Shock
The emergency department nurse assesses for which clinical manifestation in the client suspected to be in the compensatory stage of shock?
1. Decreased heart rate and decreased urinary output
2. Increased heart rate and decreased urinary output
3. Decreased blood pressure and increased heart rate
4. Decreased pulse pressure and decreased heart rate
2. Increased heart rate and decreased urinary output
A client with a longstanding diagnosis of genearlized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which of acid-base imbalance?
1. Respiratory Acidosis
2. Respiratory Alkalosis
3. Increased PaCO2
4. CNS disturbances
2. Respiratory Alkalosis
The nurse assesses for which predisposing factor for embolic stroke in the history of the client admitted to the hospital after having a stroke?
1. Seizures
2. Psychotropic drug use
3. Atrial fibrillation
4. Cerebral aneurysm
3. Atrial fibrillation
The nurse assesses a patient’s GCS score to be 3. What is the best interpretation by the nurse?
1. Does not open eyes, no motor response, and no verbal response
2. Opening eyes spontaneously, obeys verbal commands, and is oriented
3. Opening eyes to voice, localizing to pain, and is disoriented but converses
4. Opens eyes to pain, localizes to pain, and uses inappropriate words
1. Does not open eyes, no motor response, and no verbal response
The nurse administers mannitol (Osmitrol) to the client with increased intracranial pressure. Which parameter requires close monitoring?
1. Muscle relaxation
2. Intake and output
3. Widening of the pulse pressure
4. Pupil dilation
2. Intake and output
When assessing a client for early septic shock, the nurse should assess the client for which of the following?
1.Cool, clammy skin
2.Warm, flushed skin
3.Increased blood pressure
4.Hemorrhage
2.Warm, flushed skin
The nurse is caring for a patient with arterial blood gas results of: pH 7.18, PCO2 35, HCO3 15, and Pa O2 84%. The patient has a blood glucose level of 845. How should the nurse interpret these results?
1. Respiratory acidosis
2. Metabolic acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis
2. Metabolic acidosis
Which nursing intervention will be used for the client during the first 72 hours after an ischemic stroke to prevent complications?
1. Administer analgesics as ordered to promote pain relief
2. Cluster nursing procedures together to avoid fatiguing the client
3. Monitor neurologic and vital signs closely to determine early changes in status
4. Position with a flat back rest to enhance cerebral perfusion
3. Monitor neurologic and vital signs closely to determine early changes in status
A nurse is shopping and finds a woman who has collapsed with right-sided weakness and slurred speech. Which of the following action should the nurse take?
1. Provide the client with water to test the gag reflex.
2 Perform carotid massage.
3. Notify emergency management services.
4. Drive the client to the nearest medical facility.
3. Notify emergency management services.
Mechanical ventilation with a rate and volume to maintain a mild hyperventilation is used for a patient with marked increased intracranial pressure. The nurse knows that the rationale for this therapy is to
1. prevent cerebral alkalosis
2. decrease cerebral metabolism
3. promote cerebral vasoconstriction
4. prevent tissue hypoxia to the brain
3. promote cerebral vasoconstriction
A patient with hypovolemic shock has a urinary output of 30 mL/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is
1. Release of aldosterone, which increases serum osmolarity, causing release of ADH
2. Movement of interstitial fluid to the intravascular space, increasing renal blood flow
3. Activation of the sympathetic nervous system, causing vasodilation of the renal arteries
4. Beta-adrenergic receptor stimulation that causes increased cardiac output as a result of increased heart rate and myocardial contractility
1. Release of aldosterone, which increases serum osmolarity, causing release of ADH
A patient having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis. Which nursing action should the nurse take first?
1. Administer nasal oxygen at 6 L/min.
2. Give the patient a glass of orange juice.
3. Place the patient in high Fowler position.
4. Have the patient rebreathe air from a paper bag.
4. Have the patient rebreathe air from a paper bag.
The nurse admits a patient to the ED with new onset of slurred speech and right-sided weakness. What is the priority nursing action?
1. Assess for the presence of a headache.
2. Assess the patient’s general orientation.
3. Determine the patient’s drug allergies.
4. Determine the time of symptom onset.
4. Determine the time of symptom onset.
The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses a blood pressure of 180/90 mm Hg, heart rate 60 beats/min, respirations 24/min, and 50 mL of urine via Foley catheter for the past 4 hours. What is the best action by the nurse?
1. Administer acetaminophen as ordered for the headache
2. Assess for a kinked Foley catheter or bowel impaction
3. Begin an infusion of sodium nitroprusside (Nipride)
4. Notify the physician of the patient’s blood pressure
2. Assess for a kinked Foley catheter or bowel impaction
The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mmHg. What should the nurse do first?
1. Position the client on the left side
2. Control the environment by turning the lights off and decreasing stimulation for the client
3. Check the client’s bladder for distension
4. Administer pain medications
3. Check the client’s bladder for distension
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?
1. The patient is receiving low dose dopamine.
2. The patient’s central venous pressure is 1 mm Hg.
3. The patient is in sinus tachycardia at 120 beats/min.
4. The patient has had no urine output since admission.
2. The patient’s central venous pressure is 1 mm Hg.
A patient with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding indicates that the patient’s compensatory mechanisms are working?
1. Vomiting
2. Excessive thirst
3. Watery diarrhea
4. Deep rapid breathing
4. Deep rapid breathing
A client has arrived by ambulance at the emergency department after a cervical spinal cord injury. Which assessment is a priority for the nurse to perform at this time?
1. Mental status
2. Heart rate and rhythm
3. Muscle strength and reflexes
4. Respiratory pattern and airway
4. Respiratory pattern and airway
The nurse admits a patient to the ED with a suspected cervical spine injury. What is the priority nursing action?
1. Keep the neck in the hyperextended position
2. Maintain proper head and neck alignment
3. Prepare for immediate endotracheal intubation
4. Remove cervical collar upon arrival to the ED
2. Maintain proper head and neck alignment
Which problem is considered a priority for a client who experienced a stroke 24 hours ago?
1. Disturbed Sensory Perception
2. Impaired Physical Mobility
3. Ineffective Cerebral Tissue Perfusion
4. Impaired Swallowing
3. Ineffective Cerebral Tissue Perfusion
The health care provider prescribes the following interventions for a 67-kg patient who has septic shock with a blood pressure of 70/42 mm Hg and O2 saturation of 89% on room air. In which order will the nurse implement the actions?
1. Obtain blood and urine cultures.
2. Give vancomycin by IV infusion.
3. Start norepinephrine 0.5 mcg/min.
4. Infuse normal saline 2000 mL over 30 minutes.
5. Administer oxygen to keep O2 saturation above 95%.
5. Administer oxygen to keep O2 saturation above 95%.
4. Infuse normal saline 2000 mL over 30 minutes.
3. Start norepinephrine 0.5 mcg/min.
1. Obtain blood and urine cultures.
2. Give vancomycin by IV infusion.
The nurse reviews the following results for an arterial blood gas (ABG). How does the nurse interpret these results? pH 7.46, PCO2 33, HCO3 24, PaO2 88%
1. Metabolic acidosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis
4. Respiratory alkalosis
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select All That Apply
1. Mean arterial pressure (MAP)
2. Urine output
3. Bowel sounds
4. Cerebral perfusion pressure
5. Level of pain
1. Mean Arterial Pressure
4. Cerebral perfusion pressure
A client is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the client’s arrival? Select All That Apply
1. Reflexes
2. Bladder function
3. Blood pressure
4. Temperature
5. Respirations
3. Blood pressure
4. Temperature
5. Respirations
The nurse suspects that a patient is experiencing increasing ICP. What observations cause the nurse to come to this conclusion? (Select all that apply.)
1. Headache
2. Rising temperature
3. Decreasing systolic pressure
4. Dilated pupil on affected side
5. Decreasing level of consciousness (LOC)
1. Headache
2. Rising temperature
4. Dilated pupil on affected side
5. Decreasing level of consciousness (LOC)