Page 465 - Critical Care Nursing Demystified

450 CRITICAL CARE NURSING DeMYSTIFIED

10. A patient is starting on spironolactone (Aldactone) for high blood pressure
unresponsive to hydrochlorothiazide (HCTZ). During the morning assessment
the nurse notes the patient is disoriented to time and place. The patient also
states he has had cramps in his legs all night. Although the cardiac rhythm is
unchanged from the previous shift, the next course of action the nurse should
perform is to
A. Perform a more thorough neurological assessment and continue to monitor the
patient.
B. Check the patient’s last potassium level; the symptoms might indicate hyper-
kalemia.
C. Administer both medications and call the physician to report these new symp-
toms.
D. Hold both drugs until the physician is notified; this could be a rebound effect of
the diuretics.

Chapter 9

1. Upon examining the extremities of a patient suspected of having a hematologic
problem the nurse notes pinpoint red tiny dots around both ankles of the
patient. The nurse would chart these findings as Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
A. Hematoma
B. Petechiae
C. Hematopoiesis
D. Jaundice

2. The nurse suspects that a patient might be in septic shock. Which of the follow-
ing laboratory values points in this direction?
A. Increased serum ferritin and increased basophils
B. Decreased iron-binding capacity and increased eosinophils
C. Increased D-dimer and increased FDP
D. Increased fibrinogen levels and decreased INR

3. A nurse is monitoring a patient’s status after a bone marrow biopsy. Which of
the following would follow the standard of nursing care?
A. Check vital signs once a shift immediately after the procedure.
B. Feed the patient ASAP to ensure adequate nutrition.
C. Monitor the site for bleeding.
D. Institute neutropenic precautions until test results return.