EVOLVE questions Exam 4 Med Surg 2

which action will be most effective in determining if fluid overload is improving when caring for a client with heart failure?

weighing the client 1 L is equal to 2.2 lbs (1 kg)

during a clients paracentesis, 1500 ml of fluid is removed. which assessment finding by the nurse is indicative of a potentially severe response?

HR increases from 80 to 135 fluid may shift from the intravascular to the abdomen

how would the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition?

a failure of the circulatory pump

which clinical manifestation would the nurse associate with successful fluid replacement therapy?

a trended UOP of at least 30 ml/hr

which action would the nurse rake first in a client whose VS are bp 100/60, HR 104, RR 22, O2 95% two hours after hip surgery?

check the dressing on the incision (bleeding)

which finding will the nurse expect when caring for a client who is in hypovolemic shock?

cool skin

what type of shock would the nurse expect when a client is admitted to the ED after a MVA eith abdominal pain, bp decrease from 120/76 to 60/40, and HR increase from 82 to 121?

hemorrhagic shock

which type of shock would the nurse monitor for in a client with a ruptured abdominal aortic aneurysm?

hypovolemic

which clinical findings would the nurse expect when assessing a clinet who has cardiogenic shock?

pallor agitation tachycardia narrowed pulse pressure

when a critically ill client had a pulmonary artery catheter inserted, which measurement provides the most useful information about the clients left ventricular pressure?

PAWP it is the indirect measure of LV end-diastolic pressure CVP is right arterial pressure

which finding would the nurse expect when assessing a client who has lost a large amount of blood after an automobile collision?

apical HR of 142

which action would the nurse take when a client who sustained a closed head injury is being monitored for increased ICP and the results of ABG include PCO2 of 33?

continue to monitor for s/s of increased ICP

which type of shock is associated with a ruptured abdominal aneurysm?

hypovolemic shock

which type of collaborative action would the nurse anticipate the need to rapidly implement when caring for a client who had a bp of 80/60 and a HR of 120 after a MVA?

increase circulating blood volume

which complication will the nurse anticipate when caring for a client in late hypovolemic shock?

metabolic acidosis decreased perfusion will cause the formation of lactic acid which results in metabolic acidosis respiratory alkalosis can be seen in early shock bc of rapid, shallow breathing

which initial change in acid-base balance will the nurse expect when a client is in the progressive stage of shock

metabolic acidosis occurs d/t accumulation of lactic acid respiratory acidosis can occur as shock progresses with a decreased respiratory function in late shock respiratory alkalosis may occur with hyperventilation in early shock

which action would the nurse take next after observing the rhythm (PVC) in a client who came to the ED after experiencing "skipped heartbeats"?

obtain the client's bp

which likely cause would a nurse suspect is responsible for a drop in bp after a client sustains multiple internal injuries in a MVA and the blood pressure suddenly drops from 134/90 to 80/60?

reduction in the circulating blood volume

which physiological factor helps maintain bp in the client with hypovolemia?

release of aldosterone activation of angiotensin ll sympathetic nervous system activation

which action by the nurse is important when preparing for cardioversion of a client with a fib?

set synchronizer switch on defibrillator to the "on" position