A patient is admitted with a traumatic brain injury after being thrown from a horse. Despite numerous interventions, the patient is declared brain dead. The parents have consented for organ donation, and the patient's mother requests to lay next to her daughter before being taken to the operating room. Which of the following is the nurse's most appropriate response?
Answer : B
The nurse is caring for a patient with an unstable pelvic fracture related to a crush injury. The patient suddenly develops a fever, hypotension, tachycardia, respiratory distress, and petechiae is noted on the face and chest. The nurse should suspect
Answer : D
A patient who had a liver resection now has a copious amount of serous drainage from the surgical incision. Which of the following should a nurse anticipate when caring for this patient?
Answer : D
A patient with acute salicylate overdose will most likely have which of the following acid-base disturbances?
Answer : A
On evaluation of an infected pressure injury in a patient admitted with pneumonia, the nurse discovers bone exposed at the base of the wound. The nurse should be concerned with
Answer : B
A family nurse is caring for a patient who is actively dying and has several family members present. According to the unit policy, two visitors are allowed at the bedside for 15 minute intervals. The family requests that all members be able to visit together and have extended time with the patient. Which of the following is the nurse's best response?
Answer : C
An older adult patient is admitted with acute exacerbation of congestive heart failure. An echocardiogram indicates that EF is unchanged at 50%. The patient is most likely experiencing
Answer : A
A patient with a history of mastoiditis presents with fever, malaise, vomiting, altered level of consciousness, muscle hypotonia, and new-onset seizures. These symptoms are most indicative of
Answer : C
An intra-aortic balloon pump (IABP) is used in a patient with heart failure to
Answer : B
Assessment of a patient with a head injury reveals increased muscle tone and contractures positioning of the upper extremities. A nurse should
Answer : A
A patient with pneumonia is mechanically ventilated. A nursing student asks why the nurse is performing in-line and oral suction when subglottic responds that in-line, oral, and subglottic suction are performed suction is also being used. The nurse
Answer : D
A patient has visitors whose loud talking and laughing disrupts other patients and visitors in the ICU. Which of the following is the most effective way for a nurse to address this situation?
Answer : A
Which of the following intubated patients is most at risk for developing ventilator-associated pneumonia (VAP)?
Answer : B
Which of the following should a nurse anticipate in a patient with alcohol dependence after abrupt cessation of alcohol?
Answer : C
A patient who has a Sengstaken-Blakemore tube must be monitored for proper tube position and balloon inflation to reduce the risk of
Answer : A
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