Extract:

Question 1 of 5

A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Correct Answer: B

Rationale: Blood glucose of 160 mg/dL requires increasing insulin by 1 unit/hour per protocol to maintain levels below 150 mg/dL.

Question 2 of 5

After 15 minutes of cardiopulmonary resuscitation (CPR) and multiple defibrillations, a client has return of spontaneous circulation (ROSC) with a heart rate of 130 beats/minute and ST elevation in leads I,II, III, aVF, aVL, V5, V6. Which serum laboratory values are most important for the nurse to monitor?

A. Creatine kinase-MB (CK-MB). B. Serum glutamic pyruvic transaminase (SGPT). C. Lactate dehydrogenase (LDH). D. Cardiac troponin.

Correct Answer: D

Rationale: Troponin is the most specific and sensitive biomarker for myocardial infarction, indicated by ST elevation in multiple leads.

Question 3 of 5

A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1. The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?

A. Determine patellar tendon reflex response. B. Check the urinary bladder for distention. C. Ask the client to grasp an object or form a fist. D. Apply resistance while the client lifts the legs.

Correct Answer: C

Rationale: The C8 and T1 spinal nerves control hand and finger movements. Testing grip strength assesses nerve integrity at the injury level.

Question 4 of 5

A client is admitted to the neurological intensive care unit after having just sustained a C5 spinal cord injury (SCI). Which assessment finding for this client warrants immediate intervention by the nurse?

A. Respirations are shallow, labored, and 14 breaths/minute. B. Has flaccid upper and lower extremities. C. Blood pressure is 110/70 mm Hg and the apical heart rate is 68 beats/minute. D. Is unable to feel sensation in the arms and hands.

Correct Answer: A

Rationale: A C5 spinal cord injury can impair diaphragmatic function and respiratory effort, leading to respiratory failure. Shallow and labored breathing suggests that the client is experiencing respiratory compromise, which can quickly progress to hypoventilation, hypoxia, and respiratory arrest. Immediate intervention, such as assisted ventilation or intubation, may be necessary to maintain adequate oxygenation and prevent further complications.

Question 5 of 5

After an endotracheal tube (ETT) is initially placed for a client requiring mechanical ventilation, which intervention should the nurse implement first?

A. Obtain a chest x-ray to verify endotracheal tube location. B. Call the respiratory therapist (RT) to verify tube placement. C. Instill normal saline into the endotracheal tube for suctioning. D. Auscultate for breath sounds bilaterally in all lung fields.

Correct Answer: D

Rationale: The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.