Critical Care Nursing Flashcards

A patient presents with a sudden 'thunderclap' headache, neck stiffness, photophobia, and CT showing blood in the subarachnoid space. Which complication should the nurse monitor for most closely in the following days?

Answer: Cerebral vasospasm

Cerebral vasospasm is the most feared delayed complication of subarachnoid hemorrhage, typically occurring 4–14 days after the initial bleed and leading to ischemic stroke.

A patient with acute kidney injury (AKI) has a potassium level of 6.8 mEq/L and an ECG showing peaked T-waves. What is the nurse's PRIORITY intervention?

Answer: Administer calcium gluconate IV immediately

Calcium gluconate stabilizes the cardiac membrane against the arrhythmogenic effects of hyperkalemia and acts within minutes; it is the immediate priority when ECG changes are present.

A patient is diagnosed with acute respiratory distress syndrome (ARDS). Which ventilator strategy is supported by the strongest evidence?

Answer: Low tidal volume ventilation (6 mL/kg ideal body weight) with appropriate PEEP

Lung-protective ventilation using low tidal volumes (6 mL/kg ideal body weight) with PEEP is the evidence-based strategy for ARDS, reducing ventilator-induced lung injury.

A patient with traumatic brain injury is assessed and has a GCS score of 6. The nurse should interpret this score as indicating:

Answer: Severe brain injury requiring immediate airway management

A GCS score of 8 or below indicates severe brain injury; these patients typically cannot protect their airway and require endotracheal intubation.

A patient with diabetic ketoacidosis (DKA) has blood glucose 480 mg/dL, pH 7.18, HCO3 10 mEq/L, and urine ketones positive. After initial fluid resuscitation, the priority treatment is:

Answer: Start a continuous regular insulin infusion

Continuous regular insulin infusion is the cornerstone of DKA treatment after adequate fluid resuscitation; it suppresses ketogenesis and gradually lowers blood glucose.

The nurse observes bradycardia, systolic hypertension with widened pulse pressure, and irregular respirations in a patient with a severe head injury. This clinical triad is known as:

Answer: Cushing's triad

Cushing's triad (bradycardia, hypertension with widened pulse pressure, and irregular respirations) is a late and ominous sign of brainstem herniation due to critically elevated ICP.

A patient on continuous renal replacement therapy (CRRT) shows a sudden decrease in effluent flow rate. What should the nurse do FIRST?

Answer: Assess the filter and circuit for clotting or kinking

Clot formation in the CRRT circuit is the most common cause of decreased effluent flow; the nurse should inspect the filter and circuit lines for clotting or kinking before taking any other action.