Nursing care for pt with shock
A pt with GI bleeding is awake, A&O and as the following VS measurements: BP 130/90 118bpm, resp 18/min and temp 98.6 degree F (37 degree C). Which sign should the LPN consider as a possible sign of early shock?
What is: Heart rate
A female patient arrives at the HCP’s office for a routine checkup. The nurse notes that the patient has several risk factors for osteoporosis. Which test does the nurse expect the HCP to prescribe?
What is:
A dual-energy x-ray absorptiometry (DEXA)
(DAILY DOUBLE)
While observing the neurologist complete a neurological examination, the nurse notes that a patient has an absent left patellar reflex. Which possible areas of dysfunction does the nurse consider? (Select all that apply)
What is:
Spinal cord, Femoral nerve, and quadriceps femoris muscle
Which medications might be ordered to treat an immune disorder? (Select all that apply.)
What is:
Antihistamine, epinephrine, corticosteroids, antibiotic, and interferon
The nurse is collecting information about a patient’s auditory system during a physical examination. Which process will the nurse perform first?
What is:
Observation of the patient’s behavior
The nurse can expect a patient who lost 2 liters of blood after a gunshot wound to experience which type of shock?
What is: Hypovolemic shock
A patient with gout has been instructed on the prescribed medication allopurinol (Zyloprim). Which patient statement indicates understanding of the action of this medication?
What is:
It blocks formation of uric acid
The nurse is preparing to perform a Romberg test on a client. The nurse instructs the patient to stand with the feet together and eyes closed. After 20 seconds, the patient leans to one side and exhibits a swaying motion. Which conclusion can the nurse draw from these test results?
What is:
The test is positive and indicates cerebellar dysfunction
The nurse is reinforcing teaching to a person with HIV and is concerned about having AIDS. Which lab test is most concerning to the nurse?
What is:
CD4 countDuring a health history, the nurse suspects that a patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply.)
Diabetes, Cataracts, blindness and glaucoma
The nurse is caring for a group of patients. Which patient is at high risk for developing sepsis?
What is: A banker with HIV
A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition the pt’s leg was fractured. Which areas should include the pt’s neurovascular checks?
What is:
Pulse, Sensation, and Movement
The nurse is using the FOUR tool to assess a patient’s neurological functioning. In which areas does the nurse collect data when using this tool? (Select all that apply.)
What is:
Reflexes, eye responses, motor movement, and breathing patterns
he nurse is caring for a patient who has an enlarged, painful, and movable lymph node. What can the nurse hypothesize from this finding?
What is:
The patient may have an infection
(DAILY DOUBLE)
The nurse places eye drops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements are concerning and requiring additional teaching? (Select all that apply)
What is:
I should exercise my patched eye four times daily
I can watch television without moving my eye too much
I should apply pressure to the tear duct of the eye every 5 minutes
I should try to open my eyelid under the patch hourly while awake
The nurse is assisting in the care of a patient with early signs and symptoms of septic shock. Which diagnostic tests should the nurse expect to be prescribed for this patient? (Select all that apply)
What is: Procalcitonin, Chest x-ray, Endotoxins, C-reactive proteins and cardiac isoenzymes
A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The health-care provider (HCP) plans to perform an arthrocentesis. What action should the nurse implement after the procedure?
What is:
Monitor the site for bleeding and bruising
The nurse enters the room of a patient who has recently experienced a stroke. The nurse
discovers the patient lying flat and choking on saliva. What action should the nurse take firs
The nurse enters the room of a patient who has recently experienced a stroke. The nurse discovers the patient lying flat and choking on saliva. What action should the nurse take first?
What is:
Elevate the head of the bed
(DAILY DOUBLE)
The nurse is teaching a patient about a newly diagnosed latex allergy. Which food should be avoided because of latex reactivity?
What is:
Kiwi
A patient’s Snellen chart findings are 20/60. What does this information represent?
What is:
The patient must be at 20 feet to see what someone else can see at 60 feet
Which are complications of shock that the nurse should be aware of and monitoring for? (Select all that apply)
An older adult patient experiences a fracture of the lower leg and undergoes a closed reduction and placement of a fiberglass cast. What should the nurse prepare for when planning care?
What is:
Delay of healing
The nurse is assisting with a patient who was injured in an accident and experienced head injury. The RN records the patient as exhibiting decorticate posturing. Which condition does the nurse associate with the RN’s finding?
What is:
Significant impairment of cerebral functioning
The nurse is reviewing laboratory values for a patient and notes a red blood cell (RBC) count of 2.9 x 10⁶ cells/microL. How should the nurse document this finding?
What is:
Anemia
The caregiver of a patient with macular degeneration tells the nurse that they are frustrated because the patient frequently spills food and drinks, making a mess. How should the nurse reply?
What is:
The central vision is gone and only peripheral vision remains, making blind spots