Exam II Study Guide
The nurse is caring for a patient recovering from a spinal cord injury sustained during a motor vehicle crash. What assessment findings indicate that the patient is developing neurogenic shock? Select all that apply. 1. Hypotension 2. Bradycardia 3. Warm dry skin 4. Abdominal cramps 5. Palpitations
1. Hypotension 2. Bradycardia 3. Warm dry skin
A patient is brought to the emergency department with hypotension, tachycardia, reduced capillary refill, and oliguria. During the assessment, the nurse determines the patient is experiencing cardiogenic shock because of which additional finding? 1. Jugular vein distention 2. Dry mucous membranes 3. Poor skin turgor 4. Thirst
1. Jugular vein distention
The nurse is caring for a patient who is experiencing cardiogenic shock as a result of myocardial infarction. Which nursing assessment finding is most concerning? 1. PaO2 60 mm Hg 2. Blood pressure 100/56 mm Hg 3. Urine output 260 mL in eight hours 4. Heart rate 96 beats/minute
1. PaO2 60 mm Hg
A patient presents to the emergency department (ED) in a state of shock. On assessment, the nurse finds that the patient is cyanotic and has crackles on auscultation of the lungs. As which type of shock will the nurse classify this? 1. Neurogenic shock 2. Cardiogenic shock 3. Hypovolemic shock 4. Anaphylactic shock
2. Cardiogenic shock
A client is admitted to the intensive care unit with disseminated intravascular coagulation (DIC). Which clinical manifestations does the nurse anticipate? Select all that apply. A) Tachycardia B) Increased blood glucose level C) Decreased breath sounds D) Confusion E) Thick, tenacious bronchial secretions
A) Tachycardia C) Decreased breath sounds D) Confusion
The nurse is caring for a patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply). a) BP b) HR c) LOC d) Pupil respons e) Respirations f) Urine output
A. BP C. LOC F. UOP
Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses
A. Bradycardia
Which assessment data would indicate the potential development of multiple organ dysfunction syndrome (MODS)? Select all that apply. A. Severe dyspnea B. Urine Na + of 18 mEq/L C. Blood urea nitrogen (BUN)/creatinine ratio of 18:1 D. Heart rate of 110 beats/min E. BP of 86/42 mm Hg F. Respiratory rate of 32 breaths/min
A. Severe dyspnea D. Heart rate of 110 beats/min E. BP of 86/42 mm Hg F. Respiratory rate of 32 breaths/min
Which of these are signs and symptoms of sepsis? Select all that apply. A. LOC being alert and oriented B. tachycardia C. tachypnea D. dry skin E. shivering and sweaty skin
B. tachycardia C. tachypnea E. shivering and sweaty skin
The nurse is caring for a 72-year-old man in cardiogenic shock after an acute myocardial infarction. Which clinical manifestations would be of most concern to the nurse? A. Restlessness, heart rate of 124 beats/minute, and hypoactive bowel sounds B. Mean arterial pressure of 54 mm Hg, increased jaundice, and cold, clammy skin C. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites D. Agitation, respiratory rate of 32 breaths/minute, and serum creatinine level of 2.6 mg/dL
C. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and bleeding from puncture sites
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? A) Hypotension B) Bradypnea C) Heart blocks D) Tachycardia
D) Tachycardia
The nurse in the emergency department receives arterial blood gas results for four recently admitted patients with obstructive pulmonary disease. Which patient will require the most rapid action by the nurse? a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg b. 34-year-old with ABG results: pH 7.48, PaCO2 30 mm Hg, and PaO2 65 mm Hg c. 45-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg d. 65-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
a. 22-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg The pH, PaCO2 , and PaO2 indicate that the patient has severe uncompensated respiratory acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia and correct the acidosis. The other patients also should be assessed as quickly as possible but do not require interventions as quickly as the 22- year-old.
A nurse is caring for a patient who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition? a. Ineffective tissue perfusion b. impaired urinary elimination c. Disturbed personal identity d. Ineffective thermoregulation
a. Ineffective tissue perfusion
During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider? a. New onset of confusion b. Decreased bowel sounds c. Heart rate 112 beats/min d. Pale, cool, and dry extremities
a. New onset of confusion
A patient with suspected neurogenic shock after a diving accident has arrived in the emergency department. A cervical collar is in place. Which actions should the nurse take (select all that apply)? a. Prepare to administer atropine IV. b. Obtain baseline body temperature. c. Infuse large volumes of lactated Ringers solution. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation
a. Prepare to administer atropine IV. b. Obtain baseline body temperature. d. Provide high-flow oxygen (100%) by non-rebreather mask. e. Prepare for emergent intubation and mechanical ventilation
A patient in the intensive care unit has a nasogastric tube and is also receiving a proton pump inhibitor (PPI). The nurse recognizes that the purpose of the PPI is which effect? a. Prevent stress ulcers b. Reduce bacteria levels in the stomach c. Reduce gastric gas formation (flatulence) d. Promote gastric motility
a. Prevent stress ulcers
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.
a. The patient is somnolent.
When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. b. Endotracheal suctioning results in minimal mucous return. c. Sputum and blood cultures show no growth after 24 hours. d. The skin on the patient's back is intact and without redness.
a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%.
Which data collected by the nurse caring for a patient who has cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)? a. The patient's serum creatinine level is elevated. b. The patient complains of intermittent chest pressure. c. The patient's extremities are cool and pulses are weak. d. The patient has bilateral crackles throughout lung fields.
a. The patient's serum creatinine level is elevated.
The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a. The patients PaO2 is 45 mm Hg. b. The patients PaCO2 is 33 mm Hg. c. The patient's respirations are shallow. d. The patient's respiratory rate is 32 breaths/minute.
a. The patients PaO2 is 45 mm Hg.
Which preventive actions by the nurse will help limit the development of systemic inflammatory response syndrome (SIRS) in patients admitted to the hospital (select all that apply)? a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. d. Advocate for parenteral nutrition for patients who cannot take oral feedings. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
a. Use aseptic technique when caring for invasive lines or devices. b. Ambulate postoperative patients as soon as possible after surgery. c. Remove indwelling urinary catheters as soon as possible after surgery. e. Administer prescribed antibiotics within 1 hour for patients with possible sepsis.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.
a. hypotension, bradycardia, and warm extremities.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position
a. increase the oxygen flow rate.
The standard policy on the cardiac unit states, Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42. b. newly admitted patient with a BP of 150/87. c. patient with left ventricular failure who has a BP of 110/70. d. patient with a myocardial infarction who has a BP of 140/86.
a. postoperative patient with a BP of 116/42. The nurse obtains a blood pressure of 176/83 mm Hg for a patient. What is the patients mean arterial pressure (MAP)? ANS: 114 mm Hg MAP = (SBP + 2 DBP)/3
The client in the ED begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. which interventions should the nurse implement? select all that apply a. prepare to administer solu-medrol, a glucocorticoid, IV b. request and obtain a STAT chest x-ray c. initiate the rapid response team d. administer epinephrine, an adrenergic blocker, SQ then IV continuous e assess for the client's pulse and respirations
a. prepare to administer solu-medrol, a glucocorticoid, IV c. initiate the rapid response team d. administer epinephrine, an adrenergic blocker, SQ then IV continuous e assess for the client's pulse and respirations
A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: SATA a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.
a.) Rapid shallow respirations. d.) Elevated temperature.
The client is experiencing an anaphylactic reaction to bee venom. which interventions should the nurse implement? list in order of priority a. establish a patent airway b. administer epinephrine, an adrenergic agonist, IVP c. start an IV with 0.9% saline d. teach the client to carry an EpiPen when outside e. administer diphenhydramine (Benadryl), an antihistamine, IVP
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The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). What nursing diagnosis is the priority for the nurse to initiate? a Acute pain b Ineffective airway clearance c Anticipatory grieving d Deficient knowledge
b Ineffective airway clearance
A client is experiencing acute respiratory distress syndrome (ARDS). The client's spouse asks the nurse what caused ARDS. The nurse bases the response on which etiologies of indirect injury to the lungs?(Select all that apply.) a Fat embolism b Systemic sepsis c Multiple blood transfusions d Pancreatitis e Smoke inhalation
b Systemic sepsis c Multiple blood transfusions d Pancreatitis
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first? a. Administer the ordered opioid. b. Check the oxygen (O2) saturation. c. Take the blood pressure and pulse. d. Apply wrist restraints to secure IV lines.
b. Check the oxygen (O2) saturation.
The following interventions are ordered by the health care provider for a patient who has respiratory distress and syncope after eating strawberries. Which will the nurse complete first? a. Start a normal saline infusion. b. Give epinephrine (Adrenalin). c. Start continuous ECG monitoring. d. Give diphenhydramine (Benadryl).
b. Give epinephrine (Adrenalin).
A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.
b. Infuse normal saline at 250 mL/hr.
Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures
b. Insert a retention catheter
Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock? a. Check temperature every 2 hours. b. Monitor breath sounds frequently. c. Maintain patient in supine position. d. Assess skin for flushing and itching
b. Monitor breath sounds frequently.
Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.
b. Monitor the IV sites for redness, swelling, or tenderness.
A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of coughing. d. Increase oxygen level to keep O2 saturation >95%.
b. Offer the patient fluids at frequent intervals.
After receiving report on the following patients, which patient should the nurse assess first? a. Patient with rheumatic fever who has sharp chest pain with a deep breath b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg c. Patient with infective endocarditis who has a murmur and splinter hemorrhages d. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases
b. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg Hypotension in patients with acute aortic regurgitation may indicate cardiogenic shock. The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.
After change-of-shift report in the progressive care unit, who should the nurse care for first? a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 beats/minute d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood pressure of 108/58 mm Hg
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and antibiotics
Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.
b. Provide a "sedation holiday" daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution.
Which finding is the best indicator that the fluid resuscitation for a 90-kg patient with hypovolemic shock has been effective? a. Hemoglobin is within normal limits. b. Urine output is 65 mL over the past hour. c. Central venous pressure (CVP) is normal. d. Mean arterial pressure (MAP) is 72 mm Hg.
b. Urine output is 65 mL over the past hour.
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a. Blood urea nitrogen (BUN) level 32 mg/dL b. Red-brown drainage from orogastric tube c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68
b. Red-brown drainage from orogastric tube
The nurse educator is evaluating the performance of a new registered nurse (RN) who is providing care to a patient who is receiving mechanical ventilation with 15 cm H2O of peak end-expiratory pressure (PEEP). Which action indicates that the new RN is safe? a. The RN plans to suction the patient every 1 to 2 hours. b. The RN uses a closed-suction technique to suction the patient. c. The RN tapes connection between the ventilator tubing and the ET. d. The RN changes the ventilator circuit tubing routinely every 48 hours.
b. The RN uses a closed-suction technique to suction the patient.
Which finding about a patient who is receiving vasopressin to treat septic shock indicates an immediate need for the nurse to report the finding to the health care provider? a. The patient's urine output is 18 mL/hr. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's heart rate is 110 beats/minute
b. The patient is complaining of chest pain.
A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP
b. endotracheal intubation and positive pressure ventilation.
A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 40 mg IV
b. gentamicin (Garamycin) 60 mg IV
Appropriate treatment modalities for the management of cardiogenic shock include (Select all that apply) a. dobutamine to increase myocardial contractility b. vasopressors to increase systemic vascular resistance c. circulatory assist devices such as an intraaortic balloon pump d. corticosteroids to stabilize the cell wall in the infarcted myocardium e. trendelenburg positioning to facilitate venous return and increase preload
b. vasopressors to increase systemic vascular resistance d. corticosteroids to stabilize the cell wall in the infarcted myocardium
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.
b.) obtain an oxygen saturation.
a. A patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which finding by the nurse will help confirm a diagnosis of neurogenic shock? a. Cool, clammy skin b. Inspiratory crackles c. Apical heart rate 48 beats/min d. Temperature 101.2° F (38.4° C)
c. Apical heart rate 48 beats/min
To evaluate the effectiveness of ordered interventions for a patient with ventilator failure, which diagnostic test will be most useful to the nurse? a. Chest x-ray b. Oxygen saturation c. Arterial blood gas analysis d. Central venous pressure monitoring
c. Arterial blood gas analysis
The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patient's room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient.
c. Assist the patient with staged coughing.
A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patients' health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level
c. Check the medical record for most recent potassium level.
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.
c. Elevate head of bed to 30 to 45 degrees.
A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102 F (38.9 C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.
c. Infuse normal saline 500 mL over 30 minutes.
The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medications effectiveness? a. Blood pressure b. Oxygen saturation c. Intracranial pressure d. Hemoglobin and hematocrit
c. Intracranial pressure
The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs
c. Obtain oxygen saturation using pulse oximetry.
After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the health care provider? Physical Assessment • Petechiae noted on chest and legs • Crackles heard bilaterally in lung bases • No redness or swelling at central line IV site Laboratory Data • Blood urea nitrogen (BUN) 34 mg/Dl • Hematocrit 30% • Platelets 50,000/µLVital Signs • Temperature 100°F (37.8°C) • Pulse 102/min • Respirations 26/min • BP 110/60 mm Hg • O2 saturation 93% on 2L O2 via nasal cannula a. Temperature and IV site appearance b. Oxygen saturation and breath sounds c. Platelet count and presence of petechiae d. Blood pressure, pulse rate, respiratory rate
c. Platelet count and presence of petechiae
A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first? a. Insert two large-bore IV catheters. b. Initiate continuous electrocardiogram (ECG) monitoring. c. Provide oxygen at 100% per non-rebreather mask. d. Draw blood to type and cross match for transfusions.
c. Provide oxygen at 100% per non-rebreather mask.
The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which patient assessment finding indicates that the infusion rate may need to be adjusted? a. Heart rate is slow at 58 beats/min. b. Mean arterial pressure (MAP) is 56 mm Hg. c. Systemic vascular resistance (SVR) is elevated. d. Pulmonary artery wedge pressure (PAWP) is low.
c. Systemic vascular resistance (SVR) is elevated.
The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.
c. The patient's PaO2 is 45 mm Hg.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's respiratory rate has decreased from 30 to 10 breaths/min. d. The patient's pulse oximetry indicates an O2 saturation of 91%
c. The patient's respiratory rate has decreased from 30 to 10 breaths/min.
A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of a. nitroglycerine (Tridil). b. dobutamine (Dobutrex). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
c. norepinephrine (Levophed).
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse will anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride)
c. norepinephrine (Levophed).
The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a.) A liter of lactated Ringer's solution. b.) 500 ml of 5% albumin. c.) Two 14-gauge IV catheters. d.) a retention catheter.
c.) Two 14-gauge IV catheters.
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."
d. "PEEP prevents the lung air sacs from collapsing during exhalation."
After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions
d. A patient with septicemia who has intercostal and suprasternal retractions
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry
d. Assess oxygenation using pulse oximetry
When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? a. Notify the health care provider. b. Check pupils for reaction to light. c. Attempt to calm and reorient the patient. d. Assess oxygenation using pulse oximetry.
d. Assess oxygenation using pulse oximetry.
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? a. Auscultate bowel sounds. b. Palpate for abdominal pain. c. Ask the patient about nausea. d. Check stools for occult blood.
d. Check stools for occult blood.
The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a. Scattered crackles bilaterally in the posterior lung bases. b. Persistent cough that is productive of blood-tinged sputum. c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy. d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask
A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which action will the nurse anticipate taking? a. Increase the rate for the prescribed dopamine (Intropin) infusion. b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion. c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion. d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion
d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next? a. Increase the tidal volume and respiratory rate. b. Increase the fraction of inspired oxygen (FIO2 ). c. Perform endotracheal suctioning more frequently. d. Lower the positive end-expiratory pressure (PEEP).
d. Lower the positive end-expiratory pressure (PEEP).
When the nurse educator is evaluating the skills of a new registered nurse (RN) caring for patients experiencing shock, which action by the new RN indicates a need for more education? a. Placing the pulse oximeter on the ear for a patient with septic shock b. Keeping the head of the bed flat for a patient with hypovolemic shock c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
The nurse responds to a ventilator alarm and finds the patient lying in bed holding the endotracheal tube (ET). Which action should the nurse take next? a. Activate the rapid response team. b. Provide reassurance to the patient. c. Call the health care provider to reinsert the tube. d. Manually ventilate the patient with 100% oxygen
d. Manually ventilate the patient with 100% oxygen
After reviewing a patients history, vital signs, physical assessment, and laboratory data, which information shown in the accompanying figure is most important for the nurse to communicate to the health care provider? a. Q waves on ECG b. Elevated troponin levels c. Fever and hyperglycemia d. Tachypnea and crackles in lungs
d. Tachypnea and crackles in lungs
The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%
A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as a. metabolic acidosis. b. metabolic alkalosis. c. respiratory acidosis. d. respiratory alkalosis.
d. respiratory alkalosis
A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88mm Hg, PaCO2 37, and HCO3 16 mEq/L. How should the nurse interpret these results: i. Metabolic Acidosis ii. Metabolic Alkalosis iii. Respiratory Acidosis iv. Respiratory Alkalosis
i. Metabolic Acidosis
a. Cardiogenic shock assessment findings: i. Pulmonary Congestion ii. Dyspnea iii. Cool and clammy extremities, poor capillary refill, tachycardia iv. Bilateral crackles throughout the lung fields
i. Pulmonary Congestion
To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform? i. Auscultate the bowel sounds ii. Ask the patient about nausea iii. Check stools for occult blood iv. Palpate for abdominal tenderness
iii. Check stools for occult blood
A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas? i. Metabolic acidosis ii. Metabolic alkalosis iii. Respiratory Acidosis iv. Respiratory alkalosis
iv. Respiratory alkalosis
