Asleep but withdrawing from noxious stimuli with a heart rate of 80
  7. Awake with a heart rate of 124 and attempting to pull out the IV
  8. Asleep but awakening to light touch with a heart rate of 72 - 4 The nurse cares for a patient recovering from surgery who is being mechanically ventilated and experiencing pain. Which approach should the nurse use first to assess this patient's pain?
  9. Attempt an analgesic trial
  10. Ask the patient if he or she is in pain
  11. Observe the patient's face for grimacing
  12. Ask a family member if the patient is in pain - 2 The nurse administers haloperidol (Haldol) via IV push to a patient experiencing delirium. What is most important for the nurse to monitor in this patient?
  13. Heart rate
  14. QT interval
  15. PR interval
  16. Respiratory rate - 2 The nurse assesses a critically ill patient utilizing the AACN Synergy Model's characteristics. Which characteristics are identified as impacting the outcome of a critically ill patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  17. Participation in care
  18. Resource availability
  19. Stability
  20. Complexity
  21. Level of consciousness - 1,2,3, The nurse plans care for a critically ill patient. What should the nurse include to address the patient's major areas of concern? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  22. Explain the purpose of the tube in the nose.
  23. Explain the purpose of the tube in the mouth.
  24. Determine a method of communication.
  25. Explain the purpose of the intravenous tubes.
  26. Ensure that the room lights will be turned off and alarms set to low volume. - 1,2,3, The nurse providing care to a patient who is unresponsive and being mechanically ventilated uses unintentional distractions. What is the nurse doing when providing care? Select all that apply.

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Note: Credit will be given only if all correct choices and no incorrect choices are selected.

  1. Singing
  2. Humming
  3. Joking
  4. Talking to a colleague
  5. Apologizing for causing pain - 1,2, What strategies should the nurse use to communicate with an older adult patient who is intubated and being mechanically ventilated? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  6. Make sure the patient is wearing eyeglasses.
  7. Speak slowly.
  8. Decide on which gestures mean "yes" and "no."
  9. Have questions and possible answers ready so the patient can point to the response.
  10. Ask several questions at a time to limit interruptions in rest periods. - 1,2,3, A patient in the critical care unit demonstrates increasing agitation. What should the nurse use to assess this patient's agitation level? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  11. Sedation Assessment Scale (SAS)
  12. Richmond Agitation-Sedation Scale (RASS)
  13. Glasgow Scale
  14. Reaction Level Scale
  15. Ventilator Adjusted Motor Assessment Scoring Scale - 1, The nurse plans to use music therapy to help reduce a critically ill patient's level of anxiety. What should the nurse do when using this complementary and alternative therapy? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  16. Ask family members to identify the patient's preferred music.
  17. Plan for the music to be played for 30 uninterrupted minutes.
  18. Listen to the music in advance to make sure it does not have lyrics.
  19. Ensure that the music beats are between 60 to 80 per minute.
  20. Play the music from a CD player on the bedside table. - 1,2,3, The nurse assesses the nutritional needs of a patient in the intensive care unit. What information is essential for the nurse to obtain during this assessment? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  21. Patient's current height and weight
  22. Food allergies
  23. Use of nutritional supplements
  24. If the patient can swallow
  25. Amount of water consumed each day - 1,2,3, The nurse is a member of a committee that is designing improvements to the critical care waiting areas. What improvements should the nurse suggest to enhance the comfort of family members of critical care patients? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  26. Plan for a large space to be used for the waiting areas.
  27. Provide coffee and soft drinks in the waiting area.
  28. Place televisions and DVD players in the waiting area.

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  1. Dopamine and norepinephrine (Levophed)
  2. Nitroglycerin and digoxin (Lanoxin) - 3 A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. For what should the nurse assess the patient?
  3. Excessive sedation
  4. Position of the PA catheter
  5. Hypothermia
  6. Pain - 4 Which action has the highest priority for maintaining safety when caring for a patient with a PA catheter?
  7. Obtain pressures per protocol.
  8. Administer fluids and medications via pump.
  9. Maintain asepsis when providing line care.
  10. Obtain lab values as ordered. - 3 A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. For what symptoms should the nurse assess this patient?
  11. Peripheral edema and jugular vein distention
  12. Decreased peripheral pulses and cool extremities
  13. Hypovolemia and hypotension
  14. Orbital edema and disorientation - 1 The nurse is monitoring the PA pressure of a mechanically ventilated patient. When should the nurse obtain the measurement to accurately assess this pressure?
  15. Whenever, because the timing does not matter
  16. At the last clear waveform before the baseline drops
  17. At the last clear waveform before the baseline rises
  18. With the patient off of the ventilator - 3 A patient with a PA catheter has an SVO2 of 90%. For what should the nurse assess this patient?
  19. Fever
  20. Pain
  21. Hypothermia
  22. Anemia - 3 What should the nurse monitor in response to a change in SVO2 readings?
  23. Potassium level
  24. Glucose level
  25. Sodium level
  26. Hemoglobin level - 4 A patient asks the nurse, "What is blood pressure?" What should the nurse respond?
  27. "A measurement that should always be 120/80 unless complications are present."
  28. "The amount of pressure exerted on your veins by the blood."
  29. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against."
  30. "A complex measurement that should only be discussed with your health care provider." - 3

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The health care provider is preparing to insert a PA catheter. What action is a priority for the nurse?

  1. The patient is in the Trendelenburg position to prevent air embolism.
  2. The patient has received a dose of IV lidocaine.
  3. The site has been cleaned with soap and water.
  4. A tourniquet has been applied to the neck. - 1 What should the nurse do to correctly calculate cardiac output?
  5. Only take two measurements and then average the two readings.
  6. Take one measurement to prevent fluid volume overload.
  7. Obtain five measurements and record the highest reading.
  8. Take three to five measurements and take the average of the three readings that are within 10% of one another. - 4 Which observation indicates pulsus paradoxus on a patient's arterial pressure waveform?
  9. The waveform has tall, tented waves.
  10. The pulse pressure is above 20 mm Hg on exhalation.
  11. There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation.
  12. There is a single, nonperfused beat. - 3 How should the nurse calculate a patient's mean arterial pressure (MAP)?
  13. Divide the systolic pressure by the diastolic pressure.
  14. Average three of the patient's blood pressures over a 6-hour period.
  15. Divide the diastolic pressure by the pulse pressure.
  16. Add the systolic pressure and two diastolic pressures and then divide by 3. - 4 What should the nurse use to measure the contractility of the left side of a patient's heart?
  17. Left atrial pressure
  18. Pulmonary artery wedge pressure
  19. Systemic vascular resistance
  20. Left ventricular stroke work index - 4 Which nursing intervention ensures an accurate cardiac output reading for a patient?
  21. Administer the injectate within 4 seconds.
  22. Use 5 cc of iced saline as the injectate.
  23. Ensure that there is a difference of 10°C between the injectate temperature and the patient's body temperature.
  24. Inject the fluid into the pulmonary artery distal port. - 1 Which value should the nurse recognize is normal for a patient's cardiac output?
  25. 6-9 L/min
  26. 4-8 L/min
  27. 8-10 L/min
  28. 2-4 L/min - 2 A patient is experiencing reduced afterload. What should the nurse identify as causes for this finding? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  29. Sepsis
  30. Mitral stenosis
  31. Reduced circulating blood volume
  32. Vasodilator medications
  33. Myocarditis - 1,

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  1. Neurogenic shock
  2. Mitral stenosis - 1, The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How should the nurse complete this assessment? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  3. Use pulse oximetry.
  4. Send a blood sample for arterial blood gas analysis.
  5. Auscultate lung sounds.
  6. Evaluate cardiac rhythm strip.
  7. Calculate mean arterial pressure. - 1, The nurse is planning to assess the blood pressure of a patient with a BMI of 40. Which approaches should the nurse use to correctly obtain this patient's blood pressure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  8. Use a cuff with a bladder that is 80% of the patient's arm circumference.
  9. Use a thigh cuff.
  10. Use an adult cuff on the patient's forearm.
  11. Assess the blood pressure using the same approach each time.
  12. Use an adult cuff on the patient's thigh. - 1, While caring for a patient in the intensive care unit, when should the nurse plan to conduct the square wave test on the patient's arterial pressure monitoring system? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  13. At the beginning of the shift
  14. After drawing blood
  15. When the arterial tracing is not consistent with an auscultated blood pressure
  16. When the monitoring cable is disconnected from the flush system
  17. Any time the patient's position is changed - 1,2, The nurse is concerned that the hand with an arterial line in the wrist is becoming ischemic. What did the nurse assess in this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  18. Delayed capillary refill
  19. Pale skin color of the wrist and hand
  20. Reduced pulses in the brachial artery
  21. Hand cold to touch
  22. Blood pressure discrepancy of 15 mm Hg - 1,2, The health care provider is planning to insert a pulmonary artery catheter into a patient. What should the nurse explain to the patient as being the purpose of this device? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  23. Determine hemodynamic stability in heart failure.
  24. Monitor the effects of vasodilator administration.
  25. Monitor cardiac function during vascular surgical procedures.
  26. Assess cardiac output.
  27. Continuously monitor blood pressure. - 1,2,3,

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The nurse is concerned that a patient's pulmonary artery catheter has slipped into the right ventricle. What are the hallmarks of the waveform that the nurse observes on the monitor? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.

  1. Low diastolic pressure
  2. No dicrotic notch
  3. Continuous wedge waveform
  4. Sharp upstroke, a plateau, and a rapid downstroke extending below the baseline
  5. Smooth upstroke followed by a gradual downslope to the baseline - 1, A patient has a central line for fluid management and antibiotic therapy. What interventions should the nurse use to reduce the risk of infection in the access site? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  6. Practice thorough hand hygiene.
  7. Use chlorhexidine skin asepsis.
  8. Review the continued need for the line daily.
  9. Cover the insertion site with an opaque gauze dressing.
  10. Change the dressing over the insertion site using clean technique. - 1,2, A patient is admitted with atrial fibrillation. Why should the nurse identify interventions to address low cardiac output for this patient?
  11. Loss of atrial kick
  12. Pressure in the ventricles
  13. Irregular ventricular rhythm
  14. Systemic blood from the left ventricle - 1 A patient demonstrates signs of elevated pulmonary vascular resistance (PVR). For which health problem should the nurse assess this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  15. Hypoxia
  16. Aortic stenosis
  17. Pulmonary stenosis
  18. Pulmonary embolism
  19. Pulmonary hypertension - 1,3,4, A patient has a pressure-monitoring device inserted after an acute myocardial infarction. Which action should the nurse take to minimize the risk of overdampened measurements? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  20. Ensure tubing is without kinks.
  21. Add tubing to the flush system.
  22. Remove all air from the flush system.
  23. Inflate the pressure bag to 300 mm Hg.
  24. Maintain adequate normal saline in the flush bag. - 1,3,4, A patient with a PA catheter needs PCWP readings every 4 hours. What technique should the nurse follow when obtaining these pressures?
  25. Cap the port after the balloon is inflated.
  26. Keep the balloon inflated for 30 seconds.
  27. Inflate the balloon until the PA waveform changes.
  28. Open the balloon inflation valve after each measurement. - 3

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  1. An antidysrhythmic, such as lidocaine
  2. A beta adrenergic blocking agent - 2 The nurse instructs a patient with a myocardial infarction about the disease process. Which patient statement indicates that additional teaching is needed?
  3. "A heart attack is the same as a myocardial infarction (MI)."
  4. "A heart attack causes tissue death, and that part of the heart may not pump as well."
  5. "A heart attack in the anterior wall of the heart can be very serious because a large portion of the heart may not pump as well."
  6. "Angina always leads first to decreased blood flow to the heart muscle and then to tissue death." - 4 What action would be most helpful to the nurse to determine if a patient's chest pain is cardiac in origin?
  7. Gathering a complete medical history
  8. Performing a 12-lead ECG
  9. Administering NTG to see if the pain goes away
  10. Asking the patient if performing a Valsalva maneuver reduces the pain - 2 An 80-year-old woman is being assessed for a myocardial infarction. Which symptoms would more likely occur in this patient because of the patient's gender and age?
  11. Jaw and/or tooth pain
  12. Centralized chest pain
  13. Generalized fatigue accompanied by dyspnea and diaphoresis
  14. Dyspnea accompanied by crackles in all lobes - 3 Which laboratory value should the nurse review to validate a diagnosis of a myocardial infarction (MI) that was suspected of occurring approximately 3 hours earlier?
  15. CK
  16. Troponin T assay
  17. Myoglobin
  18. PTT - 3 The multidisciplinary team should identify which goals for initial collaborative management of a patient with an acute coronary event (ACS)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  19. Limit the size of infarction by decreasing oxygen demands.
  20. Maximize coronary artery blood flow.
  21. Strengthen the heart by increasing activity as soon as possible.
  22. Balance oxygen demand with supply.
  23. Prevent dysrhythmias with prophylactic antidysrhythmic medications. - 1,2, A patient is admitted with chest discomfort and a possible USA/NSTEMI. What would be a contraindication to administration of GP-IIb-IIIA inhibitors to the patient?
  24. Major surgery in the last 6 months
  25. A creatinine level of 1.4 mg/dL
  26. A stroke within the past month
  27. A platelet count greater than 150,000 mm3 - 3 The electrocardiogram of a patient receiving tPA for a myocardial infarction shows that the ST segment has returned to baseline. How should the nurse interpret this finding?
  28. The spasm in the coronary artery has resolved.
  29. The myocardial injury is evolving.

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  1. The patient has become more relaxed.
  2. The blocked artery has been reperfused. - 4 A nurse is preparing to administer the first 5 mg dose of metoprolol (Toprol) to a patient who is 12 hours post MI. For which assessment finding should the nurse withhold administration of the medication?
  3. Serum potassium 3.9 mEq/L
  4. Blood pressure of 110/65 mm Hg
  5. PR interval 0.12 second
  6. Sinus bradycardia 52 beats per minute - 4 Following angioplasty, a patient develops hematuria, hypotension, tachycardia, a drop in hemoglobin and hematocrit, and a decrease in oxygen saturation. What is most likely the cause for these symptoms?
  7. Reaction to vasovagal stimulation
  8. Myocardial ischemia
  9. Peripheral emboli distal to the insertion site
  10. Over-anticoagulation - 4 A nurse is caring for a patient who has just started to bleed from the insertion site following a cardiac catheterization. What should be the nurse's first response?
  11. Administer vitamin K (AquaMEPHYTON).
  12. Locate and apply a compression clamp.
  13. Apply a collagen patch or sheath.
  14. Apply manual pressure to the site. - 4 To increase compliance and reduce postoperative complications, the nurse should include which topics in the preoperative teaching for a patient who is to have a coronary artery bypass graft (CABG)? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  15. Reasons for cooling blankets in postop period
  16. Equipment used: IVs, Foley, pacer wires, chest tubes, NG tubes, ECG leads
  17. Alternate methods for communicating when intubated
  18. Reasons and techniques of turning, coughing, and deep breathing once extubated
  19. Drug management: need for sedation when intubated, pain med through PCA - 2,3,4, What should be included in the collaborative management of a patient's pulmonary status following coronary artery bypass graft surgery?
  20. Keeping the patient intubated for at least 48 hours to maximize gas exchange
  21. Mobilizing the patient as soon as possible to prevent atelectasis and venous stasis
  22. Evaluating readiness for extubation based on guidelines: PO2 less than 80 mm Hg with an FiO2 greater than 40% and a PCO2 greater than 45
  23. Extubating when the patient is arousable to noxious stimuli and shows increased effort for spontaneous breathing - 2 Which finding should cause the nurse to suspect that a patient recovering from coronary artery bypass surgery might be developing cardiac tamponade? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
  24. Widening pulse pressure
  25. Increased jugular vein distension
  26. Decreasing central venous pressure (CVP)
  27. Muffled heart sounds