practice questions for exam 3
Which behaviors would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain?
-slow performance and caution -impaired speech/language aphasias -awareness of deficits with depression and anxiety
a client with an infection is receiving vancomycin. Which laboratory blood test results would the nurse report?
BUN 30
When a norepi IV infusion is prescribed for a client in septic shock, which IV line would the nurse choose for the infusion?
PICC line
when a family member of a client with cardiogenic shock asks the nurse for more info about the condition, how would the nurse describe cardiogenic shock?
a failure of the circulatory pump
which change in the clients lab results indicated that the client is in septic shock?
an increased serum lactate level
which nursing intervention is the priority for a client with stroke who is transitioned from theED to other settings?
assess LOC
The nurse is assessing a client who has a head injury. Which movement of the clients arm after the nurse applies nailbed pressure would cause the most concern?
extending
which type of shock would the nurse suspect when a client is admitted to the ED after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 mm Hg to 60/40 mm Hg, and a heart rate increase from 82 bmp to 121 bmp?
hemorrhagic shock
which type of shock is associated with a ruptured abdominal aneursym?
hypovolemic shock
initally after a stroke, a clients pupils are equal and reactive to light. Later, the nurse assesses that the right pupil is reacting more slowly than the left and that the systolic BP is rising. Which complication would the nurse plan to address?
increased ICP
Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by A-fib and has been placed on anticoagulation therapy to prevent further stroke from occurring?
- wearing a medical alert bracelet -inititating bleeding precautions -refraining from estrogen therapy -obtaining routine prothrombin times -notifying providers of anticoagulation
When a client is admitted to the emergency department with a possible spinal cord injury, the nurse would monitor for which clinical manifestations of spinal shock?
-bradycardia -hypotension -urinary retention
which first line medication would the nurse use to treat anaphylactic reactions?
Epinephrine
which condition of a client with a hemorrhagic stroke resulting from a motor bike accident requires immediate attention?
body temp of 81.2 F
which client in the ICU would the nurse assess first?
client with increasingly labored respiratory effort after aspiration of gastric contents 2 days ago.
which therapeutic effect would the nurse expect to identify when mannitol is administered to a client?
decreased ICP
a HCP prescribed mannitol for a client with a head injury. Which mechanism of action is responsible for therapeutic effects of this medicaiton?
drawing fluid from brain cells into the bloodstream
the spouse of a client with an intracranial hemorrhage asks the nurse, "Why arent they administering an anticoagulant?" how will the nurse respond?
it is not advisable because bleeding will increase
A client has increased ICP and is unconscious with a heart rate of 60 bpm, RR 16, BP 142/64. The nurse reviews the treatment plan and questions which prescription?
morphine
Which condition would the nurse suspect in an ED client with C8 tetraplegia, BP of 80/40 mm Hg, pulse of 48 bpm, RR of 18?
neurogenic shock
which nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke?
place objects within the visual field
which intervention would the nurse perform first for the client admitted with a closed head injury and increased ICP?
place the head and neck in neutral alignment.
while assessing the airway patency of a client after a bomb blast, which intervention is mot appropriate when the nurse suspects the client has severe brain injury and gives the client a score of 7 using the GCS?
preparing for endotracheal intubation and mechanical ventilation
the nurse is assessing a client who had a bowel resection 4 hours ago. Which finding would the nurse identify as an early sign of shock?
restlessness
A client with a continuous IV heparin drip is prescribed IV vancomycin every 12 hours. Which action will the nurse take when it is time to administer the vancomycin?
start a second IV line for the vanco and continue heparin as prescribed
the nurse is caring for a client who has a traumatic brain injury with increased ICP. Which HCP prescription would the nurse question?
teach isometric exercises
a client who sustained a head injury from a fall off a ladder has clear fluid leaking from the left ear. Which action would the nurse take?
test the ear drainage with a glucose regent strip
the nurse is caring for a client with a brain injury who is often disoriented and agitated. Which interventions would the nurse include in the plan of care to decrease the risk for staff injury?
-daily routine -reality orientation -calendar and clocks -antipsychotic medication
which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock client immediately after sustaining a functional transection of the spinal cord at C7-C8?
-flaccid paralysis -lack of reflexes below the injury
Which medications are used to treat cerebral edema or decrease free water with submersion injuries in the ED?
-furosemide -mannitol
which assessment finding indicated that a client has had a stroke?
-lopsided smile -unilateral vision -incoherent speech -unable to raise right arm -symptoms started 2 hours ago
the nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary HCP prescriptions would the nurse do first?
draw peripheral blood cultures from two different sites
which acid-base imbalance would the nurse anticipate in a client in the progressive stage of shock?
metabolic acidosis
