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) - Answers C. Pulmonary vascular resistance (PVR)
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 - Answers A. Give PRN
furosemide (Lasix) 40 mg IV.
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 - Answers B. Increase the IV fluid infusion
per protocol.
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 - Answers 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? -
Answers A. 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 - Answers A. Indicates the need for total nursing care
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 - Answers B. Mechanical ventilation
On admission to the intensive care unit for sepsis due to ruptured appendix, a female client's
temperature is 39.8
degree celcius 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 - Answers C. Vasoconstrictors.