HESI SAUNDERS COMPLEX CARE Exam Questions and Answers| Latest
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An anaphylactic section requires immediate actions, starting with quickly assessing the client's
respiratory status. Although the PHCP and the Rapid Response Team must be notified
immediately, the nurse must stay with the client. Oxygen is administered and an IV normal
saline is started and infused per PHCP prescription. Documentation of the event, actions taken,
and client outcomes needs to be done. The head of the bed should be elevated if the client's
blood pressure is normal.
A client in shock develops a central venous pressure of 2mmHg and a mean arterial pressure of
60 mmHg. Which prescribed intervention should the nurse implement first?
1. Increase the rate of O2 flow
2. Obtain arterial gas results
3. Insert an indwelling urinary catheter
4. Increase the rate of IV fluids 4
The MAP and CVP are both low for this client, indicating a state of shock. 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 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 clients
response to prescribed therapy, but these are not the priority.
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 minimally
suspects which stage of shock based on this data?
1. Stage 1
, 2. Stage 2
3. Stage 3
4. Stage 4 2
Shock is categorized by 4 stages. Stage 1 is characterized by restlessness, increased heart rate,
cool and pale skin, and agitation. Stage 2 is characterized by cardiac output of less than 4 to 6
liters per minute, systolic blood pressure less than 100 mmHg, decreased urinary output,
confusion and cerebral perfusion pressure than is less than 70 mmHg. Stage 3 is characterized
by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4
is characterized ass unresponsiveness to vasopressors, profound hypotension, slowed heart rate
and multiple organ failure. Most often, the client will not survive.
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 knows that which intervention is the priority for this
client?
1. Administration of digoxin
2. Administrations of whole blood
3. Administration of intravenous fluids
4. Administration of packed red blood cells 1
The client in this question is likely experiencing cariogenic shock secondary to heart failure
exacerbation. It is important to note that if the shocks state is cardiogenic in nature, the infusion
of volume-expanding fluids may result in pulmonary edema; therefore restoration of cardiac
function is priority for this type of shock. Cardiotonic mediations 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 may further complicate the clients clinical status; therefore they should be
avoided.
Which clinical findings are consistent with sepsis diagnostic criteria? (SELECT ALL THAT APPLY.)
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An anaphylactic section requires immediate actions, starting with quickly assessing the client's
respiratory status. Although the PHCP and the Rapid Response Team must be notified
immediately, the nurse must stay with the client. Oxygen is administered and an IV normal
saline is started and infused per PHCP prescription. Documentation of the event, actions taken,
and client outcomes needs to be done. The head of the bed should be elevated if the client's
blood pressure is normal.
A client in shock develops a central venous pressure of 2mmHg and a mean arterial pressure of
60 mmHg. Which prescribed intervention should the nurse implement first?
1. Increase the rate of O2 flow
2. Obtain arterial gas results
3. Insert an indwelling urinary catheter
4. Increase the rate of IV fluids 4
The MAP and CVP are both low for this client, indicating a state of shock. 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 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 clients
response to prescribed therapy, but these are not the priority.
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 minimally
suspects which stage of shock based on this data?
1. Stage 1
, 2. Stage 2
3. Stage 3
4. Stage 4 2
Shock is categorized by 4 stages. Stage 1 is characterized by restlessness, increased heart rate,
cool and pale skin, and agitation. Stage 2 is characterized by cardiac output of less than 4 to 6
liters per minute, systolic blood pressure less than 100 mmHg, decreased urinary output,
confusion and cerebral perfusion pressure than is less than 70 mmHg. Stage 3 is characterized
by edema, excessively low blood pressure, dysrhythmias, and weak and thready pulses. Stage 4
is characterized ass unresponsiveness to vasopressors, profound hypotension, slowed heart rate
and multiple organ failure. Most often, the client will not survive.
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 knows that which intervention is the priority for this
client?
1. Administration of digoxin
2. Administrations of whole blood
3. Administration of intravenous fluids
4. Administration of packed red blood cells 1
The client in this question is likely experiencing cariogenic shock secondary to heart failure
exacerbation. It is important to note that if the shocks state is cardiogenic in nature, the infusion
of volume-expanding fluids may result in pulmonary edema; therefore restoration of cardiac
function is priority for this type of shock. Cardiotonic mediations 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 may further complicate the clients clinical status; therefore they should be
avoided.
Which clinical findings are consistent with sepsis diagnostic criteria? (SELECT ALL THAT APPLY.)
