Exam 4 Powerpoint Questions

Which kind of shock occurs from inadequate fluid volume in the intravascular space? A. Anaphylactic B. Cardiogenic C. Hypovolemic D. Neurogenic

ANS: C

A patient's ABG results include pH 7.31, Paco2 50 mm Hg, Pao2 51 mm Hg, and HCO3 24 mEq/L. Oxygen is administered at 2 L/min, and the patient is placed in high-Fowler's position. An hour later, the ABGs are repeated with results of pH 7.36, Paco2 40 mm Hg, Pao2 60 mm Hg, and HCO3 24 mEq/L. What is most important for the nurse to do? a. Increase the oxygen flow rate to 4 L/min. b. Document the findings in the patient's record. c. Reposition the patient in a semi-Fowler's position. d. Prepare the patient for endotracheal intubation and mechanical ventilation.

ANS: A

A patient with a history of alcoholism is admitted to the intensive care unit (ICU) with hemorrhage from esophageal varices. Admission vital signs are blood pressure 84/58 mm Hg, pulse 105 beats/min, and respiratory rate 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding: a. Pulmonary edema. b. Cardiac dysrhythmias. c. Absent bowel sounds. d. Decreasing blood pressure.

ANS: A This is the FIRST SIGN of SIRS.

A patient recovering from second-and third degree burns over 30% of his body and is now ready for discharge. The first action the nurse should take when meeting with the patient would be to? a. Arrange a return-to-the clinic appointment and prescription for pain medication. b. Teach the patient and the caregiver proper wound care to be performed at home. c. Review the patient's current health care status and readiness for discharge to home. d. Give the patient written discharge information and websites for additional information for burn survivors.

ANS: C

An example of a sign of renal failure is a urine output, despite volume resuscitation, of: a. 0.3mL/kg/hr b. 0.6mL/kg/hr c. 0.9 mL/kg/hr d. 1.2mL/kg/hr

ANS: B

Two of the SIRS criteria plus a known or suspected infection is considered which stage is the progression of sepsis? a. Severe sepsis b. Sepsis c. Septic shock d. Presepsis

ANS: B

A patient is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurses assesses the patient for which of the following manifestations? a. Weight loss b. Bilateral crackles c. Distended neck veins d. Peripheral pitting edema

ANS: B Pulmonary edema is the basis of ARDS - we see a component of pulmonary edema when pt goes into ARDS.

While performing triage in the emergency department, the nurse determines that which of the following patients should be seen first? a. A patient with a deformed leg indicating a fractured tibia; blood pressure 110/60 mm Hg, pulse 86 beats/min, respirations 18 breaths/min. b. A patient with burns on the face and chest; blood pressure 120/80 mm Hg, pulse 92 beats/min, respirations 24 breaths/min. c. A patient with type 1 diabetes in ketoacidosis; blood pressure 100/60 mm Hg, pulse 100 beats/min, respirations 32 breaths/min. d. A patient with a respiratory infection with a cough productive of greenish sputum; blood pressure 128/86 mm Hg, pulse 88 beats/min, respirations 26 breaths/min.

ANS: C because of low BP and high pulse and kussmaul respirations = shock Disaster Planning PP

A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which of the following orders implemented by the nurse has the highest priority? a. Insert an indwelling urinary catheter. b. Insert two large-bore intravenous catheters. c. Administer 0.9% normal saline at 100 mL/hr. d. Administer 100% oxygen by non-rebreather mask.

ANS: D

What occurs during the refractory stage of shock? A. Cardiac output (CO) is decreased, and tissue perfusion is threatened. B. Compensatory mechanisms begin failing. C. Homeostatic mechanisms begin to work. D. Shock becomes unresponsive to therapy.

ANS: D

When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which of the following findings is of most concern to the nurse? a. Urine output of 35 ml/hr b. Serum K+ of 4.5 mEq/L c. Decreased bowel sounds d. Blood pressure of 86/72 mm Hg

ANS: D No pulse pressure so no circulation.

During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burns, hypovolemia occurs primarily as a result of a. blood loss from injured tissue. b. third spacing of fluid into fluid-filled vesicles. c. evaporation of fluid from denuded body surfaces. d. capillary permeability with fluid shift to the interstitium.

ANS: D This is why swelling with burns is such a huge complication and needs to be assessed at all times.

Assessment of a male patient during the primary survey indicates delayed capillary refill of the extremities. He cannot explain the events before admission to the ED. Which action should the nurse take immediately? a. Apply leads to the patient's chest to initiate ECG monitoring. b. Insert one or two large-bore IV catheters to start IV fluid resuscitation. c. Continue the primary survey to complete a brief neurologic examination. d. Initiate pulse oximetry by placing a monitoring device on the patient's index finger.

ANS: D because it deals with airway!! B says one OR two; we NEED 2!! Disaster Planning PP

Septic shock is caused by which source? a. Allergens b. Loss of sympathetic tone c. Microorganisms d. Non-immunologic activation of mast cells and basophils

ANS: C

A nurse witnesses a patient going into pulmonary edema. The patient exhibits respiratory distress, but the blood pressure is stable at this time. While waiting for help to arrive, the nurse performs the following actions in which order of priority? a. Rechecks vital signs b. Places the patient in high fowler's position c. Calls the respiratory therapy department for a ventilator d. Places the patient on a pulse oximeter and cardiac monitor e. Begins the patient's oxygen at 2 liters by nasal cannula as needed f. Administers the patient morphine sulfate intravenous injection as needed

B, E, D, A, F, C (D then A because intervention then reassessment!) MSC increases O2 supply by vasodilation!!!