NCLEX Style Questions for Exam 4

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1.The neurovascular status is normal because of increased blood flow through the leg. 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.

1. An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Cardiovascular Strategy(s): Subject Priority Concepts: Clinical Judgment, Perfusion

The health care provider prescribes bedrest for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? Select all that apply. 1.Place in Fowler's position for eating. 2.Encourage coughing with deep breathing. 3.Encourage increased oral intake of water daily. 4.Place thigh-length elastic stockings on the client. 5.Place sequential compression boots on the client. 6.Encourage the intake of dark green, leafy vegetables.

2,3,4. The client with DVT may require bedrest to prevent embolization of the thrombus resulting from skeletal muscle action, anticoagulation to prevent thrombus extension and allow for thrombus autodigestion, fluids for hemodilution and to decrease blood viscosity, and elastic stockings to reduce peripheral edema and promote venous return. While the client is on bedrest, the nurse prevents complications of immobility by encouraging coughing and deep breathing. Venous return is important to maintain because it is a contributing factor in DVT, so the nurse maintains venous return from the lower extremities by avoiding hip flexion, which occurs with Fowler's position. The nurse avoids providing foods rich in vitamin K, such as dark green, leafy vegetables, because this vitamin can interfere with anticoagulation, thereby increasing the risk of additional thrombi and emboli. The nurse also would not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action and can disrupt an existing thrombus, leading to pulmonary embolism. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Strategy(s): Subject Priority Concepts: Clotting, Safety

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1.Keep the legs aligned with the heart. 2.Elevate the legs higher than the heart. 3.Clean the skin with alcohol every hour. 4.Position the client onto the side every shift.

2. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention. Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Adult Health: Cardiovascular Strategy(s): Strategic Words Priority Concepts: Infection, Perfusion

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? 1.Bilateral edema 2.Increased calf circumference 3.Diminished distal peripheral pulses 4.Coolness and pallor of the affected limb

2. The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and increased calf circumference in the affected extremity. Peripheral pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication. Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Assessment Content Area: Adult Health: Cardiovascular Strategy(s): Strategic Words, Subject Priority Concepts: Clinical Judgment, Perfusion

Which action will the nurse include in the plan of care for a 72-year-old woman admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

ANS: A A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.

An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.

ANS: A Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

ANS: A Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

Which information obtained by the nurse assessing a patient admitted with multiple myeloma is most important to report to the health care provider? a. Serum calcium level is 15 mg/dL. b. Patient reports no stool for 5 days. c. Urine sample has Bence-Jones protein. d. Patient is complaining of severe back pain.

ANS: A Hypercalcemia may lead to complications such as dysrhythmias or seizures, and should be addressed quickly. The other patient findings will also be discussed with the health care provider, but are not life threatening.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate? a. "I will call my health care provider if my stools turn black." b. "I will take a stool softener if I feel constipated occasionally." c. "I should take the iron with orange juice about an hour before eating." d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia? a. A patient with chronic heart failure b. A patient who has viral pneumonia c. A patient who has right leg cellulitis d. A patient with multiple abdominal drains

ANS: A Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/μL. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site.

ANS: A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/μL unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

The nurse caring for a patient with type A hemophilia being admitted to the hospital with severe pain and swelling in the right knee will a. immobilize the joint. b. apply heat to the knee. c. assist the patient with light weight bearing. d. perform passive range of motion to the knee.

ANS: A The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started.

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider? a. Neutropenia b. Increasing fatigue c. Thrombocytopenia d. Frequent constipation

ANS: A The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

ANS: A - There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

Which patient requires the most rapid assessment and care by the emergency department nurse? a. The patient with hemochromatosis who reports abdominal pain b. The patient with neutropenia who has a temperature of 101.8° F c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours d. The patient with thrombocytopenia who has oozing after having a tooth extracted

ANS: B A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

After receiving change-of-shift report for several patients with neutropenia, which patient should the nurse assess first? a. 56-year-old with frequent explosive diarrhea b. 33-year-old with a fever of 100.8° F (38.2° C) c. 66-year-old who has white pharyngeal lesions d. 23-year old who is complaining of severe fatigue

ANS: B Any fever in a neutropenic patient indicates infection and can quickly lead to sepsis and septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1 hour are needed. The other patients also need to be assessed but do not exhibit symptoms of potentially life-threatening problems.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia? a. Potential complication: seizures b. Potential complication: infection c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema.

A routine complete blood count indicates that an active 80-year-old man may have myelodysplastic syndrome. The nurse will plan to teach the patient about a. blood transfusion b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration.

ANS: B Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

ANS: B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

ANS: B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the a. Schilling test. b. bilirubin level. c. stool occult blood test. d. gastric analysis testing.

ANS: B Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

Which problem reported by a patient with hemophilia is most important for the nurse to communicate to the physician? a. Leg bruises b. Tarry stools c. Skin abrasions d. Bleeding gums

ANS: B Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and administration of coagulation factors. The other problems indicate a need for patient teaching about how to avoid injury, but are not indicators of possible serious blood loss.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. b. folic acid. c. cobalamin (vitamin B12). d. ascorbic acid (vitamin C).

ANS: B Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to a. provide a diet high in vitamin K. b. alternate periods of rest and activity. c. teach the patient how to avoid injury. d. place the patient on protective isolation.

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient's intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

ANS: B TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the a. platelet count. b. bleeding time. c. thrombin time. d. prothrombin time.

ANS: B The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease.

Which action will the admitting nurse include in the care plan for a 30-year old woman who is neutropenic? a. Avoid any injections. b. Check temperature every 4 hours. c. Omit fruits or vegetables from the diet. d. Place a "No Visitors" sign on the door.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

A 30-year-old man with acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient's home.

ANS: B The patient may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia (neutrophil count less than 500/µL), administration of filgrastim usually allows the chemotherapy to continue. Patients with neutropenia are at higher risk for infection when exposed to other patients in the hospital. HEPA filters are expensive and are used in the hospital, where the number of pathogens is much higher than in the patient's home environment.

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow" b. 23-year-old with no previous health problems who has a nontender lump in the axilla c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipunctures. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.

ANS: B The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly."

ANS: B This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Verify the patient identification (ID) according to hospital policy. b. Obtain the temperature, blood pressure, and pulse before the transfusion. c. Double-check the product numbers on the PRBCs with the patient ID band. d. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky; most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

ANS: B - Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

ANS: B - The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assessing the patient for signs and symptoms of infection b. Teaching the patient the purpose of neutropenic precautions c. Administering subcutaneous filgrastim (Neupogen) injection d. Developing a discharge teaching plan for the patient and family

ANS: C Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. Patient education, assessment, and developing the plan of care require RN level education and scope of practice.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Discourage deep breathing to reduce risk for splenic rupture. b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain. c. Schedule immunization with the pneumococcal vaccine (Pneumovax). d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

ANS: C Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I a. need to start eating more red meat and liver." b. will stop having a glass of wine with dinner." c. could choose nasal spray rather than injections of vitamin B12." d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

ANS: C Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis? a. Take a daily multivitamin with iron. b. Limit fluids to 2 to 3 quarts per day. c. Avoid exposure to crowds when possible. d. Drink only two caffeinated beverages daily.

ANS: C Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. emphasize the positive outcomes of a bone marrow transplant. b. discuss the need for adequate insurance to cover post-HSCT care. c. ask the patient whether there are any questions or concerns about HSCT. d. explain that a cure is not possible with any other treatment except HSCT.

ANS: C Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and also will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/μL

ANS: C The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis.

Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Teach the patient to use iron supplements. b. Avoid the use of intramuscular injections. c. Administer iron chelation therapy as needed. d. Notify health care provider of hemoglobin 11g/dL.

ANS: C The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first? a. Administer morphine sulfate 4 mg IV. b. Give acetaminophen (Tylenol) 650 mg. c. Infuse normal saline 500 mL over 30 minutes. d. Schedule complete blood count and coagulation studies.

ANS: C The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Draw blood for a new crossmatch. b. Send a urine specimen to the laboratory. c. Administer PRN acetaminophen (Tylenol). d. Give the PRN diphenhydramine (Benadryl).

ANS: C The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It means it is caused by another disease. b. It means it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension.

ANS: C - Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

ANS: D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage narcotics are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

Which patient information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level

ANS: D Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored, but are not the most important to monitor when determining the effectiveness of deferoxamine.

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

ANS: D Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

ANS: D Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy, but are not immediately life threatening.

A critical action by the nurse caring for a patient with an acute exacerbation of polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements. c. avoid use of aspirin products. d. monitor fluid intake and output.

ANS: D Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis (DVT). Iron is contraindicated in patients with polycythemia vera.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

ANS: D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

Following successful treatment of Hodgkin's lymphoma for a 55-year-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

ANS: D The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a concern after treatment.

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include a. a hematocrit (Hct) of 38%. b. an RBC count of 4,500,000/μL. c. normal red blood cell (RBC) indices. d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to a. administer oxygen therapy at a high flow rate. b. obtain a urine specimen to send to the laboratory. c. notify the health care provider about the symptoms. d. disconnect the transfusion and infuse normal saline.

ANS: D The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

ANS: D - The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

ANS: D - Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: a. Normal because of the increased blood flow through the leg b. Slightly deteriorating and should be monitored for another hour c. Moderately impaired, and the surgeon should be called. d. Adequate from the arterial approach, but venous complications are arising.

a. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.

Nursing assessment of a client receiving serum albumin for treatment of shock should include: a.) Assessing lung sounds. b.) Monitoring glucose. c.) Monitoring the potassium level. d.) Monitoring hemoglobin and hematocrit.

a.) Assessing lung sounds. Rationale: Colloids pull fluid into vascular space. Circulatory overload could occur. The nurse should assess the client for symptoms of heart failure.

A client in shock is prescribed an inotropic drug to act on alpha and beta receptors. The nurse will most likely be administering: a.) Dopamine. b.) Dobutamine. c.) Pavulon. d.) Milrinone.

a.) Dopamine.

A patient is admitted to the emergency department after sustaining abdominal injuries and a broken femur from a motor vehicle accident. The patient is pale, diaphoretic, and is not talking coherently. Vital signs upon admission are temperature 98 F (36 C), heart rate 130 beats/minute, respiratory rate 34 breaths/minute, blood pressure 50/40 mmHg. The healthcare provider suspects which type of shock? a.) Hypovolemic b.) Cardiogenic c.) Neurogenic d.) Distributive

a.) Hypovolemic

Which type of fluid is most appropriate for volume replacement for a patient with non-hemorrhagic hypovolemic shock? a.) Lactated Ringers (LR) b.) 10% Dextrose in Water (D 10 W) c.) One-half Normal Saline (1/2% NS) d.) Packed Red Blood Cells (PRBC)

a.) Lactated Ringers (LR)

The client experiences shock following a spinal cord injury. This type of shock is classified as: a.) Hypovolemic. b.) Neurogenic. c.) Cardiogenic. d.) Anaphylactic.

a.) Neurogenic.

A client has been diagnosed with sepsis. The nurse will most likely find which of the following when assessing this client: Select all that apply: a.) Rapid shallow respirations. b.) Severe hypotension. c.) Mental status changes. d.) Elevated temperature. e.) Lactic acidosis. f.) Oliguria.

a.) Rapid shallow respirations. d.) Elevated temperature.

The client in shock is prescribed an infusion of lactated Ringer's solution. The nurse recognizes that the function of this fluid in the treatment of shock is to: a.) Replace fluid, and promote urine output. b.) Draw water into cells. c.) Draw water from cells to blood vessels. d.) Maintain vascular volume.

a.) Replace fluid, and promote urine output.

A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock? a.) The cardiac output is elevated. b.) The central venous pressure (CVP) is increased. c.) The systemic vascular resistance (SVR) is high. d.) The PAWP is high.

a.) The cardiac output is elevated. Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.

A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate: a.) administration of furosemide (Lasix) IV. b.) titration of an epinephrine (Adrenalin) drip. c.) administration of a normal saline bolus. d.) assisting with endotracheal intubation.

a.) administration of furosemide (Lasix) IV. Rationale: The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.

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. Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.

The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's a.) urine output is 40 ml over the last hour. b.) hemoglobin is within normal limits. c.) CVP has decreased. d.) mean arterial pressure (MAP) is 65 mm Hg.

a.) urine output is 40 ml over the last hour. Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.

A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is a.) urine output of 0.5 ml/kg/hr. b.) decreased peripheral edema. c.) decreased CVP. d.) oxygen saturation 90% or more.

a.) urine output of 0.5 ml/kg/hr. Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? a. Pulsatile abdominal mass b. Hyperactive bowel sounds in that area c. Systolic bruit over the area of the mass d. Subjective sensation of "heart beating" in the abdomen.

b. Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: a. Familial tendency toward peripheral vascular disease b. Smoking history c. Recent exposures to allergens d. History of insect bites

b. The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

An intensive care nurse, is assessing a patient with suspected sepsis. Which predisposing factors would expect to be found in the patient with septic shock? a.) A 45 year old client with a history of renal insufficiency. b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection. c.) A 27 year old with pyelonephritis responding to treatment with an antibiotic. d.) A 50 year old with community acquired tuberculosis.

b.) A client age 65, with a history of cancer who is recovering from an abdominal peritoneal resection.

A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first? a.) Insert two 14-gauge IV catheters. b.) Administer oxygen at 100% per non-rebreather mask. c.) Place the patient on continuous cardiac monitor. d.) Draw blood to type and crossmatch for transfusions.

b.) Administer oxygen at 100% per non-rebreather mask. Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

The acute care nurse is planning an inservice to present evidence based practices to address the increasing incidence in ventilator associated pneumonia. Interventions included in this protocol include: a.) Avoid the use of agents that increase the pH of the stomach as these blocks their antibacterial properties. b.) Maintaining the head of the bed at 30 degrees and strict hand washing before and after any patient contact. c.) Changing the ventilator circuit at least every 24 hours. d.) Provide routine oral care with a combination of alcohol based products.

b.) Maintaining the head of the bed at 30 degrees and strict hand washing before and after any patient contact.

Dobutamine (Dobutrex) is used to treat a client experiencing cardiogenic shock. Nursing intervention includes: a.) Monitoring for fluid overload. b.) Monitoring for cardiac dysrhythmias. c.) Monitoring respiratory status. d.) Monitoring for hypotension.

b.) Monitoring for cardiac dysrhythmias. Rationale: Dobutamine is beneficial in cases where shock is caused by heart failure. The drug increases contractility, and has the potential to cause dysrhythmias.

A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)? a.) Administer all medications through the patient's indwelling central line. b.) Place the patient in a private room. c.) Restrict the patient to foods that have been well-cooked or processed. d.) Insert a nasogastric (NG) tube for enteral feeding.

b.) Place the patient in a private room. Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.

To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are a.) stool guaiac and bowel sounds. b.) lung sounds and oxygenation status. c.) serum creatinine and urinary output. d.) serum bilirubin levels and skin color.

b.) lung sounds and oxygenation status. Rationale: The respiratory system is usually the FIRST system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to a.) check the blood pressure. b.) obtain an oxygen saturation. c.) attach a cardiac monitor. d.) check level of consciousness.

b.) obtain an oxygen saturation. Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

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.

b.) pH 7.33, PaCO2 30 mm Hg. 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.

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. Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain a.) a liter of lactated Ringer's solution. b.) 500 ml of 5% albumin. c. ) two 14-gauge IV catheters. d.) a retention catheter.

c. ) two 14-gauge IV catheters. Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.

Which of the following characteristics is typical of the pain associated with DVT? a. Dull ache b. No pain c. Sudden onset d. Tingling

c. DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.

A client is progressing into the third stage of shock. The nurse will expect this client to demonstrate: Choose all that apply: a.) Intractable circulatory failure. b.) Neuroendocrine responses. c.) Demonstrating MODS. d.) Buildup of metabolic wastes. e.) Profound hypotension. f.) Increase in lactic acidosis.

c.) Demonstrating MODS. d.) Buildup of metabolic wastes.

A 4.5 kg infant is admitted to the pediatric intensive care unit after 33 days of watery diarrhea. The infant is diagnosed with severe dehydration. The infant's skin is mottled and turgor is poor. Capillary refill is delayed, and there is an absence of tears with crying. Which intervention should be the priority action by the healthcare provider? a.) Calculate the mean arterial pressure b.) Draw blood for a complete blood count c.) Establish vascular access d.) Take a complete set of vital signs

c.) Establish vascular access Rationale: Vascular access should be established quickly in order to replace lost volume before shock progresses.

The healthcare provider is caring for a patient who has septic shock. Which of these should the healthcare provider administer to the patient first? a.) Antibiotics to treat the underlying infection. b.) Corticosteroids to reduce inflammation. c.) IV fluids to increase intravascular volume. d.) Vasopressors to increase blood pressure.

c.) IV fluids to increase intravascular volume. Rationale: Circulation and perfusion are addressed first so IV fluids will be started immediately. After blood cultures are obtained, broad-spectrum antibiotics should be administered without delay. Vasopressors are administered if the patient is not responding to the fluid challenge. Corticosteroids may be considered to address the inflammatory-induced vasodilation and capillary leakage.

When performing a physical assessment of a patient with severe sepsis, what abnormal assessment would the nurse expect to find? a.) A WBC of 8,100 despite the presence of chills. b.) A blood pressure of 100/72 with a capillary refill of <3 seconds. c.) Leucocytosis in a patient with absent bowel sounds. d.) Renal output that fluctuates according to intravenous intake.

c.) Leucocytosis in a patient with absent bowel sounds. Rationale: Leucocytosis in a patient with absent bowel sounds A white count > 12,000/mm3 and a left shift is one of the diagnostic criteria. Absent bowel sounds indicate a possible ileus. This would allow translocation of the intestinal flora into the bloodstream.

A patient who has pericarditis related to radiation therapy, becomes dyspneic, and has a rapid, weak pulse. Heart sounds are muffled, and a 12 mmHg drop in blood pressure is noted on inspiration. The healthcare provider's interventions are aimed at preventing which type of shock? a.) Distributive b.) Neurogenic c.) Obstructive d.) Cardiogenic

c.) Obstructive Rationale: Obstructive shock can be caused by anything that impedes the heart's ability to contract and pump blood around the body, as with cardiac tamponade.

Which of the following assessment findings is an early indication of hypovolemic shock? a.) Diminished bowel sounds b.) Increased urinary output c.) Tachycardia d.) Hypertension

c.) Tachycardia Rationale: Tachycardia is an early symptom as the body compensates for a declining blood pressure the heart rate increases to circulate the blood faster to prevent tissue hypoxia.

Multiple organ dysfunction syndrome (MODS) develops in severe sepsis as a result of systemic inflammatory response syndrome (SIRS), disseminated intravascular coagulation and damage to the endothelium. Which of the following statements best describes the management of MODS? a.) The use of proton pump inhibitors and H2 agents to increase the pH of the stomach inhibit the development of stress ulcers, an ileus and malabsorption issues. b.) Maintaining ventilator settings that ensure a tidal volume of at least 6 mL/kg of body weight will keep the lungs from being injured by endothelial damage. c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s). d.) Much of the organ damage that occurs with MODS in the setting of severe sepsis is associated with pre-existing conditions.

c.) There is no specific therapies for MODS other than supportive care and the early recognition of dysfunctional organ(s).

Sepsis is the most common cause of disseminated intravascular coagulation (DIC). All of the following statements concerning this life threatening complications are true except: a.) The rapidity of onset is determined by the intensity of the trigger and is related to the condition of the patient's liver, bone marrow and endothelium. b.) In the early phase, the patient may demonstrate manifestations of thrombosis and microemboli. c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock. d.) The most critical intervention for DIC is the early identification and treatment of the underlying disorder.

c.) Though a coagulopathy is present, excessive blood loss rarely results in hemorrhagic shock.

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 Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of a.) cool, clammy skin. b.) shortness of breath. c.) heart rate of 48 beats/min d.) BP of 82/40 mm Hg.

c.) heart rate of 48 beats/min Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

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). Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is a.) activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries. b.) stimulation of cardiac -adrenergic receptors, leading to increased cardiac output. c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. d.) movement of interstitial fluid to the intravascular space, increasing renal blood flow.

c.) release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention. Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

Intravenous heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? a. Vitamin K b. Aminocaproic acid c. Potassium chloride d. Protamine sulfate

d. The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: a. Has a pale colored base b. Is deep, with even edges c. Has little granulation tissue d. Has brown pigmentation around it.

d. Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem)

When compensatory mechanisms for hypovolemic shock are activated, the nurse would expect which two patient findings to normalize? a.) Intensity of peripheral pulses and body temperature. b.) Peripheral pulses and heart rate (HR). c.) Metabolic alkalosis and oxygen saturation. d.) Cardiac output (CO) and blood pressure (BP).

d.) Cardiac output (CO) and blood pressure (BP).

The healthcare provider is caring for a patient with a diagnosis of hemorrhagic pancreatitis. The patient's central venous pressure (CVP) reading is 2, blood pressure is 90/50 mmHg, lung sounds are clear, and jugular veins are flat. Which of these actions is most appropriate for the nurse to take? a.) Slow the IV infusion rate b.) Administer dopamine c.) No interventions are needed at this time d.) Increase the IV infusion rate

d.) Increase the IV infusion rate

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. Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.