NMNC 4410 Exam #3
When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse? a. BP 88/56 mm Hg b. Apical pulse 110 beats/min c. Urine output 15 ml for 2 hours d. Arterial oxygen saturation 90%
c. Urine output 15 ml for 2 hours
Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: A. Blood pressure of 70/34 after the fluid bolus B. Serum lactate less than 2 mmol/L C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement D. Central venous pressure (CVP) of 18
A. Blood pressure of 70/34 after the fluid bolus C. Patient needs Norepinephrine to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement
A client with severe cellulitis is starting intravenous antibiotic treatment. The nurse is explaining situations that should be reported to the healthcare provider. Which situation should the nurse describe? (Select all that apply.) A. Increase in lethargy B. Decrease in pain of affected area C. Temperature over 38.3°C (101°F)D. Spread of infected area in the next 24 dash-48 hours E. Decrease in edema of affected area in the next 24-48 hours
A. Increase in lethargy C. Temperature over 38.3degrees°C (101 degrees°F) D. Spread of infected area in the next 24-48 hours
Your patient is receiving aggressive treatment for septic shock. Which findings demonstrate treatment is NOT being successful? Select all that apply: A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L D. Blood glucose 120 mg/dL E. CVP (central venous pressure) less than 2 mmHg
A. MAP (mean arterial pressure) 40 mmHg B. Urinary output of 10 mL over 2 hours C. Serum Lactate 15 mmol/L E. CVP (central venous pressure) less than 2 mmHg
The nurse is teaching a client with a skin infection about the prescriber's choice of medication. Which is the rationale for the use of topical agents, rather than systemic medications? (Select all that apply.) A. Most effective B. Least painful C. Least toxic D. Most available E. Most convenient
A. Most effective C. Least toxic
The nurse is completing a health history on a client with cellulitis. Which additional symptom should the nurse assess during the health history? (Select all that apply.) A. Muscle aches B. Numbness C. Nausea D. Stiffness E. Pain
A. Muscle aches C. Nausea D. Stiffness E. Pain
The nurse is concerned that a 9-month-old client being treated for bronchiolitis caused by respiratory syncytial virus (RSV) is developing respiratory distress. Which assessment finding supports this concern? (Select all that apply.) A. Onset of expiratory grunting B. Visible intercostal retractions with ventilations C. Respiratory rate increased from 30 to 48 breaths/min D. Systolic blood pressure 10 mmHg less than previous measurement E. Femoral pulse weak and 120 beats/min
A. Onset of expiratory grunting B. Visible intercostal retractions with ventilations C. Respiratory rate increased from 30 to 48 breaths/min
The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which manifestation should the nurse anticipate finding with this client? (Select all that apply.) A. Swollen lymph glands B. Pustules with surrounding erythema C. Deep, firm, painful nodule D. Fever and chills E. Erythema
A. Swollen lymph glands D. Fever and chills E. Erythema
The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? A. The patient's blood pressure changes from 75/48 to 110/82. B. Patient's CVP 2 mmHg C. Patient's skin is warm and flushed. D. Patient's urinary output is 20 mL/hr.
A. The patient's blood pressure changes from 75/48 to 110/82.
The nurse is teaching the client with diabetes mellitus about prevention of cellulitis. Which instruction should the nurse provide? (Select all that apply.) A. "Apply topical antibiotic to the wound daily. "B. "Wear properly fitting shoes." C. "Keep wounds uncovered." D. "Keep wounds dry." E. "Wash the wound carefully with soap and water."
A. "Apply topical antibiotic to the wound daily. "B. "Wear properly fitting shoes. "E. "Wash the wound carefully with soap and water."
The pediatric nurse is discussing with the parent the care of a toddler with multiple insect bites. Which information should the nurse include in the discussion to help prevent development of cellulitis? A. "Distract the toddler from scratching or picking at the wounds." B. "Make sure the toddler's hands are washed frequently." C. "Bathe the toddler daily using Epsom salts in the bath." D. "Administer antipyretics to help with discomfort."
A. "Distract the toddler from scratching or picking at the wounds."
The nurse has completed discharge teaching for a client who is being discharged to home after treatment for cellulitis. Which statement by the client during evaluation of the response to teaching would the nurse need to clarify? A. "Before doing wound care, I need to scrub my hands with soap and water for at least 20 seconds." B. "I should wash the wound at least once daily with soap and water." C. "After cleaning the wound, I need to apply antibiotic ointment and a clean bandage." D. "I need to carefully monitor the size of the wound to make sure it is not increasing."
C. "After cleaning the wound, I need to apply antibiotic ointment and a clean bandage."
A client with cellulitis asks the nurse if it is okay to try an herbal supplement their herbalist recommended instead of the antibiotic. Which response by the nurse best addresses this question? A. "If that is what you prefer to do, I think it would be okay for you to try it for a few days and see if it works. If not, then you can start the antibiotic." B. "Herbal supplements have a lot of myths surrounding them. They are not appropriate in any situation, let alone one this serious." C. "It is best to take the antibiotic because the supplement may actually increase the risk for a bad outcome." D. "Many herbal supplements are analogous to prescription medications. Which one are you considering?"
C. "It is best to take the antibiotic because the supplement may actually increase the risk for a bad outcome."
The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include a. pH 7.48, PaCO2 33 mm Hg. b. pH 7.33, PaCO2 30 mm Hg. c. pH 7.41, PaCO2 50 mm Hg. d. pH 7.38, PaCO2 45 mm Hg.
Correct Answer: B Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.
Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and restlessness. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? Crystalloids IV fluid bolus Norepinephrine Low-dose corticosteroids 2 units of Packed Red Blood Cells
Crystalloids IV fluid bolus
The nurse is working with a group of new nurses and discussing the importance of maintaining fluid balance in an infant with respiratory syncytial virus (RSV). Which statement demonstrates an understanding of maintaining fluid balance in infants? A. "We should encourage the parents to monitor sleeping." B. "We should encourage the parents to add proteins into the diet." C. "We should encourage the parents to force fluids." D. "We should encourage the parents to count diapers."
D. "We should encourage the parents to count diapers."
A client admitted for treatment of cellulitis appears very ill to the nurse. A WBC count has already been ordered. Which additional diagnostic test does the nurse anticipate being ordered for this client? A. Erythrocyte sedimentation rate B. C-reactive protein C. Electrolyte panel D. Blood cultures
D. Blood cultures
The nurse is meeting with a parent and a 6-month-old client who has been coughing and demonstrating signs of air hunger. Which cause should the nurse suspect for this symptom? A. Increased pulse B. Dry mouth C. Edema D. Hypoxia
D. Hypoxia
A patient in septic shock receives large amounts of IV fluids. However, this was unsuccessful in maintaining tissue perfusion. As the nurse, you would anticipate the physician to order what NEXT? A. IV corticosteroids B. Colloids C. Dobutamine D. Norepinephrine
D. Norepinephrine
The nurse examines a wound on a client with a history of cellulitis. Which manifestation suggests cellulitis? A. Intact skin with nonblanchable redness and elevated borders B. Reddened skin with indistinct borders and covered by a yellow, fibrous film C. Pink or red skin with circumscribed regular borders D. Red or lilac edematous skin with a well-defined, nonelevated border
D. Red or lilac edematous skin with a well-defined, nonelevated border
The nurse is discussing the importance of preventing the spread of infection with a mother whose 7-month-old is being discharged after hospitalization for respiratory syncytial virus (RSV). Which discharge teaching should the nurse provide to the mother of the client? A. Demonstrate nasal suctioning procedures. B. Stress the importance of isolation. C. Explain the importance of taking medications until they are gone. D. Stress the importance of not sharing cups.
D. Stress the importance of not sharing cups.
The nurse is assessing the affected area for a client hospitalized for treatment of cellulitis. During the assessment, the nurse notes that redness in the affected area extends a bit beyond the border traced during the previous assessment. Which action should the nurse take based on this finding? A. Immediately notify the healthcare provider of this change .B. Increase the elevation level of the affected body part C. Ask the client if they have noticed any change in pain. D. Trace along the new border with a marker.
D. Trace along the new border with a marker.
The health care provider prescribes these actions for a patient who has possible septicshock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will thenurse implement the actions? Put a comma and space between each answer choice (a, b,c, d, etc.) ____________________ a. Obtain blood and urine cultures. b. Give vancomycin (Vancocin) 1 g IV. c. Infuse vasopressin (Pitressin) 0.01 units/min. d. Administer normal saline 1000 mL over 30 minutes. e. Titrate oxygen administration to keep O2 saturation >95%.
E, D, C, A, B
The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. Multiparity Early menarche Early menopause Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovaries
Early menarche Family history of breast cancer High-dose radiation exposure to chest Previous cancer of the breast, uterus, or ovaries
The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? Placing cool compresses on the affected arm Elevating the affected arm on a pillow above heart level Avoiding arm exercises in the immediate postoperative period Maintaining an intravenous site below the antecubital area on the affected side
Elevating the affected arm on a pillow above heart level
The nurse is working on a plan of care with her patient which includes turning and positioning and adequate nutrition to help the patient maintain intact skin integrity. She knows this will help break the chain of infection by: Eliminating a portal of entry Increasing the patient's circulation Increasing the patient's protein Eliminating the mode of transmission
Eliminating a portal of entry
You have a patient admitted with an MRSA infection that has improved and will be discharged to home. What teaching items should you EXCLUDE for this patient? Hand hygiene for people who live with the patient is not necessary. If you are prescribed an antibiotic for a MRSA infection, complete the full course of antibiotics. Avoid sharing personal items such as towels or razors. For future care inform health care providers about MRSA status.
Hand hygiene for people who live with the patient is not necessary.
The nurse is triaging a 55-year-old African-American male client with a past history of colon polyps who complains of recent unexplained weight loss, abdominal pain, and change in bowel habits. Which lab study will the nurse want to review based on these symptoms? Hemoglobin UA BUN Bilirubin
Hemoglobin
A new nurse is having difficulty knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains which of the following should be seen first? Hypotension, tachycardia, and lethargy Febrile, tachycardia, and vomiting Abdominal pain, hypertensive and constipated Dizziness with normal vital signs
Hypotension, tachycardia, and lethargy
A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first Increase the rate of intravenous (IV) fluids Insert an indwelling urinary catheter Obtain arterial blood gas results Prepare to hang Heparin IV
Increase the rate of intravenous (IV) fluids
A 28 year old female patient asks you when it is best to perform a self breast exam. Your response is the following: It is best to perform a self breast exam 7 to 10 days after menses. It is best to perform a self breast exam every 6 months on the 1st day of bleeding. It is best to perform a self breast exam on the same time every month of the day. It is best to perform a self breast exam on the day after ovulation.
It is best to perform a self breast exam 7 to 10 days after menses
The nurse at the after hours clinic receives the following orders for a 8 month old patient with suspected RSV and showing signs of mild respiratory distress, what order should he complete FIRST? Obtain a blood sample for a CBC. Suction the patient's nose using saline drops. Perform a PO challenge to see if the patient can tolerate fluids by mouth Educate the family on reasons to follow up.
Suction the patient's nose using saline drops.
Which statement from the parents indicates to the nurse that further teaching is needed in regards to their 14 month old son with RSV: We will give cough medications every 4-6 hours. We will suction his nose at before nap times and meals. We will look for a wet diaper every 6-8 hours. We will make sure to keep him home from daycare.
We will give cough medications every 4-6 hours.
In order to provide the best intervention for a patient, the nurse is often responsible for obtaining a sample of exudate for culture. What information will this provide? What cells are being utilized by the body to attack an infection. Whether a patient has an infection. What specific type of pathogen is causing an infection. Where an infection is located.
What specific type of pathogen is causing an infection.
A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32,temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribedinterventions will the nurse implement first? a. Give normal saline IV at 500 mL/hr. b. Infuse drotrecogin- (Xigris) 24 mcg/kg. c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to70 mm Hg.
a. Give normal saline IV at 500 mL/hr.
While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for a. additional fluid replacement .b. antibiotic administration. c. infusion of a sympathomimetic drug. d. administration of increased oxygen.
a. additional fluid replacement
A patient is treated in the emergency department (ED) for shock of unknown etiology.The first action by the nurse should be to a. administer oxygen. b. attach a cardiac monitor. c. obtain the blood pressure. d. check the level of consciousness.
a. administer oxygen. (ABCs)
When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the a. cardiac output is increased and the central venous pressure (CVP) is low .b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low. c. heart rate is decreased, and the systemic vascular resistance is low. d. cardiac output is decreased and the PAWP is high.
a. cardiac output is increased and the central venous pressure (CVP) is low
Which information about a patient who is receiving vasopressin (Pitressin) to treat septicshock is most important for the nurse to communicate to the heath care provider? a. The patient's heart rate is 108 beats/min. b. The patient is complaining of chest pain. c. The patient's peripheral pulses are weak. d. The patient's urine output is 15 mL/hr.
b. The patient is complaining of chest pain.
Norepinephrine (Levophed) has been ordered for the patient in shock. Before administering the drug, the nurse ensures that the a. patient's heart rate is less than 100. b. patient has received adequate fluid replacement .c. patient's urine output is within normal range. d. patient is not receiving other sympathomimetic drugs.
b. patient has received adequate fluid replacement
While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding a. cold, mottled extremities. b. restlessness and apprehension. c. a heart rate of 120 and cool, clammy skin. d. systolic BP less than 90 mm Hg.
b. restlessness and apprehension.
After receiving 1000 mL of normal saline, the central venous pressure for a patient whohas septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nursewill anticipate the administration of a. nitroglycerine (Tridil). b. drotrecogin alpha (Xigris). c. norepinephrine (Levophed). d. sodium nitroprusside (Nipride).
c. norepinephrine (Levophed).
The nurse is providing home care instruction to the client with cellulitis. Which statement, if made by the client, should concern the nurse? A. "I will keep all follow-up appointments with my healthcare provider ."B. "I will be sure to get enough rest and stay off my affected leg. "C. "I will take my antibiotics until the affected area looks less red. "D. "I will keep my affected leg elevated to keep swelling down."
"C. "I will take my antibiotics until the affected area looks less red.
A patient in septic shock is experiencing hyperglycemia. The patient is started on an insulin drip. A blood glucose goal for this patient would be: A. <110 mg/dL B. <80 mg/dL C. >200 mg/dL D. <180 mg/dL
D. <180 mg/dL
A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? A. Fungus B. Virus C. Parasite D. Bacteria
D. Bacteria
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is appropriate? Obtain wound cultures. Notify the health care provider. Document the assessment. Start IV antibiotics.
Document the assessment.
Which of the following is an indication for using corticosteroids in septic shock? (A) Acute respiratory distress syndrome (ARDS) (B) Necrotizing pneumonia (C) Peritonitis (D) Sepsis responding well to fluid resuscitation (E) Vasopressor-dependent septic shock
E) Vasopressor-dependent septic shock. An inappropriate cortisol response is not uncommon in patients with septic shock. Low-dose IV corticosteroids (hydrocortisone 200-300 mg/day) are recommended
A client is being admitted to the hospital for treatment of acute cellulitis of the right hand. During the admission assessment, the nurse expects to note which finding? Silver, scaly patch to right hand Xeroderma of the right hand Erythema to the right hand with sharp borders a white color to the hand that is insensitive to touch
Erythema to the right hand with sharp borders
True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. True False
False
The nurse is providing teaching to a client regarding the prevention of cancer. Which statement by the client indicates teaching has been effective? Select all that apply. I will stop smoking and vaping. I will schedule regular appointments with my doctor. I will exercise daily to help myself lose extra weight. I will limit my alcohol to 3 drinks everyday.
I will stop smoking and vaping. I will schedule regular appointments with my doctor. I will exercise daily to help myself lose extra weight.
Which statement made by a parent indicates an understanding about the management of a child with cellulitis on the arm? "I am supposed to continue the antibiotic until the redness and swelling disappear." "I have been putting ice on my son's arm to relieve the swelling." "I should call the doctor if the redness disappears." "I have been putting a warm soak on my son's arm every 4 hours."
"I have been putting a warm soak on my son's arm every 4 hours."
A client is admitted with cellulitis. Which manifestation should the nurse monitor? (Select all that apply.) A. Fever B. Chills C. Itching D. Headache E. Malaise
A. Fever B. Chills D. Headache E. Malaise
The nurse is teaching the parents of a 9-month-old client with respiratory syncytial virus (RSV) about ways to help the child recover quickly from the disorder. Which information should the nurse include? (Select all that apply.) A. Provide frequent, small meals throughout the day. B. Use a bulb syringe to clear the nose before giving a bottle. C. Help the child to blow the nose to clear the airway. D. Wash hands thoroughly after caring for the child. E. Permit the child to rest and nap throughout the day.
A. Provide frequent, small meals throughout the day. B. Use a bulb syringe to clear the nose before giving a bottle. E. Permit the child to rest and nap throughout the day.
The mother of a pediatric client diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV) is upset to learn that the child will be admitted to a semi-private room. Which explanation by the nurse is appropriate regarding this room assignment? A. "RSV is not contagious, so the roommate will not contract the illness." B. "The children will have companionship when the parents are not able to visit." C. "RSV is contagious. However, placing two children with the same illness together is permissible." D. "The nurse can provide care to both children at the same time."
C. "RSV is contagious. However, placing two children with the same illness together is permissible."
The nurse would recognize which clinical manifestation as suggestive of sepsis? a- Sudden diuresis unrelated to drug therapy b- Hyperglycemia in the absence of diabetes c-Respiratory rate of seven breaths per minute d-Bradycardia with sudden increase in blood pressure
b- Hyperglycemia in the absence of diabetes
When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusionto treat shock, which finding indicates that the medication is effective? a. No heart murmur is audible. b. Skin is warm, pink, and dry. c. Troponin level is decreased. d. Blood pressure is 90/40 mm Hg.
b. Skin is warm, pink, and dry.
The nurse understands that RSV usually causes the respiratory infection: bronchiolitis laryngitis pharyngitis No answer text provided.
bronchiolitis
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).
The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy? a. The patient is restless and anxious. b. The patient has a heart rate of 134. c. The patient has hypotonic bowel sounds. d. The patient has a temperature of 94.1° F.
d. The patient has a temperature of 94.1° F.
The nurse is assigned to a client who has a draining sacral wound infected by MRSA. Which personal protective equipment (PPE) is included for contact precautions? 1. Gloves2. Goggles3. Gown4. N95 respirator5. Surgical mask6. Shoe covers 1 and 3 1, 2, and 3 1, 2, and 6 3, 4, and 5 1, 2, 3, 4, 5, and 6
1 and 3
Medical management of septic shock includes all of the following except: A. Administration of colloids. B. Administration of Drotrecogin alfa. C. Aggressive fluid resuscitation. D. Aggressive nutritional supplementation.
A. Administration of colloids.
The nurse is performing a health history for a new client in the clinic. Which should the nurse identify as a risk factor for cellulitis in an adult? (Select all that apply.) A. Peripheral vascular disease B. Hypertension C. Obesity D. Diabetes mellitus E. Impetigo
A. Peripheral vascular disease C. Obesity D. Diabetes mellitus
The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor? Age younger than 50 years History of colorectal polyps Family history of colorectal cancer Chronic inflammatory bowel disease
Age younger than 50 years
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first? Chest x-ray via stretcher Blood cultures from two sites Ciprofloxacin (Cipro) 400 mg IV Acetaminophen (Tylenol) suppository
Blood cultures from two sites
What age group is the most susceptible to sepsis? A. Infants .B. Adolescents. C. Elderly. D. Young adults.
C. Elderly.
The main goal of treating septic shock is: A. Preserving the myocardium .B. Restoring adequate fluid status. C. Identification and elimination of the cause of infection. D. Identification and elimination of the cause of allergy.
C. Identification and elimination of the cause of infection.
The nursing student is talking with an client on the medical-surgical floor, who states "I have no family history of cancer, how did this happen?" The nursing student understands that: Family history is the biggest risk factor for cancer. Cancer is most common in younger adults. Cancer can affect all individuals, regardless of age, gender, race, or socioeconomic status. Modifiable risk factors include age and family history.
Cancer can affect all individuals, regardless of age, gender, race, or socioeconomic status.
Patients receiving fluid replacement therapy should be frequently monitored for: A. Adequate urinary output .B. Changes in mental status. C. Vital sign stability. D. All of the above.
D. All of the above.
Physiologic responses to all types of shock include the following except: A. Activation of the inflammatory system. B. Activation of the coagulation system. C. Hypoperfusion of tissues. D. Vasoconstriction.
D. Vasoconstriction.
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 healthcare provider? Petechiae noted on chest and legs· Crackles heard bilaterally in lung bases· No redness or swelling at central line IV site· Blood urea nitrogen (BUN) 34 mg/dL· Hematocrit 30%· Platelets 50,000/µL· 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 Temperature and IV site appearance Oxygen saturation and breath sounds Platelet count and present of petechiae blood pressure, pulse rate, and respiratory rate
Platelet count and present of petechiae
The nurse knows that which of the following patients is at the most risk for complications of RSV: The 16 month old with a family history of asthma. The 4 month old with a history of hip dysplasia. The 3 month old who was born at 29 weeks gestation. The 9 month old who attends daycare full-time.
The 3 month old who was born at 29 weeks gestation.
Norepinephrine (Levophed) has been prescribed for a patient who was admitted withdehydration and hypotension. Which patient information indicates that the nurse shouldconsult with the health care provider before administration of the norepinephrine? a. The patient's central venous pressure is 3 mm Hg. b. The patient is receiving low dose dopamine (Intropin). c. The patient is in sinus tachycardia at 100 to 110 beats/min. d. The patient has had no urine output since being admitted.
a. The patient's central venous pressure is 3 mm Hg. (must raise CVP before a pressor can be given)
A mother reports that her child is not eating since being diagnosed with respiratory syncytial virus (RSV) a week ago. Which manifestation should the nurse assess for next? A. Insomnia B. Rapid breathing C. Nausea D. Hyperactive bowel sounds
B. Rapid breathing
The nurse collects a drainage sample to be cultured from the affected area of a client with cellulitis. Which organism should the nurse suspect is the most likely cause of the cellulitis? A. Escherichia coli B. Staphylococcus aureus C. Bacillus subtilis D. Group A Streptococcus
B. Staphylococcus aureus
A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: A. Absolute hypovolemia B. Vasodilation C. Increased capillary permeability D. Increased systemic vascular resistance E. Clot formation in microcirculation
B. Vasodilation C. Increased capillary permeability E. Clot formation in microcirculation
A patient with a fever is lethargic and has a blood pressure of 89/56. The patient's white blood cell count is elevated. The physician suspects the patient is developing septic shock. What other findings indicate this patient is in the "early" or "compensated" stage of septic shock? Select all that apply: A. Urinary output of 60 mL over 4 hours B. Warm and flushed skin C. Tachycardia D. Bradypnea
B. Warm and flushed skin C. Tachycardia
A patient is diagnosed with septic shock. As the nurse you know this is a __________ form of shock. In addition, you're aware that __________ and _________ are also this form of shock. A. obstructive; hypovolemic and anaphylactic B. distributive; anaphylactic and neurogenic C. obstructive; cardiogenic and neurogenic D. distributive; anaphylactic and cardiogenic
B. distributive; anaphylactic and neurogenic
The nurse is teaching a client with cellulitis about home care measures to increase comfort. Which instruction should the nurse provide? (Select all that apply.) A. "Apply ice packs to the affected area to reduce edema. "B. "Apply sterile saline dressings to the affected area to promote drainage. "C. "Keep the affected area below the level of the heart to promote circulation "D. "Wash hands thoroughly before touching the affected area. "E. "Get enough rest."
B. "Apply sterile saline dressings to the affected area to promote drainage. "D. "Wash hands thoroughly before touching the affected area. "E. "Get enough rest."
You're providing care to four patients. Select all the patients who are at risk for developing sepsis: A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
A. A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place. B. A 55-year-old male who is a recent kidney transplant recipient. C. A 78-year-old female with diabetes mellitus who is recovering from colon surgery. D. A 65-year-old male recovering from right lobectomy for treatment of lung cancer.
A 70-year-old man presents to the emergency department with a 2-day history of fever, chills, cough, and right-sided pleuritic chest pain. On the day of admission, the patient's family noted that he was more lethargic and dizzy and was falling frequently. The patient's vital signs are: temperature, 101.5°F; heart rate, 120 bpm; respiratory rate, 30 breaths/min; blood pressure, 70/35 mm Hg; and oxygen saturation as measured by pulse oximetry, 80% without oxygen supplementation. A chest radiograph shows a right lower lobe infiltrate.This patient's condition can best be defined as which of the following? (A) Multi-organ dysfunction syndrome (MODS) (B) Sepsis (C) Septic shock (D) Severe sepsis (E) Systemic inflammatory response syndrome(SIRS)
(D) Severe sepsis
A patient is on IV Norepinephrine for treatment of septic shock. Which statement is FALSE about this medication? A. "The nurse should titrate this medication to maintain a MAP of 65 mmHg or greater." B. "This medication causes vasodilation and decreases systemic vascular resistance." C. "It is used when fluid replacement is not unsuccessful." D. "It is considered a vasopressor."
B. "This medication causes vasodilation and decreases systemic vascular resistance."
The nurse is creating a care plan for a client hospitalized for treatment of cellulitis. The cellulitis does not seem to be responding to the antibiotic therapy. Which risk requiring monitoring secondary to this issue should the nurse include in the care plan? (Select all that apply.) A. Seizures B. Arthritis C. Serious systemic infection D. Renal failure E. Osteomyelitis
B. Arthritis C. Serious systemic infection E. Osteomyelitis
The nurse is caring for an infant who is recovering from bronchiolitis. The parents ask if there will be any future risk for the child. Which condition should the nurse describe? A. Decreased lung capacity B. Asthma C. Chronic respiratory infections D. Chronic obstructive pulmonary disease (COPD)
B. Asthma
Your patient, who is post-op from a kidney transplant, has developed septic shock. Which statement below best reflects the interventions you will perform for this patient? A. Administer Norepinephrine before attempting a fluid resuscitation. B. Collect cultures and then administer IV antibiotics. C. Check blood glucose levels before starting any other treatments. D. Administer Drotrecogin Alpha within 48-72 hours.
B. Collect cultures and then administer IV antibiotics.
. Your patient's blood pressure is 72/56, heart rate 126, and respiration 24. The patient has a fungal infection in the lungs. The patient also has a fever, warm/flushed skin, and is restless. You notify the physician who suspects septic shock. You anticipate that the physician will order what treatment FIRST? A. Low-dose corticosteroids B. Crystalloids IV fluid bolus C. Norepinephrine D. 2 units of Packed Red Blood Cells
B. Crystalloids IV fluid bolus
A client presents to the healthcare provider's office with cellulitis on the lower leg. Other than the inflammation of the leg, the client has no other symptoms. To determine the causative organism, the nurse anticipates an order for which test? A. WBC count B. Drainage culture C. RBC count D. Blood culture
B. Drainage culture
The nurse is discussing with a parent the signs of dehydration to look for in a child with respiratory syncytial virus (RSV). Which manifestation should the nurse include? (Select all that apply.) A. Bluish tint to skin B. Poor skin elasticity C. Decreased urinary output D. Dry mucous membranes E. Labored cough
B. Poor skin elasticity C. Decreased urinary output D. Dry mucous membranes (A&E deal with oxygenation not hydration status)
The nurse is examining a child with bronchiolitis. Which symptom should the nurse interpret as a sign of dehydration? (Select all that apply.) A. Intercostal muscle retractions B. Weak peripheral pulses C. Decreased urine output D. Dry, sticky mucous membranes E. Delayed capillary refill
B. Weak peripheral pulses C. Decreased urine output D. Dry, sticky mucous membranes E. Delayed capillary refill
The family of a client with cellulitis admitted for treatment with systemic antibiotics asks the nurse when they can expect to see improvement. Which response by the nurse provides the best information? A. "It is hard to say because we are also giving them analgesics, which can make it seem like they are better, even though they aren't." B. "Recovery will usually begin within 48 hours of beginning the antibiotics." C. "Clients generally start to feel better and show signs of recovery within 24 hours of starting antibiotics." D. "Because of the need for systemic antibiotics, you will likely not see progress for 5 to 7 days."
B. "Recovery will usually begin within 48 hours of beginning the antibiotics."
The nurse is preparing a plan of care for an infant diagnosed with acute bronchiolitis due to respiratory syncytial virus (RSV). Which nursing diagnosis should the nurse select to guide this infant's care? A. Cardiac Output, Decreased B. Pain Response, Impaired C. Activity Intolerance D. Urinary Elimination, Impaired
C. Activity Intolerance
The nurse is speaking with a parent who is sharing that her child has not been eating well at home since being sick with respiratory syncytial virus (RSV). Which should be the reason for consulting with a dietitian to work with this family? (Select all that apply.) A. Provide healthy snacks. B. Place a nasogastric tube. C. Assess fluid intake. D. Discuss the importance of frequent, small meals. E. Assess the caloric intake.
C. Assess fluid intake. D. Discuss the importance of frequent, small meals. E. Assess the caloric intake.
The nurse is performing a health history on a client with cellulitis that developed from a hand wound. Which factor will help determine the organism responsible for the cellulitis? (Select all that apply.) A. Current medications B. History of cellulitis C. Cause of wound D. Wound exposure to contaminated water E. History of diabetes
C. Cause of wound D. Wound exposure to contaminated water
The nurse is caring for an infant with bronchiolitis. Which situation should the nurse identify that nebulized epinephrine may be indicated? A. Treatment for nasal airway clearance B. Rescue treatment for coughing C. Rescue treatment for severe bronchiolitis D. Treatment for anorexia associated with bronchiolitis
C. Rescue treatment for severe bronchiolitis
A parent tells the nurse "When my older child had RSV years ago, the doctor prescribed a bronchodilator. Why has my child not been prescribed one this time?" When describing why bronchodilators are no longer routinely prescribed, which side effect of bronchodilators should the nurse describe? A. Muscle cramps B. Dehydration C. Tachycardia D. Increases blood pressure
C. Tachycardia
A 68-year-old client is brought to the emergency department after a mental status change in the nursing home. The client is demonstrating signs of septic secondary to Urosepsis. Which of the following types of fluids would be most appropriate to administer initially during the resuscitation period? Lactated Ringer's D10W ½ NS with potassium D5 NS
Lactated Ringer's
As an oncological nurse, you know what finding is correct regarding breast cancer? Masses are usually felt in the upper outer quadrant beneath the nipple or axilla. Women who've had a late menarche and early menopause are at risk for breast cancer. Nipple retraction is never present. The mass is typically painful and red.
Masses are usually felt in the upper outer quadrant beneath the nipple or axilla.
The nurse is receiving a client who will be having chemotherapy and radiation for his tumor. Which of these will the nurse need to implement for this client? Offer foods high in sugar. Limit time with patient by clustering care for 30 minutes only per shift. Keep the head of the bed elevated. Monitor and educate visitors to not visit while ill.
Monitor and educate visitors to not visit while ill.
The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? Initiate strict enteric precautions. Move the infant to a private room. Leave the infant in the present room, because RSV is not contagious. Inform the staff that using standard precautions is all that is necessary when caring for the child.
Move the infant to a private room.
The nurse is getting report on a newly admitted 12 month old with a diagnosis of RSV bronchiolitis and poor PO intake, the patient also has a history of frequent upper respiratory infections (URIs). The nurse anticipates which of the following orders: Rocephin IV 25mg/kg/dose x3 days Prednisolone PO 1mg/kg q 24 hours NS 0.9% 20mg/kg over 30 minutes for rehydration Racepinephrine 2.25% (0.5ml ) nebulized
NS 0.9% 20mg/kg over 30 minutes for rehydration
A patient with an open leg lesion has a white blood cell (WBC) count of 13,500/µL and a band count of 11%. What prescribed action should the nurse take first? Obtain cultures of the wound. Redress the wound with wet-to-dry dressings Continue to monitor the wound for drainage. Begin antibiotic administration.
Obtain cultures of the wound.
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? Give the scheduled IV antibiotic. Give the PRN acetaminophen (Tylenol). Obtain oxygen saturation using pulse oximetry. Notify the health care provider of the patient's vital signs.
Obtain oxygen saturation using pulse oximetry.
The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention? Restraining the infant to prevent dislodging of tubes Placing small toys in the crib to provide stimulation for the infant Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization Keeping the infant as quiet as possible.
Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization
You are caring for a 4 month old infant on day 3 of admission for RSV bronchiolitis. What assessments concerns you the MOST? Respirations 14 breaths per minute Wet diaper 4 hours ago No food intake in 18 hours Mild intercostal retraction noted.
Respirations 14 breaths per minute
When caring for a patient with septic shock, which assessment finding is most important for the nurse to report to the health care provider? Skin cool and clammy BP 92/56 mm Hg Apical pulse 118 beats/min Skin warm and dry
Skin cool and clammy
nurse plans a community education program related to prevention of the cancer with the highest death rates in both women and men. What should the nurse include in the teaching plan? Screening with colonoscopy Smoking cessation Screening with breast biopsy Regular examination of reproductive organs
Smoking cessation