Quiz 2 Passpoint

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

hypovolemic

A client suddenly loses consciousness. What should the nurse do first?

Assess for responsiveness

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

blood chemistry of serum lactate

The nurse receives shift hand-off on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply.

temperature increase BP decrease 32ml of urine in 2 hours tachypnea

The nurse on the medical unit is caring for an 86-year-old female client admitted from assisted living facility with fatigue, fever, dyspnea, and increased sputum production.

the client is at highest risk for developing sepsis AEB BP and RR

A client with sepsis and hypotension is being treated with dopamine. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine in 250 ml, the infusion pump is running at 23 mL/hour, and the client weighs 79.5 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using two decimal places.

7.71

A client presents with severe headache, blurred vision, anxiety and confusion. The client's blood pressure is 224/137 mm Hg. The family reports that the client has hypertension, but has not been taking the prescribed blood pressure medications. The nurse anticipates giving which medication?

Labetalol

A client is admitted with a spinal cord injury at level C3. The nurse notes a heart rate of 50 beat/minute and a blood pressure of 90/60 mmHg. What is the nurse's priority action?

Administer rapid infusion of intravenous fluids

A nurse administers an I.V. antihypertensive medication to a client with a blood pressure (BP) reading of 210/120 mm Hg, a mean arterial pressure (MAP) of 150 mm Hg, sudden vomiting, and severe headache. What is an appropriate outcome for treatment?

MAP 115 in 1 hour

A nurse is assessing a client with suspected cardiac tamponade. How should the nurse assess the client for pulsus paradoxus?

Measure the blood pressure in either arm as the client slowly exhales and then as the client breathes normally.

Following a coronary artery bypass graft (CABG), a client reports chest "fullness," anxiety, and dizziness. Vital signs are pulse 108, respirations 24, and blood pressure 94/62mmHg on inhalation, and 108/70mmHg on expiration. The nurse prints a lead II electrocardiogram (ECG) strip for interpretation and identifies an amplitude decrease in the QRS complex. What intervention would have the highest priority?

Prepare the client for emergency pericardiocentesis

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

mean arterial pressure less than 70 mmHg

A nurse is monitoring a client for manifestations of cardiac tamponade. Which findings would support this diagnosis? Select all that apply.

restlessness muffled heart sounds distended neck veins

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

shock

The nurse is evaluating a hemodynamically unstable client with an arterial line and notes that the client has tachycardia, cool and clammy skin, a pericardial friction rub, and the arterial waveform shows an inspiratory systolic pressure that is 15 mm Hg less than the expiratory systolic pressure. What is the priority intervention by the nurse?

Contact the health care provider

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

acute respiratory distress syndrome pneumonia pulmonary edema

The nurse is caring for a client with suspected sepsis. A new prescription for ceftriaxone is entered on the medication administration as due daily at 1000. It is currently 2200. When should the nurse administer the first dose of ceftriaxone?

as soon as it becomes available on the unit

The nurse is assessing a client who has had a myocardial infarction (MI). The nurse notes the cardiac rhythm on the monitor (see the electrocardiogram [ECG] strip). What should the nurse do first?

assess the client for changes in rhythm

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm?

cardiac tamponade

The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The health care provider prescribes tranylcypromine sulfate because the client did not respond positively to a tricyclic antidepressant. If the client's diet includes foods containing tyramine, the nurse should teach the client about which possible reaction?

hypertensive crisis

The male client presented to the emergency department via private vehicle holding right side and moaning in pain. Upon assessment, a 4.2 in (10.7 cm) penetrating wound is noted on the right side of the abdomen. Significant blood loss is noted on the blanket that was used to wrap the abdominal area.

hypovolemic shock -institute oxygen via rebreather mask -administer Ringer's lactate solution -monitor oxygen level -monitor I&O

A client with a history of myocardial infarction is admitted with shortness of breath, anxiety, and slight confusion. Assessment findings include a regular heart rate of 120 beats/minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 ml over the past hour. The nurse anticipates preparing the client for transfer to the intensive care unit and pulmonary artery catheter insertion because

the client is going into cardiogenic shock