RN61 Ch 14 & 19 Sherpath Questions With Complete
Solutions
A critically ill patient with hyperglycemia would be monitored
for which complication?
Hypotension
Skin breakdown
Fluid imbalance
Cardiac arrhythmias Correct Answers Fluid imbalance
Hyperglycemia is associated with osmotic diuresis. Loss of fluid
through diuresis places the patient at risk for a fluid imbalance,
specifically a fluid deficit. Hypotension is not directly associated
with hyperglycemia; however, it may occur from fluid loss.
Hyperglycemia is associated with hypertension and is caused by
vasoconstriction
A patient exhibiting clinical signs of a thyroid storm is at risk for
which initial acid-base imbalance?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis Correct Answers Respiratory acidosis
A pt experiencing a thyroid storm has an increase in O2 demand
because of their HYPERmetabolic state and ineffective
breathing pattern characterized by tachypnea. Because of the
retention of CO2, the pt experiences respiratory acidosis.
,After reviewing a patient's chart that was updated 1 hour ago,
which current finding requires the nurse to immediately notify
the HCP?
A 39yo patient was admitted to the unit with DKA. Treatment
for DKA was immediately initiated, with IV NS 1000mL bolus
administered upon arrival. Insulin and IV fluid protocol
initiated.
Weight 148lbs, pH 7.21, blood glucose 585 mg/dL, plasma
hyperosmolality 335 mOsm/kg.
pH 7.29
Urine output 48 mL/hr
Blood glucose 450 mg/dL
Plasma hyperosmolality 315 mOsm/kg Correct Answers Blood
glucose 450 mg/dL.
After reviewing a patient's chart that was updated 1hr ago,
which current finding requires the nurse to immediately notify
the HCP?
Hx: A 39yo patient was admitted to the unit with diabetic
ketoacidosis. Treatment for DKA was immediately initiated,
with IV normal saline 1000mL bolus administered upon arrival.
Insulin and IV fluid protocol initiated.
pH 7.29
Urine output 48 mL/hr
Blood glucose 450 mg/dL
Plasma hyperosmolality 315 mOsm/kg Correct Answers Blood
glucose 450 mg/dL
,Place the correct order the steps of providing nursing care to a
patient with a scalp laceration.
Assist with suturing
Inspect for a depressed skull fracture
Cleanse the wound
Debride the wound Correct Answers Cleanse the wound,
Debride the wound, Inspect for a depressed skull fracture, Assist
with suturing
The external carotid artery supplies blood to which area of the
body? SATA
Face
Scalp
Medulla
Inner ear
Frontal lobe Correct Answers Face, Scalp
External carotid- face & scalp
Middle cerebral- frontal lobe
Vertebral- medulla
Basil- inner ear
The hyperglycemic protocol has been initiated for a patient with
a traumatic brain injury in the critical care unit whose blood
glucose is 245 mg/dl. Which action does the nurse take after
receiving 100mL of 5% dextrose in NS (D5NS) with 100 units
of Lispro from the pharmacy?
Inspect the IV fluid for clarity
, Return the IV to the pharmacy
Double check the medication with another nurse
Assess the blood glucose before initiating the infusion Correct
Answers Return the IV to the pharmacy.
To optimize patient safety, IV delivery of short-acting insulin
that is guided by evidence-based protocol is the preferred
method for treating hyperglycemia in a critically ill patient.
Therefore, upon receiving D5NS with 100 units of Lispro, the
nurse would return the IV to the pharmacy. Lispro is a rapid-
acting insulin. Both rapid and short acting insulin appear clear in
the appropriate IV solution. The medication would be returned
to the pharmacy because the insulin mixed in the IV fluid
compromises the safety of the patient.
The nurse administers 28 units of NPH insulin to a patient at
8:00AM. Which time is the latest the nurse would expect the
insulin to peak?
9:00 AM
10:00 AM
12:00 PM
1:00 PM Correct Answers 1:00PM
The nurse asks a patient to close their eyes and stretch their arms
out with their palms up. After 20 seconds has elapsed, which
finding would concern the nurse?
Both arms remain still
One arm moves downward
The palms remain upright
Solutions
A critically ill patient with hyperglycemia would be monitored
for which complication?
Hypotension
Skin breakdown
Fluid imbalance
Cardiac arrhythmias Correct Answers Fluid imbalance
Hyperglycemia is associated with osmotic diuresis. Loss of fluid
through diuresis places the patient at risk for a fluid imbalance,
specifically a fluid deficit. Hypotension is not directly associated
with hyperglycemia; however, it may occur from fluid loss.
Hyperglycemia is associated with hypertension and is caused by
vasoconstriction
A patient exhibiting clinical signs of a thyroid storm is at risk for
which initial acid-base imbalance?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis Correct Answers Respiratory acidosis
A pt experiencing a thyroid storm has an increase in O2 demand
because of their HYPERmetabolic state and ineffective
breathing pattern characterized by tachypnea. Because of the
retention of CO2, the pt experiences respiratory acidosis.
,After reviewing a patient's chart that was updated 1 hour ago,
which current finding requires the nurse to immediately notify
the HCP?
A 39yo patient was admitted to the unit with DKA. Treatment
for DKA was immediately initiated, with IV NS 1000mL bolus
administered upon arrival. Insulin and IV fluid protocol
initiated.
Weight 148lbs, pH 7.21, blood glucose 585 mg/dL, plasma
hyperosmolality 335 mOsm/kg.
pH 7.29
Urine output 48 mL/hr
Blood glucose 450 mg/dL
Plasma hyperosmolality 315 mOsm/kg Correct Answers Blood
glucose 450 mg/dL.
After reviewing a patient's chart that was updated 1hr ago,
which current finding requires the nurse to immediately notify
the HCP?
Hx: A 39yo patient was admitted to the unit with diabetic
ketoacidosis. Treatment for DKA was immediately initiated,
with IV normal saline 1000mL bolus administered upon arrival.
Insulin and IV fluid protocol initiated.
pH 7.29
Urine output 48 mL/hr
Blood glucose 450 mg/dL
Plasma hyperosmolality 315 mOsm/kg Correct Answers Blood
glucose 450 mg/dL
,Place the correct order the steps of providing nursing care to a
patient with a scalp laceration.
Assist with suturing
Inspect for a depressed skull fracture
Cleanse the wound
Debride the wound Correct Answers Cleanse the wound,
Debride the wound, Inspect for a depressed skull fracture, Assist
with suturing
The external carotid artery supplies blood to which area of the
body? SATA
Face
Scalp
Medulla
Inner ear
Frontal lobe Correct Answers Face, Scalp
External carotid- face & scalp
Middle cerebral- frontal lobe
Vertebral- medulla
Basil- inner ear
The hyperglycemic protocol has been initiated for a patient with
a traumatic brain injury in the critical care unit whose blood
glucose is 245 mg/dl. Which action does the nurse take after
receiving 100mL of 5% dextrose in NS (D5NS) with 100 units
of Lispro from the pharmacy?
Inspect the IV fluid for clarity
, Return the IV to the pharmacy
Double check the medication with another nurse
Assess the blood glucose before initiating the infusion Correct
Answers Return the IV to the pharmacy.
To optimize patient safety, IV delivery of short-acting insulin
that is guided by evidence-based protocol is the preferred
method for treating hyperglycemia in a critically ill patient.
Therefore, upon receiving D5NS with 100 units of Lispro, the
nurse would return the IV to the pharmacy. Lispro is a rapid-
acting insulin. Both rapid and short acting insulin appear clear in
the appropriate IV solution. The medication would be returned
to the pharmacy because the insulin mixed in the IV fluid
compromises the safety of the patient.
The nurse administers 28 units of NPH insulin to a patient at
8:00AM. Which time is the latest the nurse would expect the
insulin to peak?
9:00 AM
10:00 AM
12:00 PM
1:00 PM Correct Answers 1:00PM
The nurse asks a patient to close their eyes and stretch their arms
out with their palms up. After 20 seconds has elapsed, which
finding would concern the nurse?
Both arms remain still
One arm moves downward
The palms remain upright
