RN 402 ATI Shock Practice Questions | Answered with Rationales

RN 402 ATI Shock Practice Questions | Answered with Rationales When caring for a patient with pulmonary hypertension, which parameter is most appropriate for the nurse to monitor to evaluate the effectiveness of the treatment? A. Central venous pressure (CVP) B. Systemic vascular resistance (SVR) C. Pulmonary vascular resistance (PVR) D. Pulmonary artery wedge pressure (PAWP) Rationale: ANS: 3PVR is a major contributor to pulmonary hypertension, and a decrease would indicate that pulmonary hypertension was improving. The other parameters also may be monitored but A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hours. The pulse rate is 120/minute and the central venous pressure and pulmonary artery wedge pressure are low. Which order by the health care provider will the nurse question? A. Give PRN furosemide (Lasix) 40 mg IV. B. Increase normal saline infusion to 250 mL/hr. C. Administer hydrocortisone (Solu-Cortef) 100 mg IV. D. Titrate norepinephrine (Levophed) to keep systolic BP 90 mm Hg Rationale: ANS: 1Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock. The other orders are appropriate. Following surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action is a priority for the nurse to take? A. Administer IV diuretic medications. B. Increase the IV fluid infusion per protocol. C. Document the CVP and continue to monitor. D. Elevate the head of the patient's bed to 45 degrees Rationale: ANS: 2A 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 may decrease cerebral perfusion. Documentation and continued monitoring is an inadequate response to the low CVP. A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate Rationale: The heart rate of a client with hypovolemia will be increased. B. Dyspnea Rationale: Dyspnea is characteristic of respiratory conditions, but is not usually associated with hypovolemia. C. Increased blood pressure Rationale: The client's blood pressure will decrease due to decreased blood volume. D. Thready pulse Rationale: A decreased volume of circulating blood and less pressure within the vessels results in weak thready peripheral pulses and flattened neck veins A nurse is caring for client whose throat culture is positive for group A streptococcus 24 hr after the rapid strep test (RST) was negative. Which of the following is the priority nursing action? Notify the client to return to the clinic for initiation of antibiotic therapy A nurse is assessing a client who has an 8 score using the Glasgow Coma Scale to evaluate levels of consciousness. Which of the following nursing statements most accurately describes the score? A. Indicates the need for total nursing care B. Reflects an alert client C. Indicates a client in a deep coma D. Indicates stable neurological status Rationale: The nurse understands a Glasgow Coma score of 8 indicates the client is in a coma and requires total nursing care. A client with a BMI of 60.2 kg/mm is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending MODS. What should the nurse prepare to implement first? A. Platelet transfusion B. Mechanical ventilation C. Loop diuretic therapy D. Cyanocobalamin administration On admission to the intensive care unit for sepsis due to ruptured appendix, a female client's temperature is 39.8 degree Celsius and her blood pressure is 68/42 mm Hg. Other hemodynamic findings include cardiac output of 10.7 L/min, SVR 4802 dynes/sec/cm5, and WBC 28,000. Which classification of medications is likely to stabilize the client? A. ACE inhibitors. B. Negative inotropes. C. Vasoconstrictors. D. Diuretics Six hours after surgery of a ruptured appendix, a client has a WBC of 17, abdominal tenderness, and abdominal rigidity. The nurse should recognize that the client is exhibiting symptoms of which condition? A. Regional enteritis. B. Peritonitis. C. Colitis. D. Gastritis A nurse is caring for four hospitalized clients. Which of the following clients is at greatest risk for fluid volume deficit? the client who has just been admitted, has gastroenteritis and is febrile A client is admitted to the emergency room with a respiratory rate of seven per min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm HG Saturation 80% Bicarbonate 28 mEq/L Respiratory acidosis A triage nurse in an emergency department is caring for a client who has a gunshot wound to the right side of her chest. The nurse notes a thick dressing on the chest and a sucking noise coming from the wound. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take initially? a. raise the foot of the bed to a 90 degree angle b. remove the dressing to inspect the wound c. prepare to insert a central line d. administer O2 via nasal cannula A nurse in the emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following is the priority intervention? auscultate for wheezing A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following should the nurse expect in the findings? excessive thrombosis and bleeding A nurse is caring for a client who has hypovolemic shock. Which of the following is an expected finding? a. hypertension b. purpura c. oliguria d. bradypnea A nurse is caring for an adult client who is in the compensatory stage of shock. Which of the following is an expected finding? a. mottled skin b. blood pressure 115/68 mmHg c. heart rate 160/min d. metabolic acidosis A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? a. decrease in the resp. rate from 20 to 16 b. decrease in urinary output from 50 to 30 mL per hour c. increase the temperature from 37.5 to 38.6 d. increase in heart rate from 88 to 110 A client experiences anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? a. dobutamine b. corticosteriods c. furosemide d. epinephrine Rationale: Epinephrine does reverse the most severe manifestations of anaphylactic shock; therefore, should be the treatment of choice. A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has septic shock. Which of the following nursing statements indicates an understanding of the condition? A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count" C. "DIC is caused by abnormal coagulation involving fibrinogen." D. "DIC is a genetic disorder involving vitamin K deficiency." A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Decreased urine output C. Narrowing pulse pressure D. Decreased level of consciousness Rationale: Narrowing pulse pressure is the earliest indicator of shock. A septic patient with hypotension is being treated with dopamine hydrochloride. The nurse asks a colleague to double-check the dosage that the client is receiving. There are 400 mg of dopamine hydrochloride in 250 ml D5W, the infusion pump is running at 23 ml/hr, and the client weighs 79.5 kg. How many micrograms per kilogram per minute (mcg/kg/min) is the client receiving? Do not round off your answer 7.71 mkg/kg/min When initiating a dopamine IV infusion for hypotensive client, which intervention should the nurse include in the client's plan of care? A. Assess bilateral breath sounds. B. Perform neuro assessment every 12 hours. C. Monitor urine output every hour. D. Observe pulmonary capillary wedge pressure Assuming that vascular volume is adequate, which medication would have the strongest effect on raising the blood pressure in a hypotensive patient? A. norepinephrine (Levophed). B. dobutamine (Dobutrex). C. epinephrine (Adrenalin). D. esmolol (Brevibloc). A nurse is caring for a client who has hypovolemic shock. Which of the following blood products does the nurse anticipate administering to this client? A. Cryoprecipitates B. Platelets C. Fresh frozen plasma (FFP) Dd. Pack red blood cells A nurse on a critical care unit is caring for a client who has shallow and rapid respirations, paradoxical pulse, CVP 4 cm H2O, BP 90/50 mm Hg, skin cold and pale, and urinary output 55 mL over the last 2 hr. From these findings, the nurse concludes that he may be developing which of the following? A. Hypovolemic shock B. Cardiac tamponade C. Sepsis D. Atelectasis Rationale: The client's signs and symptoms are all indicative of hypovolemic shock. The nurse should conclude that the client may be developing this outcome. A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion? A. Confusion B. lethargy C. unconsciousness d. Petechiae Rationale: Confusion characterizes the compensatory stage of shock, as do decreased urinary output, cold and clammy skin, and respiratory alkalosis A nurse is assessing a client who is postoperative and has anemia due to excess blood loss during surgery. The nurse should expect which of the following findings? A. Fatigue B. Respiratory depression C. Bradycardia D. Muscle cramps Rationale: Fatigue is an expected finding with a client who has anemia due to surgical blood loss. This is because of the decreased ability of the body to carry oxygen to vital tissues and organs. A nurse is caring for a client who has a prescription for an afterload‐reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? Cardiogenic A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? Administer Antibiotic therapy A nurse in the emergency department is caring for a client who had an allergic reaction related to a bee sting. The client is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? Epinephrine IV A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? Seizure activity Respiratory rate 42/min Weak, thready pulse A nurse in a cardiac unit is assisting with the admission of a client who is to undergo hemodynamic monitoring. Which of the following actions should the nurse anticipate performing? Assist with the insertion of pulmonary artery catheter The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a.Assess the blood pressure by Doppler. b.Estimate the systolic pressure as 60 mm Hg. c.Obtain an electronic blood pressure monitor. d.Record the blood pressure as "not assessable." The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with severe sepsis. One hour later, which laboratory result requires immediate nursing action? a.Creatinine 1.0 mg/dL b.Lactate 6 mmol/L c.Potassium 3.8 mEq/L d.Sodium 140 mEq/L The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a.Breath sounds and capillary refill b.Blood pressure and oral temperature c.Oral temperature and capillary refill d.Right atrial pressure and urine output The nurse is caring for a young adult patient admitted with shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a.Blood pressure b.Heart rate c.Level of consciousness d.Pupil response e.Respirations f.Urine output A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg. The nurse anticipates administering which therapeutic intervention? a.Human albumin infusion b.Hypotonic saline solution c.Lactated Ringer's bolus d.Packed red blood cells A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse? a.The assessed values are within normal limits. b.The patient is at risk for developing cardiogenic shock. c.The patient is at risk for developing fluid volume overload. d.The patient is at risk for developing hypovolemic shock. The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL of lactated Ringer solution over the past 4 hours. Morning laboratory results show a hemoglobin of 8 g/dL and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a.Blood transfusion with packed red blood cells is required. b.Hemoglobin and hematocrit results indicate hemodilution. c.Fluid resuscitation has resulted in fluid volume overload. d.Fluid resuscitation has resulted in third spacing of fluid. The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a.High pulmonary artery occlusive pressure and high cardiac output b.High systemic vascular resistance and low cardiac output c.Low pulmonary artery occlusive pressure and low cardiac output d.Low systemic vascular resistance and high cardiac output The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders, which intervention should the nurse carry out first? a.Acetaminophen suppository b.Blood cultures from two sites