Medsurge: Surgery & Shock

How long can kidneys tolerate reduce blood flow before cells begin to die

1 hour

What causes disseminated intravascular coagulation (DIC)

Abnormal coagulation invoking fibrinogen

Manifestation of compartment syndrome is

Absence of pulse

Patient had ORIF Of fractured femur which of the following would be a priority

Altered level of consciousness

Possible symptom of compartment syndrome

Altered sensation of toes

A nurse in the emergency department is assisting with the care of a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. which of the following actions should the nurse take first

Apply pressure directly to the wound

Patient with heavily bleeding wound. what does the nurse do first

Apply pressure over the bleeding site

Patient post abdominal surgery started on regular diet and now has nausea and vomiting

Asses bowel sounds

Patient post abdominal surgery started on a regular diet and now has nausea and vomiting what should the nurse do first

Assess for bowel sounds

A nurse is collecting data on a client who is postoperative following abdominal surgery which of the following data should the nurse collect first

Check the clients blood pressure

A food high in protein is

Chicken

A nurse is reinforcing teaching with a class about preventing deep vein thrombosis the nurse should include in the teaching that which of the following is a risk factor for this disorder

Dehydration Oral contraceptive use Immobility

A nurse is collecting data on a client who is one day postoperative the nurse should recognize which of the following findings is a manifestation of atelectasis?

Dyspnea

What nursing intervention is appropriate for a patient with DVT

Elevate affected leg

A nurse is contributing to the care plan of a client who is postoperative and has an increase risk of deep vein from Boces which of the following intervention should the nurse include in the plan?

Encourage fluid intake Apply elastic compression stockings Encourage frequent leg exercises Measure thighs

A nurse is caring for a client who is postoperative following a total knee replacement which of the following actions should the nurse implement to prevent deep vein thrombophlebitis

Encourage increased fluid intake.

Which medication do you administer first for anaphylactic shock

Epinephrine

A nurse is caring for a client who is at risk for shock which of the following findings should the nurse expect?

HYPOTENSION?

Patient c/o Abdominal gas pain following abdominal surgery what action should the nurse take

Help the patient ambulate

A nurse in the emergency department is collecting data from a client who was admitted following a bee sting. Which of the following findings should the nurse expect in the client who is experiencing anaphylaxis

Hypotension

Patient hemorrhaging has rapid respiratory rate what is the likely cause

Inadequate tissue perfusion

A contributing factor of septic shock is

Infection

A nurse is measuring the vital signs of a client he suspects has hypovolemic shock which of the following findings should the nurse expect?

Low BP, high pulse rate.

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker which of the following prescriptions should the nurse question?

MRI of the chest

A nurse is measuring a client for knee high antiembolic stockings to help prevent venous stasis which of the following actions should the nurse take?

Measure from the clients heel to the popliteal space

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions which of the following is an acceptable method for the nurse to use to thin the client secretions

Provide humidified oxygen

Symptoms of pulmonary embolus is

Sudden shortness of breath (dyspnea)

A nurse is assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock. Which of the following findings should the nurse expect

Tachycardia

Patient post foot surgery is NWB On that foot and you find that he hopped into the bathroom on 1 foot what should the nurse do

Tell Client to stay on toilet and get a wheelchair

A nurse is reinforcing teaching with a client following surgery who has anti-embolism stockings in place. which of the following information should the nurse include in the teaching?

The stockings prevent venous stasis

A nurse is collecting data from a client who is postoperative following abdominal surgery. which of the following findings should cause the nurse to suspect deep vein thrombosis?

Unilateral leg edema

A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the clients brain which of the following pulse sites should the nurse use

carotid

A client who is postoperative is receiving IV fluids and a unit of whole blood the nurse should observe the client for which of the following as an early sign of circulatory overload?

dyspnea

A nurse is collecting data from a client who has anemia due to excess blood loss during surgery the nurse should expect which of the following findings?

dyspnea on exertion

A nurse is caring for a client who is experiencing hypovolemic shock which of the following findings should the nurse expect

oliguria

A nurse is collecting data from a client who sustained blood loss which of the following findings should the nurse identify as a manifestation of Hypovolemia

thready pulse