TEST BANK INTRODUCTION TO CRITICAL CARE
NURSING 7TH EDITION
Chapter06:NutritionalTherapy
1.Thenurseisworkingforahospitalthatholdsanagreementwithalocalorganprocurementorganizatio
n (OPO).ThepatienthasaGlasgowComaScale(GCS)scoreof3anddiscussionshavebeenheldwiththe
familyaboutwithdrawinglifesupport.Whichstatementbythenursebestdescribesrequirementsthat
must bemettosustainCentersforMedicareandMedicaidServices(CMS)ConditionsofParticipation?
- ANSWER-a. I need to notify TransLife (OPO) of my patients impending death
2.Thenurseismanagingadonorpatientsixhourspriortothescheduledharvestingofthepatients
organs.Whichassessmentfindingrequiresimmediateactionbythenurse - ANSWER-b. pH 7.30;
PaCO2 38mm Hg; HCO316mEq/
3.Thechargenurseisreviewingthestatusofpatientsinthecriticalcareunit.Whichpatientshouldthe
nursenotifytheorganprocurementorganizationtoevaluateforpossibleorgandonation? - ANSWER-
a. A36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on
electroencephalogram
4.Thetransplantcliniccoordinatorisevaluatingrelativesofapatientwithend-
stagerenaldisease,whose
bloodtypeisApositive,forsuitabilityasalivingdonorforkidneytransplantation.Whichfamilymember
best qualifiesforevaluation? - ANSWER-b. A35-year-old female with a history of food allergies;
blood type O negative
5.Thenurseiscaringforapatientwhoisbeingevaluatedclinicallyforbraindeathbyaphysician.Which
assessmentfindingsbythenursesupportbraindeath - ANSWER-Absence of a corneal reflex
6.Thenurseisprovidingpreoperativecaretoapatientwhowillreceiveatransplant.Thepatienthashigh
panelreactiveantibodies(PRA).Aspartofinductiontherapyforthispatient,thenurseunderstandswhi
ch medicationtobeofpriorityforadministrationintheoperatingroom? - ANSWER-
Alemtuzumab(Campath)
.Thenurseiscaringforamechanicallyventilatedpatientfollowingbilaterallungtransplantation.When
planningthecareofthispatient,whatistheprioritynursingintervention? - ANSWER-Endotracheal
suctioning as needed
,8.Afamilymemberapproachesthenursecaringfortheirgravelyillsonandstates,Wewanttodonateour
sonsorgans.Whatisthebestactionbythenurse? - ANSWER-Notify the organ procurement
organization (OPO)
9.Thenurseiscaringforapatientinthecriticalcareunitwho,afterbeingdeclaredbraindead,isbeing
managedbytheOPOtransplantcoordinator.Thirtyminutesintotheshift,assessmentbythenurseinclu
des abloodpressure75/50mmHg,heartrate85beats/min,andrespiratoryrate12breaths/minvia
assist/controlventilation.Theoxygensaturation(SpO2)is99%andcoretemperature93.8F.Which
physicianordershouldthenurseimplementfirst? - ANSWER-Beginphenylephrine(Neo-
Synephrine)forsystolicBP<90mmH
10.Thechargenurseofatransplantunitisreviewingtheclinicalcourseofseveraltransplantpatients
beingcaredforintheunit.Whichpatientassessedbythechargenurserequiresimmediateaction? -
ANSWER-d. Liver transplant recipient,12 hours post op with a serum glucose of 58mg/dL
11.Thenurseiscaringforarenaltransplantrecipientinthepost-
anesthesiacareunit.Bloodpressureis125/70
mmHg;heartrateis115beats/min;respiratoryrateis24breaths/min;oxygensaturation(SpO2)is95%o
n3
L/minofoxygenvianasalcannula,temperatureis97.8F,andthecentralvenouspressure(CVP/RAP)is2
mm Hg.Whatisthebestactionbythenurse? - ANSWER-a. Administer fluid replacement therapy;
monitor intake and output closely.
12.Thenurseiscaringforapostoperativerenaltransplantrecipientinthecriticalcareunit.Afterseeing
minimalurineoutputinthecatheterformostoftheday,thepatientexpressesconcerntothenurse.What
is thebestresponsebythenurse? - ANSWER-It can take a few days for your kidney to start
working
13.Thenurseisprovidingdischargeinstructionstoarenaltransplantrecipient.Thepatienthasafollow-
up appointmentthenextdayforroutinepost-
transplantlaboratorybloodwork,includingtroughlevelsofantirejectionmedications.Whichinstructi
ondescribeswhatthepatientshoulddoregardingtheanti-rejection medicationsthenextday -
ANSWER-b. Take your morning dose of medications after labs have been drawn
14.Thenurseiscaringforapatientfollowingabilaterallungtransplant.Whenplanningpostoperativecar
eof
thepatient,priorityisplacedonpulmonaryhygiene.Whichstatementprovidesthebestexplanationfor
this priority? - ANSWER-d. Loss of cough reflex results in decreased ability to remove secretions
effectively
, 15.Whilefollowinguponapostoperativerenaltransplantrecipient,thenursediscoversthatthedonor
testedpositiveforcytomegalovirus(CMV).Whatisthepriorityactionbythenurse - ANSWER-a. Notify
the OPO transplant coordinator
16.Thetransplantclinicnurseisconductingpatienteducationontheimportanceoffollow-uphealth
screeningactivitiesimportantindetectingcomplicationsassociatedwithlong-
termimmunosuppressant
therapy.Whichstatementismostimportantforthenursetoincludeinthediscussion - ANSWER-Avoid
sun exposure during peak hours of the day
1.ApatientishavingcomplicationsfromabdominalsurgeryandremainsNPO.Becauseenteraltubefee
dingsarenotpossible,thedecisionistoinitiateparenteralfeedings.Whatarethemajorcomplicationsfo
rthistherapy - ANSWER-b. Fluidandelectrolyteimbalancesandsepsis
.Apatientisbeingventilatedandhasbeenstartedonenteralfeedingswithanasogastricsmall-
borefeedingtube.Whatistheprimaryreasonthenursemustfrequentlyassesstubeplacement? -
ANSWER-d. Topreventaspirationofthefeedings
3.Thepatientistostartparenteralnutrition.Thenurseknowstopreparewhichsiteforcatheterinsertion
? - ANSWER-d. Subclavianvein
4.Apatienthasbeenadmittedtothecriticalcareunitafterastroke.Afterfailingaswallowstudy,thepatie
ntisplacedonenteralfeedings.Followingplacementofanasogastrictubefortubefeeding,whatisthen
extcriticalstep? - ANSWER-c. Obtainachestradiograph.
5.Apatientsfeedingtubehasbeensuccessfullyplacedinthesmallintestinewithcontinuousflowtubefe
eding.Thenurseknowsthatthisapproachwaschosenbecause: - ANSWER-c.
theintestinalmucosanormallyreceivesnutrientsfromthestomachinperistalticwaves
6.Apatientisbeingfedthroughanasogastrictubeplacedinhisstomach.Thenursewouldcarryoutwhich
interventiontominimizeaspirationrisk? - ANSWER-Elevatetheheadofthebed30degrees.
7.Apatientwhoisreceivingcontinuousenteralfeedingshasjustvomited250mLofmilkygreenfluid.This
isaconcernbecausethismostlikelydemonstratesthatthepatienthas: - ANSWER-d. tube feeding
intolerance.
8.Apatientisreceivingenteralfeedingsandhasjustvomited250mLofmilkygreenliquid.Thenursehold
sthetubefeeding,whichhadbeeninfusingat100mL/hr.Thenurseknowsthatthenextactionshouldbe:
- ANSWER-d. recheck the residual in 2hours
9.Inadditiontoresidualstomachvolume,whatotherevidencesuggestsfeedingintolerance? -
ANSWER-a. Abdominal distention
NURSING 7TH EDITION
Chapter06:NutritionalTherapy
1.Thenurseisworkingforahospitalthatholdsanagreementwithalocalorganprocurementorganizatio
n (OPO).ThepatienthasaGlasgowComaScale(GCS)scoreof3anddiscussionshavebeenheldwiththe
familyaboutwithdrawinglifesupport.Whichstatementbythenursebestdescribesrequirementsthat
must bemettosustainCentersforMedicareandMedicaidServices(CMS)ConditionsofParticipation?
- ANSWER-a. I need to notify TransLife (OPO) of my patients impending death
2.Thenurseismanagingadonorpatientsixhourspriortothescheduledharvestingofthepatients
organs.Whichassessmentfindingrequiresimmediateactionbythenurse - ANSWER-b. pH 7.30;
PaCO2 38mm Hg; HCO316mEq/
3.Thechargenurseisreviewingthestatusofpatientsinthecriticalcareunit.Whichpatientshouldthe
nursenotifytheorganprocurementorganizationtoevaluateforpossibleorgandonation? - ANSWER-
a. A36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on
electroencephalogram
4.Thetransplantcliniccoordinatorisevaluatingrelativesofapatientwithend-
stagerenaldisease,whose
bloodtypeisApositive,forsuitabilityasalivingdonorforkidneytransplantation.Whichfamilymember
best qualifiesforevaluation? - ANSWER-b. A35-year-old female with a history of food allergies;
blood type O negative
5.Thenurseiscaringforapatientwhoisbeingevaluatedclinicallyforbraindeathbyaphysician.Which
assessmentfindingsbythenursesupportbraindeath - ANSWER-Absence of a corneal reflex
6.Thenurseisprovidingpreoperativecaretoapatientwhowillreceiveatransplant.Thepatienthashigh
panelreactiveantibodies(PRA).Aspartofinductiontherapyforthispatient,thenurseunderstandswhi
ch medicationtobeofpriorityforadministrationintheoperatingroom? - ANSWER-
Alemtuzumab(Campath)
.Thenurseiscaringforamechanicallyventilatedpatientfollowingbilaterallungtransplantation.When
planningthecareofthispatient,whatistheprioritynursingintervention? - ANSWER-Endotracheal
suctioning as needed
,8.Afamilymemberapproachesthenursecaringfortheirgravelyillsonandstates,Wewanttodonateour
sonsorgans.Whatisthebestactionbythenurse? - ANSWER-Notify the organ procurement
organization (OPO)
9.Thenurseiscaringforapatientinthecriticalcareunitwho,afterbeingdeclaredbraindead,isbeing
managedbytheOPOtransplantcoordinator.Thirtyminutesintotheshift,assessmentbythenurseinclu
des abloodpressure75/50mmHg,heartrate85beats/min,andrespiratoryrate12breaths/minvia
assist/controlventilation.Theoxygensaturation(SpO2)is99%andcoretemperature93.8F.Which
physicianordershouldthenurseimplementfirst? - ANSWER-Beginphenylephrine(Neo-
Synephrine)forsystolicBP<90mmH
10.Thechargenurseofatransplantunitisreviewingtheclinicalcourseofseveraltransplantpatients
beingcaredforintheunit.Whichpatientassessedbythechargenurserequiresimmediateaction? -
ANSWER-d. Liver transplant recipient,12 hours post op with a serum glucose of 58mg/dL
11.Thenurseiscaringforarenaltransplantrecipientinthepost-
anesthesiacareunit.Bloodpressureis125/70
mmHg;heartrateis115beats/min;respiratoryrateis24breaths/min;oxygensaturation(SpO2)is95%o
n3
L/minofoxygenvianasalcannula,temperatureis97.8F,andthecentralvenouspressure(CVP/RAP)is2
mm Hg.Whatisthebestactionbythenurse? - ANSWER-a. Administer fluid replacement therapy;
monitor intake and output closely.
12.Thenurseiscaringforapostoperativerenaltransplantrecipientinthecriticalcareunit.Afterseeing
minimalurineoutputinthecatheterformostoftheday,thepatientexpressesconcerntothenurse.What
is thebestresponsebythenurse? - ANSWER-It can take a few days for your kidney to start
working
13.Thenurseisprovidingdischargeinstructionstoarenaltransplantrecipient.Thepatienthasafollow-
up appointmentthenextdayforroutinepost-
transplantlaboratorybloodwork,includingtroughlevelsofantirejectionmedications.Whichinstructi
ondescribeswhatthepatientshoulddoregardingtheanti-rejection medicationsthenextday -
ANSWER-b. Take your morning dose of medications after labs have been drawn
14.Thenurseiscaringforapatientfollowingabilaterallungtransplant.Whenplanningpostoperativecar
eof
thepatient,priorityisplacedonpulmonaryhygiene.Whichstatementprovidesthebestexplanationfor
this priority? - ANSWER-d. Loss of cough reflex results in decreased ability to remove secretions
effectively
, 15.Whilefollowinguponapostoperativerenaltransplantrecipient,thenursediscoversthatthedonor
testedpositiveforcytomegalovirus(CMV).Whatisthepriorityactionbythenurse - ANSWER-a. Notify
the OPO transplant coordinator
16.Thetransplantclinicnurseisconductingpatienteducationontheimportanceoffollow-uphealth
screeningactivitiesimportantindetectingcomplicationsassociatedwithlong-
termimmunosuppressant
therapy.Whichstatementismostimportantforthenursetoincludeinthediscussion - ANSWER-Avoid
sun exposure during peak hours of the day
1.ApatientishavingcomplicationsfromabdominalsurgeryandremainsNPO.Becauseenteraltubefee
dingsarenotpossible,thedecisionistoinitiateparenteralfeedings.Whatarethemajorcomplicationsfo
rthistherapy - ANSWER-b. Fluidandelectrolyteimbalancesandsepsis
.Apatientisbeingventilatedandhasbeenstartedonenteralfeedingswithanasogastricsmall-
borefeedingtube.Whatistheprimaryreasonthenursemustfrequentlyassesstubeplacement? -
ANSWER-d. Topreventaspirationofthefeedings
3.Thepatientistostartparenteralnutrition.Thenurseknowstopreparewhichsiteforcatheterinsertion
? - ANSWER-d. Subclavianvein
4.Apatienthasbeenadmittedtothecriticalcareunitafterastroke.Afterfailingaswallowstudy,thepatie
ntisplacedonenteralfeedings.Followingplacementofanasogastrictubefortubefeeding,whatisthen
extcriticalstep? - ANSWER-c. Obtainachestradiograph.
5.Apatientsfeedingtubehasbeensuccessfullyplacedinthesmallintestinewithcontinuousflowtubefe
eding.Thenurseknowsthatthisapproachwaschosenbecause: - ANSWER-c.
theintestinalmucosanormallyreceivesnutrientsfromthestomachinperistalticwaves
6.Apatientisbeingfedthroughanasogastrictubeplacedinhisstomach.Thenursewouldcarryoutwhich
interventiontominimizeaspirationrisk? - ANSWER-Elevatetheheadofthebed30degrees.
7.Apatientwhoisreceivingcontinuousenteralfeedingshasjustvomited250mLofmilkygreenfluid.This
isaconcernbecausethismostlikelydemonstratesthatthepatienthas: - ANSWER-d. tube feeding
intolerance.
8.Apatientisreceivingenteralfeedingsandhasjustvomited250mLofmilkygreenliquid.Thenursehold
sthetubefeeding,whichhadbeeninfusingat100mL/hr.Thenurseknowsthatthenextactionshouldbe:
- ANSWER-d. recheck the residual in 2hours
9.Inadditiontoresidualstomachvolume,whatotherevidencesuggestsfeedingintolerance? -
ANSWER-a. Abdominal distention
