Test 4 Questions

The client diagnosed with cardiogenic shock is receiving norepinephrine. Which priority interven<on should the nurse implement? 1. Do not abruptly discontinue the medica<on. 2. Administer medication on an infusion pump. 3. Check the client's creatinine and BUN levels. 4. Monitor the client's blood pressure continuously.

. Monitor the client's blood pressure continuously.

Which child may need extra fluids to prevent dehydration? Select all that apply. 1. A 7-day-old receiving phototherapy. 2. A 6-month-old with newly diagnosed pyloric stenosis. 3. A 2-year-old with pneumonia. 4. A 2-year-old with full-thickness burns to the chest, back, and abdomen. 5. A 13-year-old who has just started her menses.

1,2,3,4

Which assessment of an 18-month-old with burns on his feet would cause suspicion of child abuse? 1. Splash marks on his right lower leg. 2. Burns noted on right arm. 3. Symmetrical burns on both feet. 4. Burns mainly noted on right foot.

3. Symmetrical burns on both feet.

A client is to have a transfusion of packed red blood cells from a designated donor. The client asks if any diseases can be transmitted by this donor. The nurse should inform the client that which of the following diseases can be transmitted by a designated donor? Select all that apply. 1. Epstein-Barr virus. 2. Human immunodeficiency virus (HIV). 3. Cytomegalovirus (CMV). 4. Hepatitis A. 5. Malaria.

1. Epstein-Barr virus. 2. Human immunodeficiency virus (HIV). 3. Cytomegalovirus (CMV).

Which of the following is a risk factor for hypovolemic shock? 1. Hemorrhage. 2. Antigen-antibody reaction. 3. Gram-negative bacteria. 4. Vasodilation.

1. Hemorrhage.

A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings should the nurse monitor? 1. Serum creatinine. 2. Spinal fluid analysis. 3. Arterial blood gases. 4. Serum osmolality.

1. Serum creatinine.

Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate? 1. Urine output greater than 30 mL/h. 2. Systolic blood pressure greater than 110 mm Hg. 3. Diastolic blood pressure greater than 90 mm Hg. 4. Respiratory rate of 20 breaths/min.

1. Urine output greater than 30 mL/h.

The nurse receives shift handoff 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. 1. temperature increase 2. blood pressure decrease 3. 32ml of urine in 2hours 4. pulse rate of 32 beats per minute 5. tachypnea

1.2.3.5 1. temperature increase 2. blood pressure decrease 3. 32ml of urine in 2hours 5. tachypnea A client with sepsis (a systemic response to infection) can rapidly deteriorate into septic shock

A client is receiving dopamine hydrochloride for treatment of shock. The nurse should: 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. 3. Evaluate arterial blood gases at least every 2 hours. 4. Monitor for signs of infection.

2. Monitor blood pressure continuously.

Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply. 1. Verify that the ABO and Rh of the 2 units are the same. 2. Infuse a unit of PRBCs in less than 4 hours. 3. Stop the transfusion if a reaction occurs, but keep the line open. 4. Take vital signs every 15 minutes while the unit is transfusing. 5. Inspect the blood bag for leaks, abnormal color, and clots. 6. Use a 22-gauge catheter for optimal flow of a blood transfusion.

2, 3, 5

When a blood transfusion is terminated following a reaction, the nurse must do which of the following? Select all that apply. 1. Send freshly collected urine samples to the laboratory. 2. Return the remainder of the blood component unit to the blood bank. 3. Return the intravenous administration set to the blood bank. 4. Alert Risk Management about the incident. 5. Report the incident to the Infection Control Manager.

2,4,5

Which of the following is an indication of a complication of septic shock? 1. Anaphylaxis. 2. Acute respiratory distress syndrome (ARDS). 4. Mitral valve prolapse. 3. Chronic obstructive pulmonary disease (COPD).

2. Acute respiratory distress syndrome (ARDS).

A client who is receiving a blood transfusion begins to have difficulty breathing. The nurse notes an elevated blood pressure and a cough. Based on these signs, the nurse should prepare to manage which of the following complications? 1. Anaphylactic reaction. 2. Circulatory overload. 3. Sepsis. 4. Acute hemolytic reaction.

2. Circulatory overload.

A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next? 1. Administer prescribed antihistamine and aspirin. 2. Collect blood and urine samples and send to the lab. 3. Administer prescribed diuretics. 4. Administer prescribed vasopressors.

2. Collect blood and urine samples and send to the lab.

The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, the nurse should assess the client for: 1. Increased renal and mesenteric blood flow. 2. Increased cardiac output. 3. Vasoconstriction. 4. Reduced preload and afterload.

2. Increased cardiac output.

A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last? 1. Notify the attending physician and blood bank 2. Complete the appropriate transfusion reaction form 3. Stop the transfusion 4. keep the IV open with normal saline infusion

3,4,2,1 3. Stop the transfusion 4. Keep the IV open with normal saline infusion 1. Notify the attending physician and blood bank 2. Complete the appropriate transfusion reaction forms.

In a postoperative client, the hematocrit decreased from 36% (0.36) to 34% (0.34) on the third day even though the red blood cell (RBC) count and hemoglobin value remained stable at 4.5 million/ μL (4.5 × 1012/L) and 11.9 g/dL (119 g/L), respectively. The nurse should next: 1. Check the dressing and drains for frank bleeding. 2. Call the physician. 3. Continue to monitor vital signs. 4. Start oxygen at 2 L/min per nasal cannula.

3. Continue to monitor vital signs.

The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full- thickness burns. Which interventions should the nurse implement? List in order of priority. 1. Estimate the amount of burned area using the rule of nines. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 4. Determine the client's airway status. 5. Administer morphine sulfate, a narcotic analgesic, IV.

4,2,3,1,5

Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters.

4. Maintaining asepsis of indwelling urinary catheters.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? 1. Fluid balance. 2. Anaphylactic reaction. 3. Pain. 4. Altered level of consciousness.

Anaphylactic reaction.

Platelets should not be administered under which of the following conditions? 1. The platelet bag is cold. 2. The platelets are 2 days old. 3. The platelet bag is at room temperature. 4. The platelets are 12 hours old.

answer: 1 Platelets cannot survive cold temperatures. The platelets should be stored at room temperature and last for no more than 5 days.

The nurse is preparing to administer platelets. The nurse should: 1. Check the ABO compatibility. 2. Administer the platelets slowly. 3. Gently rotate the bag. 4. Use a whole blood tubing set.

answer: 3 The bag containing platelets needs to be gently rotated to prevent clumping.

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order should the nurse implement the following physician prescriptions? 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin k 2.5mg by mouth 3.Schedule client for sigmoidoscopy 4. Administer IV dextrose 5% in 0.45% normal saline

answer: 4, 1, 2, 3 4. Administer IV dextrose 5% in 0.45% normal saline 1. Give 1 unit fresh frozen plasma 2. Administer vitamin K 2.5 by mouth 3. Schedule client for sigmoidoscopy

A client has been admitted with active rectal bleeding, and has been typed and crossmatched for 2 units of packed red blood cells (RBCs). Within 10 minutes of admission, the client faints when getting up to go to the bedside commode. The nurse notifies the health care provider, who prescribes a unit of blood to be administered immediately. The nurse can safely administer which type of blood for immediate transfusion? 1. A negative. 2. B negative. 3. AB negative. 4. O negative.

4. O negative.

Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss? 1.Pulse rate less than 60 bpm. 2. Respiratory rate of 4 breaths/min. 3. Pupils unequally dilated. 4. Systolic blood pressure less than 90 mm Hg.

4. Systolic blood pressure less than 90 mm Hg.

When assessing a client for early septic shock, the nurse should assess the client for which of the following? 1. Cool, clammy skin. 2. Warm, flushed skin. 3. Increased blood pressure. 4. Hemorrhage.

2. Warm, flushed skin

Which of the following is the most important goal of nursing care for a client who is in shock? 1. Manage fluid overload. 2. Manage increased cardiac output. 3. Manage inadequate tissue perfusion. 4. Manage vasoconstriction of vascular beds.

3. Manage inadequate tissue perfusion.

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: 1. Discontinue the IV catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted central catheter line with a 20- gauge needle. 3. Flush PRBCs with 5% dextrose and 0.45% normal saline solution. 4. Stay with the client during the first 15 minutes of infusion.

4. Stay with the client during the first 15 minutes of infusion.