NURS 434 Exam 4 Study Questions
What assessment finding requires immediate intervention if found while a patient is receiving Mannitol? A. An ICP of 10 mmHg B. Crackles throughout lung fields C. BP 110/72 D. Patient complains of dry mouth and thirst
B
Which patient below is at MOST risk for increased intracranial pressure? A. A patient who is experiencing severe hypotension. B. A patient who is admitted with a traumatic brain injury. C. A patient who recently experienced a myocardial infarction. D. A patient post-op from eye surgery.
B
Which of the following signs and symptoms is NOT expected with Diabetes Insipidus? A. Polyuria B. Polydipsia C. Polyphagia D. Extreme thirst
C
Which patient below with ICP is experiencing Cushing's Triad? A patient with the following:* A. BP 150/112, HR 110, RR 8 B. BP 90/60, HR 80, RR 22 C. BP 200/60, HR 50, RR 8 D. BP 80/40, HR 49, RR 12
C
During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit
D
You're collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient's temperature? A. Rectal B. Oral C. Axillary
A
You're maintaining an external ventricular drain. The ICP readings should be?* A. 5 to 15 mmHg B. 20 to 35 mmHg C. 60 to 100 mmHg D. 5 to 25 mmHg
A
You're providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock?* A. Low central venous pressure B. High pulmonary artery wedge pressure C. Elevated mean arterial pressure D. Low systemic vascular resistance
A
________________ is the amount the ventricle stretches at the end of diastole. A. Preload B. Afterload C. Stroke Volume D. Contractility
A
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
A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs: A. Oxygen nasal cannula 5-6 Liters B. 100% oxygen via non-rebreather mask C. Continuous Bipap D. Venturi mask 6 L oxygen
B
A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication? A. Mannitol will remove water from the brain and place it in the blood to be removed from the body. B. Mannitol will cause water and electrolyte reabsorption in the renal tubules. C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion. D. Mannitol is not for patients who are experiencing anuria.
B
A patient is receiving large amounts of fluids for aggressive treatment of hypovolemic shock. The nurse makes it PRIORITY to? A. Rapidly infuse the fluids B. Warm the fluids C. Change tubing in between bags D. Keep the patient supine
B
Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.
B
A patient with cardiogenic shock has a blood pressure of 70/38. In addition, the patient is experiencing dyspnea with a respiratory rate of 32 breaths per minute and has an oxygen saturation of 82% on room air. On auscultation, you note crackles throughout the lung fields. You notify the physician. What order below would you ask for an order clarification? A. Dopamine IV stat B. Normal saline IV bolus stat C. Furosemide IV stat D. Place patient on CPAP (continuous positive airway pressure)
B
During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day
B
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr
A
A 45 year old female patient has superficial partial thickness burns on the posterior head and neck, front of the left arm, front and back of the right arm, posterior trunk, front and back of the left leg, and back of right leg. The patient weighs 91 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 22,932 mL B. 26,208 mL C. 16,380 mL D. 12,238 mL
A
A patient arrives to the ER and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly "water" weight. In addition, they report the patient hasn't been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient's HR is 115 and BP 180/92. Patient sodium level is 90. Which of the following conditions do you suspect the patient is most likely presenting with? A. SIADH B. Diabetes Insipidus C. Addison's Disease D. Fluid Volume Deficient
A
A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to: A. Elevate and extend the extremities B. Elevate and flex the extremities C. Keep extremities below heart level and extended D. Keep extremities level with the heart level and flexed
A
A patient has lost 750 mL of blood volume. The MD orders Normal Saline infusion. Using the 3:1 rule, how much crystalloid solution should be prescribed by the doctor? A. 2,250 mL of Normal Saline B. 250 mL of Normal Saline C. 375 mL of Normal Saline C. 1,225 mL of Normal Saline
A
A patient is 1 hour post-op from abdominal surgery and had lost 20% of their blood volume during surgery. The patient is experiencing signs and symptoms of hypovolemic shock. What position is best for this patient? A. Modified Trendelenburg B. Trendelenburg C. High Fowler's D. Supine
A
A patient is receiving treatment for an acute myocardial infarction. The nurse is closely monitoring the patient for signs and symptoms associated with cardiogenic shock. Which value below is associated with cardiogenic shock? A. Cardiac index 1.5 L/min/m2 B. Pulmonary capillary wedge pressure (PCWP) 10 mmHg C. Central venous pressure (CVP) 4 mmHg D. Troponin <0.01 ng/mL
A
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
Which of the following is contraindicated in a patient with increased ICP?* A. Lumbar puncture B. Midline position of the head C. Hyperosmotic diuretics D. Barbiturates medications
A
Which patient is most at risk for developing Syndrome of Inappropriate Anti-diuretic Hormone (SIADH)? A. A patient diagnosed with small cell lung cancer. B. A patient whose kidney tubules are failing to reabsorb water. C. A patient with a tumor on the anterior pituitary gland. D. A patient taking Declomycin.
A
You are developing a care plan for a patient with SIADH. Which of the following would be a potential nursing diagnosis for this patient?A. Fluid volume overload B. Fluid volume deficient C. Acute pain D. Impaired skin integrity
A
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 63% B. 81% C. 72% D. 54%
A Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.
What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition
A B
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 B C E
A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?* A. Coughing B. Sneezing C. Talking D. Valsalva maneuver E. Vomiting F. Keeping the head of the bed between 30- 35 degrees
A B D E
A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury? A. Carbonaceous sputum B. Hair singeing on the head and nose C. Lhermitte's Sign D. Bright red lips E. Hoarse voice F. Tachycardia
A B D E F
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 C
Select the main structures below that play a role with altering intracranial pressure: A. Brain B. Neurons C. Cerebrospinal Fluid D. Blood E. Periosteum F. Dura mater
A C D
You're developing a nursing plan of care for a patient with neurogenic shock. As the nurse, you know that due to venous blood pooling from vasodilation a deep vein thrombosis can occur in this type of shock. A patient goal is that the patient will be free from the development of a deep vein thrombosis. Select all the nursing interventions below that can help the patient meet this goal A. Perform range of motion exercises daily. B. Place a pillow underneath the patient knees as needed. C. Administer anticoagulants as scheduled per physician's order. D. Apply compression stockings daily.
A C D
You're providing an in-service to new nurse graduates on the fluid treatment for hypovolemic shock. You ask the participants to list the types of crystalloid solutions used in hypovolemic shock. Which responses are INCORRECT? Select all that apply: A. Albumin B. Lactated Ringer's C. Normal Saline D. Hetastarch
A D
Select all the signs and symptoms that occur with increased ICP:* A. Decorticate posturing B. Tachycardia C. Decrease in pulse pressure D. Cheyne-stokes E. Hemiplegia F. Decerebrate posturing
A D E F
You receive a patient in the ER who has sustained a cervical spinal cord injury. You know this patient is at risk for neurogenic shock. What hallmark signs and symptoms, if experienced by this patient, would indicate the patient is experiencing neurogenic shock? Select all that apply: A. Blood pressure 69/38 B. Heart rate 170 bpm C. Blood pressure 250/120 D. Heart rate 29 E. Warm and dry extremities F. Cool and clammy extremities G. Temperature 104.9 'F H. Temperature 95 'F
A D E H
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr
A The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr
During the assessment of a patient with increased ICP, you note that the patient's arms are extended straight out and toes pointed downward. You will document this as: A. Decorticate posturing B. Decerebrate posturing C. Flaccid posturing
B
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.
All of the above
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
External ventricular drains monitor ICP and are inserted where?* A. Subarachnoid space B. Lateral Ventricle C. Epidural space D. Right Ventricle
B
A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 46% B. 37% C. 36% D. 28%
B
A 29 year old male patient has superficial partial thickness burns on the anterior right arm, posterior left leg, and anterior head and neck. The patient weighs 78 kg. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 11,232 mL B. 5,616 mL C. 2,808 mL D. 16,848 mL
B
A 42-year-old male patient is admitted with a spinal cord injury. The patient is experiencing severe hypotension and bradycardia. The patient is diagnosed with neurogenic shock. Why is hypotension occurring in this patient with neurogenic shock?* A. The patient has an increased systemic vascular resistance. This increases preload and decreases afterload, which will cause severe hypotension. B. The patient's autonomic nervous system has lost the ability to regulate the diameter of the blood vessels and vasodilation is occurring. C. The patient's parasympathetic nervous system is being unopposed by the sympathetic nervous system, which leads to severe hypotension. D. The increase in capillary permeability has depleted the fluid volume in the intravascular system, which has led to severe hypotension.
B
A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management?* A. Emergent B. Acute C. Rehabilitative
B
A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful? A. The patient can move the extremity. B. The right foot's capillary refill is less than 2 seconds. C. The patient reports a new sensation of extreme pain. D. The patient has a positive babinski reflex.
B
A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? A. Patient heart rate is 115 bpm B. Patient experiences dyspnea and crackles in lung fields C. Patient is anxious D. Patient's urinary output is 35 mL/hr
B
A patient in neurogenic shock is ordered intravenous fluids due to severe hypotension. During administration of the fluids the nurse will monitor the patient closely and immediately report?* A. Increase in blood pressure B. High central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) C. Urinary output of 300 mL in the past 5 hours D. Mean arterial pressure (MAP) 85 mmHg
B
If a patient has a blood volume of 5 Liters and loses 2 Liters, what is the percentage amount of volume loss this patient has experienced?* A. 25% B. 40% C. 30% D. 10%
B
While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention? A. "He takes medication for glaucoma". B. "I think it has been 10 years or more since he had a tetanus shot." C. "He was told he had COPD last year." D. "He smokes 2 packs of cigarettes a day."
B
You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene? A. The nursing assistant elevates the head of the bed above 30 degrees. B. The nursing assistant places a pillow under the patient's head. C. The nursing assistant places rolled towels under the patient's shoulders. D. The nursing assistant covers the patient with sterile linens.
B
You're providing education to a group of local firefighters about carbon monoxide poisoning. Which statement is correct about the pathophysiology regarding this condition? A. "Patients are most likely to present with cyanosis around the lips and face." B. "In this condition, carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body." C. "Carbon monoxide poisoning leads to a hyperoxygenated state, which causes hypercapnia." D. "Carbon monoxide binds to the hemoglobin of the red blood cell and prevents the transport of carbon dioxide out of the blood, which leads to poisoning."
B
You're providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, "What is a normal cerebral perfusion pressure level?" Your response is:* A. 5-15 mmHg B. 60-100 mmHg C. 30-45 mmHg D. >160 mmHg
B
Your patient in neurogenic shock is not responding to IV fluids. The patient is started on vasopressors. What option below, if found in your patient, would indicate the medication is working? A. Decreased CVP (central venous pressure) B. Mean arterial pressure (MAP) 90 mmHg C. Serum lactate 6 mmol/L D. Blood pH 7.20
B
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
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
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 C
The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection
B C
You're working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A. A 36-year-old with a spinal cord injury at L4. B. A 42-year-old who has spinal anesthesia. C. A 25-year-old with a spinal cord injury above T6. D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.
B C
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 F. A significantly decreased cardiac output
B C E
A patient is being treated for cardiogenic shock. Which statement below best describes this condition? Select all that apply: A. "The patient will experience an increase in cardiac output due to an increase in preload and afterload." B. "A patient with this condition will experience decreased cardiac output and decreased tissue perfusion." C. "This condition occurs because the heart has an inadequate blood volume to pump." D. "Cardiogenic shock leads to pulmonary edema."
B D
The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply: A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord B. Vasodilation of cerebral vessels C. Decreasing cerebrospinal fluid production D. Leaking proteins into the brain barrier
B D
You're caring for a patient with cardiogenic shock. Which finding below suggests the patient's condition is worsening? Select all that apply: A. Blood pressure 95/68 B. Urinary output 20 mL/hr C. Cardiac Index 3.2 L/min/m2 D. Pulmonary artery wedge pressure 30 mmHg
B D
A patient has a 10% loss of their blood volume. Select all the signs and symptoms this patient may present with? A. Cool, clammy skin B. Blood pressure within normal limits C. Anxiety D. Capillary refill less than 2 seconds E. Urinary output greater than 30 mL/hr F. Mild tachycardia
B D E
Select all the conditions below that increases a patient's risk for absolute hypovolemic shock: A. Burns B. Vomiting C. Long bone fracture D. Surgery E. Diarrhea F. Sepsis
B D E
You're assessing your patient with cardiogenic shock, what signs and symptoms do you expect to find in this condition? Select all that apply: A. Warm, flushed skin B. Prolonged capillary refill C. Urinary output >30 mL/hr D. Systolic blood pressure <90 mmHg E. Crackles in lung fields F. Dyspnea D. Decreased BUN and creatinine G. Strong peripheral pulses H. Chest pain
B D E F H
Select all the fluid types below that are considered colloids? A. Fresh Frozen Plasma B. Albumin C. Normal Saline D. Lactated Ringer's E. Hetastarch F. Platelets
B E
A 30 year old female patient has deep partial thickness burns on the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. The patient weighs 150 lbs. Use the Parkland Burn Formula to calculate the total amount of Lactated Ringers that will be given over the next 24 hours? A. 14,960 mL B. 12,512 mL C. 10,064 mL D. 16,896 mL
C
A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient's vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 'F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? A. Collect a urine sample B. Obtain an EKG C. Establish 2 large-bore IV access sites D. Place a warming blanket on the patient
C
A 68 year old male patient has partial thickness burns to the front and back of the right and left leg, front of right arm, and anterior trunk. Using the Rule of Nines, calculate the total body surface area percentage that is burned? A. 40.5% B. 49.5% C. 58.5% D. 67.5%
C
A patient has a ventriculostomy. Which finding would you immediately report to the doctor A. Temperature 98.4 'F B. CPP 70 mmHg C. ICP 24 mmHg D. PaCO2 35
C
A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?* A. cause vasoconstriction and decrease the ICP B. promote diuresis and decrease the ICP C. cause vasodilation and increase the ICP D. cause vasodilation and decrease the ICP
C
A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication? A. Bradycardia B. Decerebrate posturing C. Restlessness D. Unequal pupil size
C
A patient who has cardiogenic shock is experiencing labored breathing and low oxygen levels. A STAT chest x-ray is ordered. The x-ray results show pulmonary edema. The physician orders Furosemide IV. What finding would require immediate nursing action? A. Blood pressure 98/54 B. Urinary output 45 mL/hr C. Potassium 1.8 mEq/L D. Heart rate 110 bpm
C
A patient who is experiencing hypovolemic shock has decreased cardiac output, which contributes to ineffective tissue perfusion. The decrease in cardiac output occurs due to? A. An increase in cardiac preload B. An increase in stroke volume C. A decrease in cardiac preload D. A decrease in cardiac contractility
C
A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 'F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?* A. Administered PRN dose of a vasopressor B. Administer 2 L of oxygen C. Remove extra blankets and give the patient a cool bath D. Perform suctioning
C
A patient with neurogenic shock is experiencing a heart rate of 30 bpm. What medication does the nurse anticipate will be ordered by the physician STAT? A. Adenosine B. Warfarin C. Atropine D. Norepinephrine
C
As the nurse you know that in order for hypovolemic shock to occur the patient would need to lose __________ of their blood volume.* A. <30% B. >25% C. >15% D. >10%
C
The anti-diuretic hormone is __________ in Diabetes Insipidus and _________ in SIADH. A. high, low B. absent, absent C. low, high D. low, low
C
The patient with hypovolemic shock is in need of clotting factors. Which type of fluid would best benefit this patient? A. Platelets B. Albumin C. Fresh Frozen Plasma D. Packed Red Blood Cells
C
They physician orders a Dobutamine IV drip on a patient in cardiogenic shock. After starting the IV drip, the nurse would make it priority to monitor for? A. Rebound hypertension B. Ringing in the ears C. Worsening hypotension D. Severe headache
C
Where is the anti-diuretic hormone PRODUCED in the body? A. Anterior pituitary gland B. Posterior pituitary gland C. Hypothalamus D. Medulla
C
Where is the anti-diuretic hormone SECRETED in the body?A. Hypothalamus B. Thyroid C. Posterior Pituitary gland D. Anterior pituitary gland
C
You're providing care to a patient experiencing neurogenic shock due to an injury at T4. As the nurse, you know which of the following is a patient safety priority? A. Keeping the head of the bed greater than 45 degrees at all times. B. Repositioning the patient every thirty minutes. C. Keeping the patient's spine immobilized. D. Avoiding log-rolling the patient during transport.
C
Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for all the medications below. Which medication is best for this patient? A. IM morphine B. PO morphine C. IV morphine D. Subq morphine
C
One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply: A. Temperature 104.8 'F B. Heart rate 40 bpm C. Heart rate 140 bpm D. Anxiety, restlessness E. Urinary output 15 mL/hr F. Blood pressure 70/56 G. Pale, cool skin H. Weak peripheral pulses I. Blood pressure 220/106
C D E F G H
Which medications below are used in cardiogenic shock that provide a positive inotropic effect on the heart? Select all that apply: A. Nitroglycerin B. Sodium Nitroprussidde C. Dobutamine D. Norepinephrine E. Dopamine
C E
A 59 year old male patient has full thickness burns on both of the legs on the back, front and back of the trunk, both arms on the front and back, and front and back of the head and neck. The patient weighs 186 lbs. Use the Parkland Burn Formula: You've already infused fluids during the first 8 hours. Now what will you set the flow rate during the next 16 hours (mL/hr) based on the total you calculated? A. 563 mL/hr B. 854 mL/hr C. 289 mL/hr D. 861 mL/hr
D
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
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
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
During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find? A. The eyes will roll down as the head is moved side to side. B. The eyes will move in the opposite direction as the head is moved side to side. C. The eyes will roll back as the head is moved side to side. D. The eyes will be in a fixed mid-line position as the head is moved side to side.
D
Which patient below is at MOST risk for developing cardiogenic shock?* A. A 52-year-old male who is experiencing a severe allergic reaction from shellfish. B. A 25-year-old female who has experienced an upper thoracic spinal cord injury. C. A 72-year-old male who is post-op from a liver transplant. D. A 49-year-old female who is experiencing an acute myocardial infarction.
D
While positioning a patient in bed with increased ICP, it important to avoid? A. Midline positioning of the head B. Placing the HOB at 30-35 degrees C. Preventing flexion of the neck D. Flexion of the hips
D
True or False: A patient with acute pancreatitis is presenting with Turner and Cullen's Sign. This patient is at risk for absolute hypovolemic shock.
False
True or False: Hypovolemic shock occurs where there is low fluid volume in the interstitial compartment
False
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.
False
True or False: The parasympathetic nervous system loses the ability to stimulate nerve impulses in patients who are experiencing neurogenic shock. This leads to hemodynamic changes.
False
