Test 2- Pratice Questions

The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client? 1. administration of dopamine 2. administration of whole blood 3. administration of IV fluids 4. administration of packed red blood cells

1

The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best represents a therapeutic end point for goal-directed fluid therapy? 1. Central venous pressure >8 mm Hg 2. Heart rate >60 beats/min 3. Serum lactate level >6 mEq/L 4. Mean arterial pressure >50 mm Hg

1

The nurse is caring for a patient who has blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs. Which symptoms should the nurse assess for? 1. Multisystem organ failure and/or dysfunction 2. Increased cerebral perfusion pressure 3. Disseminated intravascular coagulation (DIC) 4. Acute respiratory distress syndrome (ARDS)

1

The nurse is caring for a patient with hypovolemia. Which large-volume crystalloid solution should the nurse anticipate the health care provider to order? Select all that apply. 1. Lactated Ringer's (LR) 2. 0.45% Normal Saline 3. 5% dextrose 4. Albumin

1

When assessing the norepinephrine infusion site, the nurse notes that the skin around the IV insertion site is cool and pale. Which action should be taken first? 1. Shut off the infusion pump 2. assess for pain 3. notify the HCP about possible extravasation 4. Inject the pale area with phentolamine solution per hospital protocol

1

A client develops an anaphylactic reaction after receiving morphine. The nurse would plan to institute which actions? SATA 1. administer oxygen 2. quickly assess the client's respiratory status 3. document the event, interventions and client's response 4. keep the client supine regardless of the blood pressure readings 5. leave the client brief to contact a PHCP 6. start an IV infusion of D5W and administer a 500 ml bolus

1,2,3

After a successful intubation, the nurse performs a rapid assessment of Ms. D and documents the findings: "apical pulse irregularly irregular. Face flushed and warm. Extremities cool and mottled. Breath sounds audible bilaterally with crackles present in lung bases. Reports pain with suprapubic palpation. Urine is amber and cloudy with red streaks. 100 mL of urine when FC inserted" The pt. Current vital signs values: BP- 86/40, HR- 102, O2- 93%, RR- 32, Temp- 103, BG- 167 Based on the assessment data and VS, which actions should the nurse anticipate at this time? SATA 1. Send specimens for blood and urine culture 2. Start a norepinephrine infusion at 8mcg/min 3. Give fluid bolus of 30 ml/kg 4. Draw blood for serum lactate level 5. Administer vancomycin 1mg IV 6. Administer sodium bicarbonate 1 meg/kg/IV

1,3,4,5

Mr. D, a 54-year-old patient, is brought to the ER by her daughter because of weakness and a decreasing level of consciousness. The daughter says that Ms. D has been reporting nausea, with associated abdominal and back pain. Although usually, Ms. D is alert and oriented, today she has been increasingly lethargic. Her History includes hypertension, A-Fib, and diabetes mellitus type 2 Her Vitals are: BP- 102/38, HR- 102, O2- 76%, RR: 30, Temp- 102.4F What is the nurse's first action based on the intake and assessment? 1. Administer an acetaminophen suppository to lower the temp. 2. start oxygen and maintain oxygen saturation at 90% or higher 3. Place the patient on a cardiac monitor 4. Initiate intravenous access with normal saline at a keep-open rate

2

The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering which medication in an effort to improve cardiac output by increasing the contractile force of the heart? 1. Dopamine (Intropin) 2. Dobutamine (Dobutrex) 3. Phenylephrine (Neo-Synephrine) 4. Nitroprusside (Nipride)

2

The nurse educator is presenting a lecture on crystalloid fluid replacement therapy in shock states. Which statement by a nurse indicates that the teaching has been effective? 1. Solutions of 0.45% normal saline are used routinely in shock. 2. Lactated Ringer's should not be infused if lactic acidosis is severe. 3. 3 mL of crystalloid is administered to replace 10 mL of blood loss. 4. Administration of colloids is preferred over crystalloids.

2

The nurse is caring for a patient with possible distributive shock. Which should the nurse look for on assessment? 1. Decreased cardiac output. 2. Vasodilation and relative hypovolemia. 3. Blood loss and actual hypovolemia. 4. Third-spacing of fluids into peritoneal space

2

The nurse reviews Ms. D latest lab values, Hematocrit- 32% Hemoglobin- 10.9 Platelet- 96,000 WBC- 26,000 Blood urea nitrogen- 56 Creatinine- 2.9 Glucose- 330 Potassium- 5.2 Sodium- 140 Which value requires the most immediate action? 1. Creatinine 2. Glucose 3. Potassium 4. Hemoglobin

2

Which Method of oxygen administration will be best to increase Ms. D's oxygen saturation? 1. Nasal Cannula 2. Non Rebreather mask 3. Venturi Mask 4. Simple face mask

2

a client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68. The nurse suspects which stage of shock? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4

2

After 2 hrs, the vital signs are: BP- 104/56 HR- 104 O2- 92 CVP- 1 mmhg RR-26 Temp- 101.6 Which information about mr. D is most important for the nurse to communicate rapidly to the HCP? 1. Decreased BP 2. Ongoing A-Fib 3. Low CVP 4. Continue temp elevation

3

After receiving the handoff report from the night shift, the nurse completes the morning assessment of a patient with sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32 breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 100.5° F, central venous pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains orders for treatment that include which of the following? 1. Increase supplemental oxygen therapy to 60% Venturi mask. 2. Administer acetaminophen (Tylenol) 650 mg suppository per rectum. 3. Administer at least 30 mL/kg of intravenous crystalloid fluid within the first 3 hours 4. Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr.

3

The nurse is caring for a patient in shock. Which is a priority action by the nurse? 1. Prevent third-spacing of fluids. 2. Support mechanical ventilation. 3. Maintain adequate tissue perfusion. 4. Ensure adequate cellular hydration.

3

When the nurse if infusing the NS, which action is most important in evaluating for an adverse reaction to the rapid fluid infusion? 1. Palpating for an peripheral edema 2. monitoring urine output 3. listening to lungs 4. Checking for abdomen distention

3

Which hemodynamic values should the nurse anticipate in a patient who is in the initial stages of septic shock state? 1. Low heart rate; high blood pressure 2. High SVR; normal blood pressure 3. High heart rate; low right atrial pressure 4. High PAOP; low cardiac output

3

which clinical findings are consistent with sepsis diagnostic criteria? SATA 1. urine output 50 ml/hr 2. hypoactive bowel sounds 3. temp of 102 4. hr of 96 5. map of 65 6. SBP of 110

3,4,5

A client in shock develops a central venous pressure of 2 mmhg and mean arterial pressure of 60. Which prescribed intervention would the nurse implement first? 1. increase the rate of O2 flow 2. obtain arterial blood gas result 3. insert an indwelling urinary catheter 4. increase the rate of IV fluids

4

The nurse is caring for a patient in neurogenic shock. Which should the nurse assess for? 1. Hypertension 2. Tachycardia 3. Hypoventilation 4. Vasodilation

4

Which of these actions prescribed by the HCP will be most important to the nurse to question? 1. Increase flow rate 2. Raise NS rate to 450 3. Administer acetaminophen 650 mg rectally 4. Increase norepinephrine infusion rate to 12 mcg/kg

4