WEEK 3 (31)

13)Which nursing interventions would be appropriate for a client in impending shock with decreased cardiac output? Select all that apply.

*Restrict activity to total rest.*Establish at least one IV site with a large-gauge catheter.*Administer IV fluids or blood products at the prescribed rate.

16)Which type of shock is caused by an infection?

*Septic

18)Which type of shock is caused by an infection?

*Septic

23)The nurse anticipates that an immunosuppressed client is at greatest risk for which type of shock?

*Septic

17)The nurse is assessing a 6-year-old child in the emergency department (ED) who was brought in by the mother. The child was stung by a bee and is allergic to bee venom. The child is now having trouble breathing, and is vasodilated, hypotensive, and has broken out in hives. What does the nurse suspect is wrong with this child?

*The child is having an allergic reaction and going into anaphylactic shock.

9)The nursing instructor is talking with her class about spinal anesthesia. What would be the nursing care intervention required when caring for a client recovering from spinal anesthesia? Select all that apply.

*Turn the client from side to side at least every 2 hours, if permitted.*Assist the client to a sitting position at the side of the bed.*Instruct the client to stay in bed until sensation and movement returns.*Monitor respiratory rate and sensation every 2 hours or as per ordered.

31)Which patient instructions are necessary for a client receiving systemic internal radiation therapy who is being discharged? Select all that apply.

*Wash hands carefully following toileting.

1)It is important for the nurse to assist a postsurgical client to sit up and turn the head to one side when vomiting in order to

*avoid aspiration.

26)A client returns to the surgeon's office for a report on a diagnostic procedure to determine the cell composition of the client's abdominal neoplasm. Which terms are significant to indicate the likelihood of the tumor spreading? Select all that apply.

*benign,*neoplasm,*angiogenesis

20)A client who is suffering a myocardial infarction is transported to the ED by ambulance. This client is at greatest risk for developing which type of shock?

*cardiogenic shock

11)Which nursing considerations are required when caring for a client being treated for shock who has been administered norepinephrine? Select all that apply.

*carefully monitor blood pressure (BP),*monitor for photophobia,*avoid suddenly discontinuing infusion,*monitor for restlessness and palpitations

15)A client who was brought to the ED 3 days ago remains unresponsive in the ICU. Presenting symptoms included elevated temperature and flushed skin; assessment revealed a rapid, bounding pulse. Treatment has been ineffective, and the client's body is no longer compensating for shock symptoms. What are expected changes in this client's condition? Select all that apply.

*cellular hypoxia*cardiovascular changes

27)The nurse is teaching a client about carcinogens. What carcinogens does the nurse include in the teaching? Select all that apply.

*dietary substances*environmental factors*viruses*chemical agents*defective genes*hormone replacement therapy

10)A responsibility of the scrub nurse is to:

*prepare sutures.

28)A nurse is caring for a client newly diagnosed with cancer. Which therapies are used to treat cancer? Select all that apply.

*surgery*hyperthermia*radiation therapy*chemotherapy

6)The nurse is completing an assessment of the client prior to surgery. What areas of the client assessment should the nurse question further? Select all that apply.

*Medication,*Elimination,*Activity,*Support system

24)Cardiogenic shock is most commonly seen in which patient population?

*Myocardial infarction

22)A client is in a driving accident creating a spinal cord injury. The nurse caring for a client realizes that the client is at risk for which type of shock?

*Neurogenic

8)When practicing perioperative care, the nurse monitors clients for what symptoms that are indicative of malignant hyperthermia? Select all that apply.

*Cyanosis,*Muscle rigidity,*Diaphoresis,*Irregular heart rate

7)When planning care for a client in the postoperative period, prioritize nursing diagnoses in the sequence from highest to lowest priority?

*Impaired Gas Exchange,*Fluid Volume Deficit,*Altered Comfort,*Anxiety,*Risk for Infection

5)A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

*Leg exercises improve circulation and prevent venous thrombosis.

4)The nurse is completing a preoperative assessment. The nurse notices the client is tearful and constantly wringing their hands. The client states, "I'm really nervous about this surgery. Do you think it will be ok?" What is the nurse's best response?

* "What are your concerns?"

29)Based on the understanding of the effects of chemotherapy, the nurse would anticipate which clinical finding in a client 2 weeks after therapy?

* fever

30)During a routine physical examination, a client confides that he is terrified of developing prostate cancer like his father. What are the warning signs of prostate cancer? Select all that apply.

* weak and interrupted urine flow*continuous pain in the lower back*pain in the upper thighs

3)A client is scheduled for an invasive procedure. What priority documentation is needed regarding the procedure?

*A signed consent form from the client

21)The nurse is caring for a client with shock. The nurse is concerned about hypoxemia and metabolic acidosis with the client. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?

*Arterial blood gas (ABG) findings

2)When assessing the client postoperatively, which nursing consideration is essential before offering oral fluids?

*Assess ability to swallow.

25)Which of the following clinical manifestations occur in cardiogenic shock

*Blood pressure falls

14)The nurse recognizes that many risk factors exist for the development of hypovolemic shock. Which are considered "internal" risk factors? Select all that apply.

*Burns*Dehydration

19)The nurse is caring for as 78-year-old client with extensive cardiovascular disease. Which type of shock is the client most likely to develop?

*Cardiogenic shock

12)Which of the following types of shock are older adults more likely to develop? Select all that apply.

*Cardiogenic shock,*Hypovolemic shock