NSG 420 Exam 2 _Shocks and Sepsis

The nurse is assessing a client whose blood pressure is dropping and heart rate and respiratory rate are increasing. Which finding indicates the client is at risk for hypovolemic shock?

severe hemorrhage

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock?

A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume.

The nurse is caring for a client 1 day after having a colectomy. The client is lethargic and difficult to arouse; the temperature is 101.5°F (38.6°C), blood pressure is 92/36 mm Hg (mean arterial pressure [MAP 55 mm Hg]), and heart rate is 114 bpm, with a percutaneous oxygen saturation (SpO2) of 88% on oxygen at 2 L per minute per nasal cannula (previously 94%). A saline lock has been established and is patent. Which prescription should the nurse implement first?

Draw blood cultures.

A client arrives via ambulance with a suspected pelvic fracture from a motor vehicle collision. The client's vital signs are: blood pressure 85/50 mm Hg, heart rate 120 beats/min, respiratory rate 22 breaths/min, and an oxygen saturation of 98% on room air. The client is afebrile. The health care provider has written several prescriptions. What is the nurse's priority action?

Obtain STAT hemoglobin and group and match.

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?

blood chemistry of serum lactate

A nurse is teaching a client who has a severe allergy to bee stings how to manage a reaction. What medication does the nurse encourage the client to take first after being stung by a bee?

epinephrine

The client is admitted in septic shock. Which assessment data warrants immediate intervention by the nurse?

a urinary output of 50 mL in the past 3 hours

A nurse is preparing to teach a client recovering from an anaphylaxis reaction about the prevention and management of reactions. What should the nurse include in the teaching? Select all that apply.

take vital signs every day how to administer emergency medications antigens that should be avoided

The nurse is planning care for an older adult with an indwelling catheter who is at risk for septic shock. Which nursing action will be most important for this client?

using aseptic technique when caring for the catheter

A client with sepsis begins having labored breathing, confusion, and lethargy. What complication should the nurse assess for in this client?

Acute respiratory distress syndrome (ARDS)

A nurse is caring for a client who is experiencing sinus bradycardia with a pulse rate of 40 beats/minute. The blood pressure is 80/50 mm Hg and the client reports dizziness. What is the nurse's priority action?

Administer atropine 0.5 mg I.V. push as ordered.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?

hypovolemic

When assessing a client for early sepsis, which assessment finding would most concern the nurse?

mean arterial pressure less than 70 mmHg

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first?

obtain cultures