Saunders questions Mr. Keene exam 2 "med emergency"
The nurse is caring for a client with systemic inflammatory response syndrome (SIRS) related to bacterial pneumonia. Which interventions would be most appropriate for this client? Select all that apply. 1.Electrocardiogram (ECG) monitoring 2Fluid replacement 3Frequent ambulation 4Antibiotic administration 5Venous thromboembolism prophylaxis
answer:1,2,4,5 Rationale:Because SIRS is a systemic inflammatory response, several body systems may be involved that are unrelated to the original infection. It is important for the interventions to center on monitoring, restoring tissue perfusion, fluid volume, and correcting the underlying cause of infection. Frequent ambulation is an inappropriate intervention because of the systemic inflammatory response and the need for rest to assist in healing.
The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
answer:2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur.
A client is brought to the emergency department with partial-thickness burns to the face, neck, arms, and chest after trying to put out a car fire. The nurse needs to implement which nursing actions for this client? Select all that apply 1.Restrict fluids. 2Assess for airway patency. 3Administer oxygen as prescribed. 4Place a cooling blanket on the client. 5Elevate extremities if no fractures are present. 6Prepare to give oral pain medication as prescribed.
answer:2,3,5 Rationale:The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury.
The nurse is caring for a client with cardiogenic shock. After reviewing the medication administration record, the nurse determines a need for follow-up when noticing which entry in the record? 1.Digoxin 0.5 mg/day orally 2Morphine sulfate 2 mg intravenous (IV) PRN for chest pain 3Verapamil 10 mg IV; may repeat every 15 minutes 4Dopamine IV 1 mcg/kg/min to maintain systolic BP >100 mm Hg
answer:3 Rationale:Medication management for clients in cardiogenic shock needs to focus on increasing cardiac output. Vasopressors and positive inotropes are examples of medications that will achieve this outcome. Additionally, clients may be prescribed pain medication to treat secondary symptoms and medications that help maintain blood pressure.
The nurse is assisting in caring for a client diagnosed with multiple organ dysfunction syndrome (MODS). Which client problem would the nurse assign as the highest priority for this client? 1.Anxiety 2.Activity intolerance 3.Risk for ineffective coping 4.Poor or imbalanced nutrition
answer:4 Rationale:Interventions that surround the care of a client with MODS include support of the failing organ systems, maintenance of tissue oxygenation, promoting nutrition to meet metabolic needs, and care, education, and comfort measures. Addressing the client's psychological needs is important; however, providing care to support the client's organ systems is essential
A client is admitted after an accidental chemical ingestion. The nurse notes the following findings on assessment: dyspnea, pulse oximetry of 90% on 4 L/minute via nasal cannula, and bilateral lower lobe diminished breath sounds. The nurse analyzes these findings as indicating which priority client need? 1.Fluid restriction 2High-Fowler position 3Chest-ray and laboratory studies 4Treatment for systemic inflammatory response syndrome (SIRS) and acute respiratory distress syndrome
answer:4 Rationale:SIRS is a systemic inflammatory response that results from an infection, trauma, or perfusion deficit. SIRS affects organs separate from the initial affected area. The signs and symptoms the client is portraying are associated with acute respiratory distress syndrome (ARDS), a complication of SIRS, and treatment needs to be instituted. Fluid restriction would worsen the condition and intravenous fluids may be prescribed. A High-Fowler position could place pressure on the diaphragm worsening the dyspnea. A chest x-ray and laboratory studies may be prescribed but treatment needs to be instituted as the priority.
The nurse is monitoring the client after cardiac surgery. The nurse notes the following signs and symptoms: decreased urinary output, decreased bowel sounds, capillary refill >4 seconds, and changes in mental status. What would the nurse do next? 1.Continue to monitor; these may be signs of potential shock. 2Collect an arterial blood gas to check to see whether the client is compensating. 3Place the client on oxygen; these are signs of increased oxygen requirement. 4Contact the primary health care provider (PHCP); these may be signs of potential shock.
answer:4 Rationale:Signs and symptoms of shock may mirror other signs and symptoms of sepsis or other severe complications. Early recognition of signs and symptoms that are not expected need to be reported to the PHCP immediately. Contacting the PHCP is the next action. Options 1 and 2 delay necessary interventions. Oxygen would already be administered to a client after cardiac surgery.
Which client would most likely be the highest risk for systemic inflammatory response syndrome (SIRS)? 1.A client admitted for new-onset seizures 2A client admitted for new-onset diabetes mellitus 3A client admitted for a gastrointestinal bleeding ulcer 4A client with cancer admitted for a central line placement
answer:4 Rationale:The client with cancer is at increased risk for infection. In addition, this client is admitted for the placement of a central line, an invasive procedure. This combination would place this client at highest risk for developing SIRS secondary to an infection.
The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month
answer:4 Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.
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 intravenous fluids 4. Administration of packed red blood cells
answer: 1 The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.
Which finding indicates that tissue perfusion has been improved in a client with septic shock? 1. The client's capillary refill is less than 3 seconds. 2The client's blood glucose has decreased to 120 mg/dL. 3The client tolerated a rapid infusion of isotonic intravenous fluids. 4The client's pulse oximetry is maintained at 94% on 4 liters per minute of oxygen via nasal cannula
answer: 1 The client's capillary refill is less than 3 seconds.2The client's blood glucose has decreased to 120 mg/dL.3The client tolerated a rapid infusion of isotonic intravenous fluids.4The client's pulse oximetry is maintained at 94% on 4 liters per minute of oxygen via nasal cannula
The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect? 1. Meningitis 2. Spinal cord injury 3. Intracranial bleeding 4. Decreased cerebral blood flow
answer: 1 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.
. The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the ability to move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe self without assistance.
answer: 1, 2, 4 Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic, unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating.
The nurse caring for a client suspected of being in hypovolemic shock is trying to anticipate treatment and management interventions. What plan is most appropriate for this client? Select all that apply. 1.Oxygen administration 2Mental status checks every 15 minutes 3Further assessment to confirm the type of shock 4High-dose diuretics to minimize fluid accumulation 5Laboratory blood draws every 30 minutes to trend abnormal values
answer: 1, 2,3 Rationale:The avenues of treatment and management for hypovolemic shock encompass varying levels of complexity and acuity, and each treatment plan will depend on what type of shock the client is experiencing; thus further assessment is needed to confirm hypovolemic shock. Oxygen is an important intervention to ensure tissue perfusion. Mental status checks are also important to monitor for any deterioration in the client's condition. High-dose diuretics would worsen hypovolemic shock and every 30 minute blood draws are not necessary.
The nurse plans care for a client with sepsis, understanding that which of the following are characteristic of sepsis? Select all that apply. 1.The client can develop coagulopathy. 2The infection can be caused by a parasite. 3Sepsis is the bodily response to an infection. 4The causative organism is always gram-negative bacteria. 5The client may display abnormal vital signs along with abnormal laboratory values.
answer: 1, 2,3, 5 Rationale:Sepsis is a group of symptoms in response to an infection. The infection can be caused by gram-positive or gram-negative bacteria, or it can be viral, fungal, or parasitic in origin. Sepsis can cause coagulopathy. The client's vital signs, as well as laboratory values, will be abnormal.
The nurse caring for a client with sepsis as a result of bacterial pneumonia is monitoring for signs of systemic inflammatory response syndrome (SIRS). Which conditions are indicative of this complication? Select all that apply. 1.Fever 2.Diabetes insipidus 3.Altered mental status 4.Development of severe hypotension 5. Development of acute respiratory distress syndrome (ARDS)
answer: 1, 3,4,5 Rationale:SIRS is a systemic inflammatory response characterized by generalized inflammation in organs separate from the initial affected area and is caused by severe bacterial infections, trauma, or pancreatitis. A fever will occur related to the infection. The client will have global vasodilation and thus will have decreased blood pressure and perfusion to the other important organs such as the lungs and brain, affecting breathing and mentation. SIRS can also be triggered by many other complications associated with tissue trauma, such as burns.
A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis? 1. Clear CSF, decreased pressure, and elevated protein level 2. Clear CSF, elevated protein, and decreased glucose levels 3. Cloudy CSF, elevated protein, and decreased glucose levels 4. Cloudy CSF, decreased protein, and decreased glucose levels
answer: 3 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.
The nurse is caring for a client admitted for fever and urinary tract infection (UTI) who is at risk for sepsis. What initial intervention would the nurse anticipate? 1. Rechecking the temperature to ensure accuracy 2.Obtaining a history and physical to find out the source of the fever 3.Obtaining a urine culture and sensitivity prior to beginning antibiotics 4. Administering prophylactic antibiotics until the client becomes afebrile
answer: 3 Rationale:Fever is the most common and earliest manifestation of a UTI. It is essential to obtain a urine culture and sensitivity to determine the source of infection so that antibiotic therapy is effective. Rechecking the temperature will be necessary to monitor the trend of the fever but is not the initial action. The source of the fever is likely related to the UTI. Prophylactic antibiotics are used only in very specific situations. The client has already been confirmed to have a UTI; therefore, antibiotic use would not be considered prophylactic at this time.
The nurse plans care understanding that which is the primary reason clients experience vasodilation in septic shock? 1. There is a release of endotoxins from bacteria. 2There is heart failure with diminished cardiac output. 3There is blood or fluid loss, and the body compensates by dilating the blood vessels. 4There is an obstruction of blood flow, and the body compensates by dilating the blood vessels.
answer: 1 Rationale:A massive infection can lead to sepsis as a result of endotoxins being released, which causes vasodilation, pooling of blood, and capillary permeability. The remaining options do not provide the reason for vasodilation in septic shock.
A client who had a myocardial infarction is at risk for cardiogenic shock. The nurse plans care knowing that the primary cause of cardiogenic shock results from which process? 1.A pump failure and reduction in cardiac output 2. A physical obstruction that decreases filling or outflow of blood 3.Dilated vasculature decreasing the movement of blood to the body 4.Loss of vasoconstrictor tone, leading to pooling of blood in vessels
answer: 1 Rationale:Cardiogenic shock is caused by the heart itself not being able to pump effectively, resulting in decreased cardiac output. Cardiac output reflects blood reaching the tissues and vasculature. The remaining options do not describe the pathophysiology associated with cardiogenic shock.
A client with systemic inflammatory response syndrome (SIRS) is being monitored in an intensive care unit. The client is being mechanically ventilated for a secondary complication of acute respiratory distress syndrome (ARDS). The nurse is planning care for the client. What interventions would be best to include? Select all that apply. 1.Monitor urinary output. 2Implement continuous ECG monitoring. 3Reposition the client every 2 hours. 4Allow the client to eat to promote healing. 5Follow improvement with frequent chest x-rays.
answer: 1,2,3 Rationale:Nursing interventions appropriate for a mechanically ventilated client with SIRS and ARDS should focus on restoring tissue perfusion and circulating volume, and correcting lung compliance. Monitoring urinary output and continuous ECG are important indicators of both tissue perfusion and circulating volume. Repositioning the client will help decrease the risk of pressure ulcers and will also reduce dependent edema and worsening lung function. Nutrition is important to help with healing and meeting the metabolic needs of the body, but not when a client is acutely ill and on a mechanical ventilator. Additionally, frequent chest x-rays expose the client to too much radiation.
A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank. (Whole number, no comma.)
answer: 14940 Rationale:The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.
A new graduate nurse is taking a critical care course focusing on cardiogenic shock. Which statement made by the graduate nurse indicates that the teaching was effective? 1.Cardiogenic shock is caused by diuretics. 2Cardiac tissue death can lead to cardiogenic shock. 3Cardiac arrest is the most common cause for cardiogenic shock. 4Each valve within the heart must be faulty to decrease cardiac output.
answer: 2 Rationale:Cardiogenic shock is the failure of the heart to pump adequately. This results in decreased cardiac output and decreased tissue perfusion. Cardiac tissue or vessel necrosis can lead to an occlusion within the heart vessels themselves, thus affecting the heart's ability to pump properly. It is not caused by diuretics. Options 3 and 4 are incorrect
A client diagnosed with pneumonia has been hypotensive for the last four hours, with systolic blood pressures (SBP) ranging from 80 to 100 mm Hg. The nurse is concerned that the client may be developing sepsis. What intervention would the nurse anticipate taking priority for this client? 1.Set up to begin a vasopressor drip. 2Administer fluid resuscitation with isotonic crystalloids. 3Continue to monitor the client's systolic blood pressure. 4Prepare to start an arterial line to monitor the SBP more accurately.
answer: 2 Rationale:Pneumonia is an infectious process. The toxins released by the organism causing the infection create a reaction from the immune system to release cytokines. Cytokines cause vasodilation, causing the blood pressure to decrease. Clients may experience SBP of less than or equal to 100 mm Hg or a decrease of SBP of more than 40 mm Hg. Thus, the client needs fluid resuscitation to raise the BP. Continuing to monitor the client's systolic blood pressure delays necessary treatment. Options 1 and 4 would be done if fluid resuscitation did not assist in raising the BP.
The client is admitted to the medical-surgical unit for a urinary tract infection (UTI). The nurse obtains the following vital signs: temperature 101.1 degrees Fahrenheit (38.3 degrees Celsius), heart rate 95 beats per minute, respiratory rate 22 breaths per minute, and blood pressure 97/65 mm Hg. The nurse would take which action next? 1.Administer an antipyretic to manage fever. 2Notify the physician and assess the client for sepsis. 3Prepare to administer an isotonic bolus to increase the blood pressure. 4Document the vital signs, as they are expected for a client with an infection.
answer: 2 Rationale:The nurse needs to be aware of the diagnostic criteria for sepsis. The client's vital signs may reflect hyperthermia or hypothermia, tachycardia, tachypnea, and hypotension. Sepsis signs and symptoms occur congruently with a client who has an infection. This client has an elevated temperature, heart rate, and respiratory rate. Additionally, the client has hypotension; these are indications of sepsis.
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 mm Hg. The nurse suspects which stage of shock based on this data? 1. Stage 1 2. Stage 2 3. Stage 3 4. Stage 4
answer: 2 Shock is categorized by four stages. Stage 1 is characterized by restlessness, increased heart rate, cool and pale skin, and agitation. Stage 2 is characterized by a cardiac output that is less than 4 to 6 liters per minute, systolic blood pressure of less than 100 mm Hg, decreased urinary output, confusion, and cerebral perfusion pressure that is less than 70 mm Hg. Stage 3 is characterized by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4 is characterized as unresponsiveness to vasopressors, profound hypotension, slowed heart rate, and multiple organ failure. Most often, the client will not survive.
The nurse is reviewing the record of a child with increased intracranial pressure from a head injury and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
answer: 3 Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.
The nurse is caring for a client with sepsis. Which intervention performed by the nurse indicates an inaccurate action and the need for teaching? 1.Administering the prescribed antibiotics 2Obtaining blood glucose readings as ordered 3Waiting to obtain cultures until the antibiotic is complete 4Suggesting that the physician order albumin for fluid resuscitation
answer: 3 Intervening early with intravenous (IV) antibiotics is crucial for clients diagnosed with sepsis. To ensure that the antibiotic will kill the microorganism causing the infection, blood cultures should be obtained before beginning IV antibiotics. The results of the culture will ensure that the correct antibiotic is prescribed. Options 1, 2, and 4 are accurate interventions.
A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy would the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors
answer: 3 The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.
Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1. Urine output 50 mL/hr 2. Hypoactive bowel sounds 3. Temperature of 102° F (38.9° C) 4. Heart rate of 96 beats per minute 5. Mean arterial pressure 65 mm Hg 6. Systolic blood pressure 110 mm Hg
answer: 3,4,5 Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), heart rate above 90 beats per minute, tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg or arterial hypotension (SBP below 90 mm Hg), MAP of less than 70 mm Hg, or a decrease in SBP of more than 40 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.
A 5-year-old child arrives at the emergency department, and the child's parents state that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1. Nausea 2. Irritability 3. Headache 4. Bradycardia
answer: 4 Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.
The nurse has instructed the family of a client with a stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? 1. "We need to discourage wearing eyeglasses." 2. "We need to place objects in the impaired field of vision." 3. "We need to approach from the impaired field of vision." 4. "We need to encourage head turning to scan the lost visual field."
answer: 4 Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia needs to have objects placed in the intact field of vision, and the nurse also would approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available.
The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention would be included in the plan of care? 1. Maintain enteric precautions. 2. Maintain neutropenic precautions. 3. No precautions are required as long as antibiotics have been started. 4. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.
answer: 4 Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the prescribed antibiotic as soon as a culture is obtained. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.
A client in shock develops a central venous pressure (CVP) of 2 mm Hg and mean arterial pressure (MAP) of 60 mm Hg. Which prescribed intervention would the nurse implement first? 1. Increase the rate of O2 flow. 2. Obtain arterial blood gas results. 3. Insert an indwelling urinary catheter. 4. Increase the rate of intravenous (IV) fluids.
answer: 4 Rationale: The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not the priority
The charge nurse understands that there is a need for further teaching when the nurse caring for a client with septic shock states which of the following? 1. "Frequent assessments of mental status may be necessary." 2"It will be important to watch the trend of the client's lab values." 3"Blood transfusions may be needed to help with the client's coagulopathy." 4"Administering antibiotics is the best way to correct and treat septic shock
answer: 4 Rationale:Antibiotics are an important piece of the treatment and management of shock, but the treatment and management encompass many different interventions and methods, not just administering antibiotics. Discovering what the underlying condition is will be crucial in treating the client properly, and restoration of tissue perfusion and circulating volume must be achieved first. Options 1, 2, and 3 are correct actions.
Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock? 1.Use of diuretics to decrease circulating volume 2. Use of whole blood to easily restore fluid volume 3. Use of intravenous and oral fluids to restore circulating volume 4. Restriction of volume expanders because of secondary pulmonary edema
answer: 4 Rationale:Because there are several types of shock, it is important to know which shock state the client is in so that it can be managed appropriately. A client in cardiogenic shock may have secondary issues such as pulmonary edema due to the ineffective pumping mechanism of the heart. Fluid restoration is a key ingredient in treating shock states although it must be used conservatively in clients with cardiogenic shock. Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because the problem is with the pumping action of the heart and not increased blood volume.
What primary characteristic of cardiogenic shock helps determine what nursing interventions are performed? 1. Blood pools in the heart, so care is focused on diuresing. 2Urinary output is low, so care is focused on increasing circulating volume. 3Hypotension is severe, so care is focused on blood pressure monitoring. 4Cardiac output is compromised, so care is focused on restoring tissue perfusion.
answer: 4 Rationale:Cardiogenic shock occurs when the heart fails to pump adequately, thus reducing cardiac output and compromising tissue perfusion. The goal of management and treatment for cardiogenic shock is to restore cardiac output and tissue perfusion; then treatment of the underlying cause can be managed. Options 1, 2, and 3 are not primary characteristics.
The nurse is caring for a client with a urinary tract infection diagnosed with sepsis. In reviewing the client's chart, the nurse notices that the C-reactive protein is elevated. The nurse plans care, knowing that the primary reason for this change is based on which interpretation? 1. It is the client's response to an active infection 2. The C-reactive protein is unrelated to the diagnosis of sepsis. 3. It is an immune response to assist with coagulation abnormalities. 4. The body activates proinflammatory and antiinflammatory responses.
answer: 4 Rationale:In response to invading microorganisms, the body activates a proinflammatory and antiinflammatory response. The C-reactive protein laboratory value will be elevated as an indication of the inflammatory process. Option 2 is incorrect. Although option 1 is correct and option 3 is partially correct in that the elevated laboratory value indicates an immune response, option 4 identifies the primary reason.
The nurse is assisting in caring for a client with multiple organ dysfunction syndrome (MODS). The nurse understands that which intervention is most important in the care of clients with this syndrome? 1.Treatment of the infection 2.Maintaining tissue oxygenation 3.Prevention and early identification 4. Supporting the failing organ systems
answer: 4 Rationale:Prevention and early identification of sepsis are the most effective interventions, but when sepsis and a systemic inflammatory response have already occurred, the client who has organ dysfunction needs to be treated and managed to support the organ systems that are failing.
The nurse is caring for a client with a diagnosis of a urinary tract infection (UTI). The client has begun to become hypotensive, edematous, and oliguric, and has a prolonged capillary refill time. What would the nurse do first? 1.Administer a prescribed diuretic; these are anticipated findings. 2Administer the prescribed antibiotics; this client has an active infection .3Administer an IV fluid bolus, which will help the client's hypotension and oliguria. 4Contact the primary health care provider (PHCP); this client is becoming septic.
answer: 4 The assessment data gathered by the nurse indicate a need to contact the PHCP, as there has been a substantial change in client status. If sepsis diagnostic criteria are not recognized and interventions implemented, the client may go into septic shock. These findings are not anticipated and do not indicate an active infection. Although a bolus of IV fluid may be prescribed, the first action needs to be to contact the PHCP.
The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse would bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Nasal cannula and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray
answer: 4 The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray needs to be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse needs to assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.
A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning
answer: 4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.
The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self
answer: 4 Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt.
