NUR417 / NUR 417 EXAM 1 Care of Adult II | Questions
and Verified Answers | Latest Update 2026/2027 |
Graded A+ - Concordia.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which
action should be included in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Measure the patient's urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
Answer
B
Monitoring urine output will help determine whether the patient's cardiac output has
improved and also help monitor for balloon displacement blocking the renal arteries.
The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent
thrombus formation. Limited movement is allowed for the extremity with the balloon
insertion site to prevent displacement of the balloon.
Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse
gives to reduce a patient's left ventricular afterload?
a. Mean arterial pressure (MAP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
,Answer
B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters
may be monitored but do not reflect afterload as directly.
The nurse is caring for a patient receiving a continuous norepinephrine IV infusion.
Which patient assessment finding indicates that the infusion rate may need to be
adjusted?
a. Heart rate is slow at 58 beats/min.
b. Mean arterial pressure (MAP) is 56 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low.
ANSWER
C
Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the
work of the heart and decrease peripheral perfusion. The infusion rate may need to be
decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not
associated with norepinephrine infusion.
When evaluating a patient with a central venous catheter, the nurse observes that the
insertion site is red and tender to touch and the patient's temperature is 101.8° F. What
should the nurse plan to do?
a. Discontinue the catheter and culture the tip.
b. Use the catheter only for fluid administration.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.
ANSWER
A
The information indicates that the patient has a local and systemic infection caused by
the catheter, and the catheter should be discontinued to avoid further complications
such as endocarditis. Changing the flush system, continued monitoring, or using the line
for fluids will not help prevent or treat the infection.
,stroke volume
A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac
output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest
whole number.)
ANSWER
52
Stroke volume = Cardiac output/heart rate52 mL = (4.7 L x 1000 mL/L)/90
After surgery for an abdominal aortic aneurysm, a patient's central venous pressure
(CVP) monitor indicates low pressures. Which action should the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient's bed to 45 degrees.
ANSWER
B
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
Diuretic administration will contribute to hypovolemia and elevation of the head or
increasing vasodilators may decrease cerebral perfusion.
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic
shock. Which assessment data indicate to the nurse that the goals of treatment with the
IABP are being met?
a. Urine output of 25 mL/hr
b. Heart rate of 110 beats/minute
c. Cardiac output (CO) of 5 L/min
d. Stroke volume (SV) of 40 mL/beat
ANSWER
C
, A CO of 5 L/min is normal and indicates that the IABP has been successful in treating
the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low
urine output also suggest continued cardiogenic shock.
A nurse is discussing the concept of shock with a new graduate nurse. Which statement
indicates the new graduate nurse understood the information?
a. Shock is a physiologic state resulting in hypotension and tachycardia.
b. Shock is an acute, widespread process of inadequate tissue perfusion.
c. Shock is a degenerative condition leading to organ failure and death.
d. Shock is a condition occurring with hypovolemia that results in hypotension.
ANSWER
B
Shock is an acute, widespread process of impaired tissue perfusion that results in
cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic
process that often results in multiple-organ dysfunction syndrome and death. All types of
shock eventually result in ineffective tissue perfusion and the development of acute
circulatory failure.
PTS: 1 DIF: Cognitive Level: Understanding REF: p. 801
OBJ: Nursing Process Step: Diagnosis TOP: Shock
MSC: NCLEX: Physiologic Integrity
Which assessment information is most important for the nurse to obtain to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANSWER
D
Because the airway edema that is associated with anaphylaxis can affect airway and
breathing, the oxygen saturation is the most critical assessment. Improvements in the
other assessments will also be expected with effective treatment of anaphylactic shock.
and Verified Answers | Latest Update 2026/2027 |
Graded A+ - Concordia.
The nurse is caring for a patient who has an intraaortic balloon pump in place. Which
action should be included in the plan of care?
a. Avoid the use of anticoagulant medications.
b. Measure the patient's urinary output every hour.
c. Provide passive range of motion for all extremities.
d. Position the patient supine with head flat at all times.
Answer
B
Monitoring urine output will help determine whether the patient's cardiac output has
improved and also help monitor for balloon displacement blocking the renal arteries.
The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent
thrombus formation. Limited movement is allowed for the extremity with the balloon
insertion site to prevent displacement of the balloon.
Which hemodynamic parameter best reflects the effectiveness of drugs that the nurse
gives to reduce a patient's left ventricular afterload?
a. Mean arterial pressure (MAP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
,Answer
B
SVR reflects the resistance to ventricular ejection, or afterload. The other parameters
may be monitored but do not reflect afterload as directly.
The nurse is caring for a patient receiving a continuous norepinephrine IV infusion.
Which patient assessment finding indicates that the infusion rate may need to be
adjusted?
a. Heart rate is slow at 58 beats/min.
b. Mean arterial pressure (MAP) is 56 mm Hg.
c. Systemic vascular resistance (SVR) is elevated.
d. Pulmonary artery wedge pressure (PAWP) is low.
ANSWER
C
Vasoconstrictors such as norepinephrine will increase SVR, and this will increase the
work of the heart and decrease peripheral perfusion. The infusion rate may need to be
decreased. Bradycardia, hypotension (MAP of 56 mm Hg), and low PAWP are not
associated with norepinephrine infusion.
When evaluating a patient with a central venous catheter, the nurse observes that the
insertion site is red and tender to touch and the patient's temperature is 101.8° F. What
should the nurse plan to do?
a. Discontinue the catheter and culture the tip.
b. Use the catheter only for fluid administration.
c. Change the flush system and monitor the site.
d. Check the site more frequently for any swelling.
ANSWER
A
The information indicates that the patient has a local and systemic infection caused by
the catheter, and the catheter should be discontinued to avoid further complications
such as endocarditis. Changing the flush system, continued monitoring, or using the line
for fluids will not help prevent or treat the infection.
,stroke volume
A patient's vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac
output is 4.7 L/min. The patient's stroke volume is _____ mL. (Round to the nearest
whole number.)
ANSWER
52
Stroke volume = Cardiac output/heart rate52 mL = (4.7 L x 1000 mL/L)/90
After surgery for an abdominal aortic aneurysm, a patient's central venous pressure
(CVP) monitor indicates low pressures. Which action should the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient's bed to 45 degrees.
ANSWER
B
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
Diuretic administration will contribute to hypovolemia and elevation of the head or
increasing vasodilators may decrease cerebral perfusion.
An intraaortic balloon pump (IABP) is being used for a patient who is in cardiogenic
shock. Which assessment data indicate to the nurse that the goals of treatment with the
IABP are being met?
a. Urine output of 25 mL/hr
b. Heart rate of 110 beats/minute
c. Cardiac output (CO) of 5 L/min
d. Stroke volume (SV) of 40 mL/beat
ANSWER
C
, A CO of 5 L/min is normal and indicates that the IABP has been successful in treating
the shock. The low SV signifies continued cardiogenic shock. The tachycardia and low
urine output also suggest continued cardiogenic shock.
A nurse is discussing the concept of shock with a new graduate nurse. Which statement
indicates the new graduate nurse understood the information?
a. Shock is a physiologic state resulting in hypotension and tachycardia.
b. Shock is an acute, widespread process of inadequate tissue perfusion.
c. Shock is a degenerative condition leading to organ failure and death.
d. Shock is a condition occurring with hypovolemia that results in hypotension.
ANSWER
B
Shock is an acute, widespread process of impaired tissue perfusion that results in
cellular, metabolic, and hemodynamic alterations. It is a complex pathophysiologic
process that often results in multiple-organ dysfunction syndrome and death. All types of
shock eventually result in ineffective tissue perfusion and the development of acute
circulatory failure.
PTS: 1 DIF: Cognitive Level: Understanding REF: p. 801
OBJ: Nursing Process Step: Diagnosis TOP: Shock
MSC: NCLEX: Physiologic Integrity
Which assessment information is most important for the nurse to obtain to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANSWER
D
Because the airway edema that is associated with anaphylaxis can affect airway and
breathing, the oxygen saturation is the most critical assessment. Improvements in the
other assessments will also be expected with effective treatment of anaphylactic shock.
