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Adult Health (Viterbo University)

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Total Questions : 49

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Question 1:

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

A. Temperature of 96.8°F B. Blood pressure 110/68 C. Respiratory rate of 20 breaths/min D. Heart rate of 70 beats/min

Answer and Explanation

Choice A:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

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Question 2:

A patient with a spinal cord lesion at T4 tells the nurse that he has a headache and feels flushed. The BP is significantly elevated to 190/100. The first action by the nurse is to:

A. Elevate the head of the bed immediately and notify the provider B. Administer PRN tylenol for the patient's headache C. Recheck all of the patient's vital signs D. Elevate the patient's knees and lower the head of the bed

Answer and Explanation

Choice A:

Elevating the head of the bed and notifying the provider is the correct initial action when a patient with a spinal cord lesion at T4 experiences a significantly elevated blood pressure (190/100), headache, and flushing. These symptoms suggest autonomic dysreflexia, a potentially life-threatening condition that requires immediate intervention. Elevating the head of the bed helps to lower blood pressure, and notifying the provider ensures that further medical treatment can be administered promptly.

Choice B:

Administering PRN Tylenol for the patient's headache is not the appropriate first action in this scenario. While Tylenol may help with the headache, it does not address the underlying cause of the elevated blood pressure and autonomic dysreflexia. Immediate intervention to lower blood pressure is critical to prevent complications.

Choice C:

Rechecking all of the patient's vital signs is important but not the priority action in this situation. The nurse should first take measures to lower the blood pressure and address the symptoms of autonomic dysreflexia by elevating the head of the bed and notifying the provider. Monitoring vital signs can be done concurrently, but it should not delay the immediate intervention required.

Choice D:

Elevating the patient's knees and lowering the head of the bed is contraindicated in this situation. Lowering the head of the bed can further increase intracranial pressure and exacerbate symptoms of autonomic dysreflexia. The proper position to help reduce blood pressure is to elevate the head of the bed.

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Question 3:

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

A. Assess the level at which the client has intact sensation B. Determine the level at which the client has retained mobility C. Monitor respiratory effort and oxygen saturation level D. Check the blood pressure and pulse for signs of spinal shock

Answer and Explanation

Choice A:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

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Question 4:

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

A. Flaccid paralysis and lack of sensation below the level of the injury B. Hypotension, bradycardia, and warm extremities C. Presence of hyperactive reflex activity below the level of the injury D. Severe headache, hypertension, and flushed face

Answer and Explanation

Choice A:

Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.

Choice B:

Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.

Choice C:

The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.

Choice D:

Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.

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Question 5:

A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

A. Heparin B. Vitamin K C. Iron D. Protamine

Answer and Explanation

Choice A:

Administering Heparin to a patient who is already taking Warfarin and experiencing rectal bleeding is not appropriate. Heparin is an anticoagulant, similar to Warfarin, and would not help in reversing the anticoagulant effects of Warfarin. Instead, it could potentially exacerbate the bleeding.

Choice B:

Vitamin K is the correct answer because it acts as an antidote to Warfarin. Warfarin works by inhibiting the synthesis of Vitamin K-dependent clotting factors, so administering Vitamin K helps to reverse the effects of Warfarin and promote blood clotting, which is necessary to control the rectal bleeding in this patient.

Choice C:

Iron is not the appropriate treatment for rectal bleeding due to Warfarin. While iron supplements can help with anemia (which might result from chronic blood loss), they do not address the immediate need to reverse the anticoagulant effects of Warfarin and stop the active bleeding.

Choice D:

Protamine is used to reverse the effects of Heparin, not Warfarin. Therefore, administering Protamine would not be effective in addressing the Warfarin-induced rectal bleeding in this patient.

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Question 6:

A nurse is planning the care of a patient with heart failure. Which of the following interventions does the nurse include in the plan?

A. Use non-steroidal anti-inflammatory drugs for discomfort. B. Limit sodium in the diet to 3.5 g/day. C. Place client in a lateral position. D. Limit fluid intake to 2 liters/day.

Answer and Explanation

Choice A:

Using non-steroidal anti-inflammatory drugs (NSAIDs) for discomfort is not recommended for patients with heart failure because NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also interfere with the effects of certain heart failure medications.

Choice B:

Limiting sodium in the diet to 3.5 g/day is not restrictive enough for heart failure patients. Typically, heart failure management involves reducing sodium intake to around 2-2.3 g/day to help prevent fluid retention and reduce the workload on the heart.

Choice C:

Placing the client in a lateral position is not specifically beneficial in the management of heart failure. While changing positions can be part of general patient care, it does not directly address the fluid balance or cardiac workload in heart failure patients.

Choice D:

Limiting fluid intake to 2 liters/day is a common intervention for managing heart failure. This helps to prevent fluid overload, which can exacerbate heart failure symptoms and lead to complications such as pulmonary edema. Maintaining a careful balance of fluid intake is essential for managing heart failure effectively.

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Question 7:

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

A. The patient is coughing B. The ETT has a cuff leak C. The ventilator tubing has become disconnected D. The patient is complaining of a headache 8/10 pain

Answer and Explanation

Choice A:

The patient coughing is the most likely cause of the high pressure alarm on a mechanical ventilator. Coughing can increase airway resistance and pressure, triggering the alarm. This is a common occurrence and should be addressed by assessing the patient's need for suctioning or other interventions to relieve the cough.

Choice B:

An endotracheal tube (ETT) cuff leak would typically cause a low pressure alarm, not a high pressure alarm. A cuff leak results in a loss of pressure within the ventilator circuit, leading to insufficient ventilation and a different alarm response.

Choice C:

If the ventilator tubing becomes disconnected, it would result in a low pressure alarm due to the loss of circuit integrity. A disconnection is a serious issue that needs immediate correction but does not cause high pressure alarms.

Choice D:

The patient's complaint of a headache does not directly relate to a high pressure alarm on the ventilator. While patient discomfort should always be addressed, it is not the most likely cause of the alarm in this scenario.

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Question 8:

A nurse is preparing to infuse one unit, 330 mL, of packed red blood cells over 4 hours to a patient with heart failure. The nurse should set the pump to deliver how many mL/hr?

Round to the nearest whole number.

Answer and Explanation

Correct Answer: "83" mL/hr

Explanation

To calculate the infusion rate, divide the total volume of fluid to be infused by the total time over which the infusion should occur.

\(\frac{330 \text{ mL}}{4 \text{ hours}} = 82.5 \text{ mL/hr}\)

Rounding to the nearest whole number, the nurse should set the pump to deliver 83 mL/hr.

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Question 9:

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

A. The spouse assists the client into a wheelchair and coaches deep coughing. B. The spouse assists the client into high-Fowler position and encourages taking a number of deep breaths. C. The spouse places hands on the client's lateral chest and pushes inward on exhalation. D. The spouse places hands below the client's diaphragm and pushes upward with exhalation.

Answer and Explanation

Choice A:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

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Question 10:

After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

A. Maintaining proper body positioning B. Preventing infection C. Maintaining adequate organ perfusion D. Avoiding the use of vasopressors

Answer and Explanation

Choice A:

Maintaining proper body positioning is important for the overall care of a patient, but it is not the priority in the context of organ donation. The primary focus should be on ensuring the viability of the organs for transplantation.

Choice B:

Preventing infection is critical in any clinical setting, particularly in the care of an organ donor, as infections can compromise the quality of the organs. However, it is not the immediate priority action. The most crucial aspect is maintaining organ perfusion to ensure the organs remain viable for transplantation.

Choice C:

Maintaining adequate organ perfusion is the priority nursing action in caring for an organ donor. Adequate perfusion ensures that the organs receive sufficient blood flow and oxygen, which is essential for preserving their function until they can be transplanted. This action takes precedence over other considerations to ensure the success of the organ donation process.

Choice D:

Avoiding the use of vasopressors is important because they can impact organ perfusion and function. However, if necessary, vasopressors may be used to maintain adequate blood pressure and perfusion. The overall priority remains ensuring adequate perfusion to preserve organ function.

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Adult Health (Viterbo University)

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