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When caring for a patient with C. Pulmonary vascular resistance (PVR)
pulmonary hypertension, which Rationale: ANS: 3PVR is a major contributor to pulmonary
parameter is most appropriate hypertension, and a decrease would indicate
for the nurse to that pulmonary hypertension was improving. The other
monitor to evaluate the parameters also may be monitored but
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)
A 78-kg patient with septic A. Give PRN furosemide (Lasix) 40 mg IV.
shock has a urine output of Rationale: ANS: 1Furosemide will lower the filling pressures
30 mL/hr for the past 3 and renal perfusion further for the patient
hours. The pulse rate is with septic shock. The other orders are appropriate.
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
,Following surgery for an B. Increase the IV fluid infusion per protocol.
abdominal aortic aneurysm, a Rationale: ANS: 2A low CVP indicates hypovolemia and a
patient's central venous need for an increase in the infusion rate.
pressure (CVP) monitor Diuretic administration will contribute to hypovolemia and
indicates elevation of the head may decrease
low pressures. Which action is cerebral perfusion. Documentation and continued monitoring
a priority for the nurse to is an inadequate response to the
take? low CVP.
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
A nurse is caring for a client who D. Thready pulse
sustained blood loss. Which of Rationale: A decreased volume of circulating blood and less
the following is a pressure within the vessels results in weak thready peripheral
manifestation of pulses and flattened neck veins
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
, A nurse is caring for client A. Notify the client to return to the clinic for initiation of antibiotic
whose throat culture is therapy
positive for group A
streptococcus 24 hr after the
rapid strep test (RST) was
negative. Which of the
following is the priority
nursing action?
A nurse is assessing a client who A. Indicates the need for total nursing care
has an 8 score using the Rationale: The nurse understands a Glasgow Coma score of 8
Glasgow Coma Scale to indicates the client is in a coma and
evaluate levels of requires total nursing care.
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