Page 466 - Critical Care Nursing Demystified

FINAL EXAM QUESTIONS 451

4. It is decided to institute drotrecogin (Xigris) in a patient with severe DIC. Which
of the following would the nurse perform to safely administer this medication?
Xigris can cause
A. Severe clotting; monitor for edema and redness in extremities.
B. Hemorrhage if the patient has had recent surgery or stroke within 3 months.
Notify the physician.
C. Monitor the aPTT for severe elevation, which can indicate pending hemorrhage.
Continuously monitor this test.
D. Pain at the insertion site while being administered through an epidural catheter.
Give the patient morphine sulfate if this occurs.

5. The nurse is interviewing the son of an unconscious patient admitted to the ICU
with severe sepsis secondary to acute myelogenous leukemia. The son tells you
the patient self-administers an “injection to prevent blood transfusions.” The
son is most likely describing
A. Epoetin alfa (Epogen)
B. Aminocaproic acid (Amicar)
C. Dobutamine (Dobutrex)
D. Intropin (dopamine)
6. You are the mentor for a new graduate who started 2 weeks ago in the ICU. 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.
Jointly you are caring for a patient post septic shock who has recently been
extubated off the ventilator. Which statement by this new nurse would the men-
tor question?
A. “I will encourage the family to bring in this patient’s favorite foods. I believe he
likes fresh baked apples.”
B. “I will take his temperature rectally.”
C. “I need to talk to the family about flowers. We can keep them in his/her room.”
D. “I should stop his friend with a cold from visiting him.”

7. The nurse is monitoring a patient admitted to the ICU with chronic lung disease
in acute respiratory distress. Systemic inflammatory response syndrome (SIRS)
is suspected. Which of the following would add to this suspicion?
A. Temperature 99.8°F
B. Bradycardia
C. Tachycardia
D. Bradypnea

8. In order to be most effective and efficient when obtaining cultures for sensitiv-
ity in patients with hematological problems, the nurse should
A. Give antibiotics after all cultures have been obtained.
B. Start antibiotics as soon as they are available.