Exam 3

The nurse is assessing a patient with a severe traumatic brain injury (TBI). Which finding suggests impending brain herniation?

A) Restlessness and confusion
B) Bilateral equal and reactive pupils
C) Bradycardia, irregular respirations, and hypertension
D) Increased muscle strength in all extremities

✅ Answer: C) Bradycardia, irregular respirations, and hypertension
Rationale: Cushing’s triad (bradycardia, irregular breathing, and hypertension) is a late sign of increased intracranial pressure (ICP) and indicates impending brain herniation. (A) Restlessness is an early sign of increased ICP but not specific to herniation. (B) Normal pupils do not indicate herniation. (D) Increased muscle strength suggests recovery, not herniation.

A patient with a TBI has a Glasgow Coma Scale (GCS) score of 6. Which additional finding is most concerning for brain herniation?

A) Fixed and dilated pupils
B) Blood pressure of 110/70 mmHg
C) Decorticate posturing
D) Heart rate of 100 bpm

A) Fixed and dilated pupils
Rationale: Fixed and dilated (blown) pupils indicate compression of cranial nerve III (oculomotor nerve), a critical sign of Uncal herniation. (B) Normal blood pressure does not indicate herniation. (C) Decorticate posturing suggests severe brain injury but is not as specific as fixed pupils. (D) A heart rate of 100 bpm is not immediately concerning.

A patient with a severe head injury exhibits decerebrate posturing, a GCS of 5, and irregular respirations. What is the nurse’s priority intervention?

A) Elevate the head of the bed to 30 degrees
B) Perform a sternal rub to assess responsiveness
C) Prepare for emergency intubation
D) Administer a bolus of IV fluids

C) Prepare for emergency intubation
Rationale: A GCS ≤ 8 indicates severe neurological compromise, and irregular breathing suggests brainstem dysfunction. Immediate airway protection is required. (A) Elevating the head of the bed is helpful but not the priority. (B) Assessing responsiveness does not address airway compromise. (D) IV fluids do not directly treat brain herniation.

A nurse is monitoring a patient with increased ICP from a TBI. Which change suggests uncal herniation?

A) Sudden hypertension and tachycardia
B) Unilateral dilated pupil with contralateral motor weakness
C) Bilateral pinpoint pupils and bradypnea
D) Increased deep tendon reflexes and tremors

B) Unilateral dilated pupil with contralateral motor weakness
Rationale: Uncal herniation occurs when the medial temporal lobe shifts across the tentorium, compressing cranial nerve III, causing a dilated pupil on the affected side and motor weakness on the opposite side.

The nurse is caring for a patient with a TBI who suddenly becomes unresponsive. What is the most critical assessment?

A) Blood pressure and heart rate
B) Pupil size and reactivity
C) Deep tendon reflexes
D) Bowel and bladder function

✅ Answer: B) Pupil size and reactivity
Rationale: Sudden changes in pupil size, particularly fixed and dilated pupils, suggest brainstem compression and herniation, requiring immediate intervention. (A) Vital signs change later in herniation. (C) Reflexes are not the priority in an emergency. (D) Bowel and bladder function are irrelevant to acute herniation assessment.

1. A patient in hypovolemic shock has the following ABG results: pH 7.30, PaCO₂ 35 mmHg, HCO₃⁻ 18 mEq/L, PaO₂ 85 mmHg. What is the most likely acid-base imbalance?

A) Respiratory acidosis
B) Metabolic acidosis
C) Respiratory alkalosis
D) Metabolic alkalosis

Answer: B) Metabolic acidosis
Rationale: A low pH (acidic) and low bicarbonate (HCO₃⁻) indicate metabolic acidosis. In shock, lactic acidosis develops due to anaerobic metabolism from poor perfusion. (A) Respiratory acidosis would have a high PaCO₂. (C) Respiratory alkalosis

A patient with septic shock is experiencing rapid, deep breathing. What ABG result would the nurse expect?

A) pH 7.50, PaCO₂ 30 mmHg, HCO₃⁻ 22 mEq/L
B) pH 7.28, PaCO₂ 48 mmHg, HCO₃⁻ 26 mEq/L
C) pH 7.35, PaCO₂ 40 mmHg, HCO₃⁻ 24 mEq/L
D) pH 7.60, PaCO₂ 50 mmHg, HCO₃⁻ 30 mEq/L

✅ Answer: A) pH 7.50, PaCO₂ 30 mmHg, HCO₃⁻ 22 mEq/L
Rationale: Early septic shock often causes respiratory alkalosis due to hyperventilation. The low PaCO₂ reflects increased breathing efforts, leading to a higher pH (alkalosis). (B) Respiratory acidosis is incorrect. (C) Normal ABG values do not indicate shock-related changes. (D) Metabolic alkalosis is not expected in septic shock

A nurse reviews ABG results for a patient in cardiogenic shock: pH 7.28, PaCO₂ 50 mmHg, HCO₃⁻ 24 mEq/L. What is the most likely condition?

A) Metabolic acidosis
B) Metabolic alkalosis
C) Respiratory acidosis
D) Respiratory alkalosis

Respiratory acidosis
Rationale: A low pH (acidosis) and high PaCO₂ suggest respiratory acidosis. In cardiogenic shock, pulmonary edema can impair gas exchange, leading to CO₂ retention.

A patient in shock has an ABG showing pH 7.30, PaCO₂ 38 mmHg, HCO₃⁻ 18 mEq/L. Which intervention is most appropriate?

A) Administer sodium bicarbonate
B) Increase oxygen therapy
C) Administer IV fluids to improve perfusion
D) Encourage slow, deep breathing

Answer: C) Administer IV fluids to improve perfusion
Rationale: The ABG shows metabolic acidosis (low pH, low HCO₃⁻), likely from lactic acidosis due to poor perfusion. IV fluids improve circulation and oxygenation, reducing anaerobic metabolism. (A) Sodium bicarbonate is only used in severe cases. (B) Oxygen alone does not correct the perfusion problem. (D) Breathing changes are ineffective for metabolic acidosis.

A patient in septic shock is developing Multiple Organ Dysfunction Syndrome (MODS). Which organ system is typically affected first?

A) Liver
B) Lungs
C) Kidneys
D) Heart

B: Lungs
Rationale: The lungs are usually the first organ to fail in MODS, often leading to Acute Respiratory Distress Syndrome (ARDS) due to inflammatory response and fluid leakage into the alveoli.

Which laboratory finding would be most concerning in a patient with MODS?

A) Creatinine 3.5 mg/dL
B) White blood cell count 12,000/mm³
C) Hemoglobin 14 g/dL
D) Blood glucose 150 mg/dL

A) Creatinine 3.5 mg/dL
Rationale: A high creatinine level suggests acute kidney injury (AKI), a common complication in MODS due to hypoperfusion. (B) An elevated WBC count is expected in infection but not as critical as organ failure. (C) Hemoglobin of 14 g/dL is normal. (D) Mild hyperglycemia is common in stress responses.

The nurse is assessing a patient with MODS. Which clinical finding suggests worsening hepatic dysfunction?

A) Decreased urine output
B) Jaundice and elevated bilirubin levels
C) Increased platelet count
D) Bilateral crackles in the lungs

B) Jaundice and elevated bilirubin levels
Rationale: Liver dysfunction in MODS leads to impaired bilirubin metabolism, causing jaundice. (A) Decreased urine output is associated with kidney failure, (C) MODS often leads to thrombocytopenia (low platelets), and (D) crackles suggest lung involvement but not liver dysfunction.

The nurse suspects MODS in a critically ill patient. Which finding requires immediate intervention?

A) Blood pressure of 92/58 mmHg
B) Lactate level of 7.0 mmol/L
C) Mild confusion and restlessness
D) Urine output of 30 mL/hr

B) Lactate level of 7.0 mmol/L
Rationale: A lactate level >4 mmol/L indicates severe tissue hypoxia and anaerobic metabolism, requiring immediate intervention to improve perfusion. (A) Hypotension is concerning but not as critical as high lactate. (C) Mild confusion is a sign of worsening perfusion but is not the most urgent. (D) Urine output of 30 mL/hr is within an acceptable range.

A patient with MODS develops thrombocytopenia and prolonged bleeding times. The nurse suspects which complication?

A) Acute Respiratory Distress Syndrome (ARDS)
B) Disseminated Intravascular Coagulation (DIC)
C) Acute Kidney Injury (AKI)
D) Myocardial infarction

B) Disseminated Intravascular Coagulation (DIC)
Rationale: DIC is a severe complication of MODS where widespread clotting depletes clotting factors, leading to excessive bleeding. (A, C, and D) do not explain the bleeding abnormalities.

A patient in the ICU has MODS affecting the kidneys and liver. Which finding indicates worsening kidney failure?

A) Increased albumin levels
B) Urine output of 5 mL/hr
C) Decreased ammonia levels
D) Decreased respiratory rate

B) Urine output of 5 mL/hr
Rationale: Severely decreased urine output (oliguria/anuria) is a sign of acute kidney injury (AKI), a key complication in MODS. (A) Albumin typically decreases in MODS. (C) Ammonia levels increase, not decrease, with liver dysfunction. (D) Decreased respiratory rate is not directly related to kidney failure.

Which intervention is most important in the management of MODS?

A) Administering diuretics to increase urine output
B) Providing aggressive IV fluid resuscitation
C) Identifying and treating the underlying cause
D) Restricting enteral nutrition to prevent gut ischemia

Identifying and treating the underlying cause
Rationale: The most important intervention in MODS is addressing the primary cause (e.g., sepsis, trauma) to stop further organ damage. (A, B, and D) may be used selectively but are not the primary focus.

A patient with MODS has progressed to requiring mechanical ventilation. What is the priority nursing intervention?

A) Maintain strict bed rest
B) Monitor for signs of ventilator-associated pneumonia (VAP)
C) Limit fluid intake to prevent pulmonary congestion
D) Position the patient supine to improve lung expansion

Monitor for signs of ventilator-associated pneumonia (VAP)
Rationale: Patients with MODS requiring ventilation are at high risk for VAP. Preventive strategies (e.g., oral care, elevating HOB) are critical. (A) Bed rest increases risk of complications. (C) Fluid restriction may be needed but is not the primary focus. (D) Supine positioning worsens aspiration risk.

Which statement by a nurse about MODS requires correction?

A) "MODS is a progressive condition affecting multiple organ systems."
B) "The lungs are often the first organ affected in MODS."
C) "MODS is always reversible with aggressive treatment."
D) "Sepsis is the most common cause of MODS."

"MODS is always reversible with aggressive treatment."
Rationale: MODS has a high mortality rate, and while early treatment can improve outcomes, it is not always reversible. (A, B, and D) are correct statements.

A patient with MODS develops metabolic acidosis. Which assessment finding is most concerning?

A) Kussmaul respirations
B) Serum pH of 7.32
C) Lactate level of 3.5 mmol/L
D) Blood glucose of 180 mg/dL

A) Kussmaul respirations
Rationale: Kussmaul respirations (deep, rapid breathing) indicate worsening acidosis and respiratory compensation failure, requiring immediate intervention. (B) A pH of 7.32 is mildly low but not as critical as breathing changes. (C) A lactate of 3.5 is concerning but not an emergency. (D) A glucose level of 180 mg/dL is expected in critically ill patients.

The nurse is administering norepinephrine to a patient in septic shock. Which assessment finding indicates the medication is effective?

A) Blood pressure increases to a MAP of 70 mmHg
B) Decreased urine output to 10 mL/hr
C) Extremities become cool and mottled
D) Heart rate decreases to 40 bpm

A) Blood pressure increases to a MAP of 70 mmHg
Rationale: A mean arterial pressure (MAP) of ≥65 mmHg indicates improved perfusion, which is the goal of norepinephrine therapy. (B) Decreased urine output suggests worsening perfusion. (C) Cool, mottled extremities indicate excessive vasoconstriction. (D) Bradycardia is an adverse effect, not a sign of improvement.

The nurse is preparing to administer vasopressin to a patient in septic shock. What is the primary action of this medication?

A) Increases urine output to improve fluid balance
B) Stimulates beta-adrenergic receptors to increase heart rate
C) Causes peripheral vasoconstriction to improve blood pressure
D) Directly increases myocardial contractility

C ) Causes peripheral vasoconstriction to improve blood pressure
Rationale: Vasopressin is a potent vasoconstrictor that increases blood pressure by constricting blood vessels. (A) It decreases urine output due to its antidiuretic effects. (B) It does not act on beta receptors. (D) It does not directly affect myocardial contractility.

A patient receiving dopamine for shock has a blood pressure of 92/60 mmHg and a heart rate of 130 bpm. What is the nurse’s priority action?

A) Increase the dopamine infusion rate
B) Discontinue the dopamine infusion immediately
C) Notify the provider about the tachycardia
D) Administer a beta-blocker to reduce heart rate

: C) Notify the provider about the tachycardia
Rationale: Dopamine can cause tachycardia as a side effect. The provider should be notified to adjust the dose if necessary. (A) Increasing the infusion may worsen tachycardia. (B) Stopping dopamine abruptly can cause hypotension. (D) Beta-blockers should not be given without provider approval in shock patients.

A patient in neurogenic shock is receiving phenylephrine. Which assessment requires immediate action?

A) Heart rate of 58 bpm
B) Capillary refill greater than 3 seconds
C) Blood pressure of 90/60 mmHg
D) Temperature of 96.8°F (36°C)

B) Capillary refill greater than 3 seconds
Rationale: Prolonged capillary refill suggests excessive vasoconstriction, which may impair tissue perfusion. (A) Mild bradycardia is expected in neurogenic shock. (C) BP of 90/60 mmHg is not immediately critical. (D) A temperature of 96.8°F is not a life-threatening concern.

The nurse is reviewing vasoconstrictor medications used in shock. Which statement indicates a need for further teaching?

A) "Vasopressors should be administered through a central line whenever possible."
B) "These medications improve blood pressure by increasing systemic vascular resistance."
C) "I should expect a decrease in urine output while the patient is receiving these medications."
D) "Vasopressors can be stopped immediately once blood pressure stabilizes."

D) "Vasopressors can be stopped immediately once blood pressure stabilizes."
Rationale: Vasopressors must be tapered gradually to prevent rebound hypotension. (A, B, and C) are correct statements about vasopressors.

A patient in septic shock is receiving norepinephrine. Which assessment finding requires immediate intervention?

A) Blood pressure increases from 75/40 mmHg to 95/60 mmHg
B) Urine output increases from 10 mL/hr to 35 mL/hr
C) The patient reports pain and redness at the IV infusion site
D) Heart rate remains at 100 bpm

C) The patient reports pain and redness at the IV infusion site
Rationale: Norepinephrine is a vesicant, meaning extravasation can cause severe tissue necrosis. Immediate intervention (stopping the infusion, assessing the site, and possibly administering phentolamine) is needed. (A) BP improvement is expected, (B) increased urine output is a good sign, and (D) HR of 100 bpm is not critical.

Which of the following is the primary action of vasoconstrictor medications in shock management?

A) Decrease systemic vascular resistance (SVR)
B) Increase myocardial contractility
C) Constrict blood vessels to increase blood pressure
D) Promote diuresis and fluid excretion

C) Constrict blood vessels to increase blood pressure
Rationale: Vasoconstrictors like norepinephrine, epinephrine, and vasopressin work by constricting blood vessels, increasing systemic vascular resistance (SVR), and raising blood pressure to maintain perfusion. (A) Vasoconstrictors increase, not decrease, SVR. (B) Inotropes increase contractility, not vasoconstrictors. (D) Diuresis is not their primary function.

A nurse is administering dopamine to a patient in shock. Which assessment is the highest priority?

A) Monitor for changes in mental status
B) Assess for extravasation at the IV site
C) Monitor urine output every 8 hours
D) Check blood glucose levels regularly

Answer: B) Assess for extravasation at the IV site
Rationale: Dopamine is a vasopressor that can cause severe tissue necrosis if extravasation occurs. It should be given through a central line whenever possible. (A) Mental status changes are important but not as urgent as extravasation. (C) Urine output should be checked more frequently in shock patients. (D) Blood glucose monitoring is relevant but not the highest priority.

A patient receiving phenylephrine for neurogenic shock reports feeling cold and has weak peripheral pulses. What is the most appropriate nursing intervention?

A) Increase the infusion rate of phenylephrine
B) Stop the infusion and administer a beta-blocker
C) Assess capillary refill and continue monitoring
D) Titrate the dose based on blood pressure and perfusion status

D) Titrate the dose based on blood pressure and perfusion status
Rationale: Phenylephrine is a potent vasoconstrictor. Excessive vasoconstriction can impair peripheral perfusion, so titration is necessary to balance perfusion and BP maintenance. (A) Increasing the infusion may worsen vasoconstriction. (B) Beta-blockers are contraindicated. (C) Capillary refill should be assessed, but monitoring alone is insufficient.

A patient in anaphylactic shock is receiving epinephrine. What is the expected therapeutic effect?

A) Bronchoconstriction and vasodilation
B) Increased cardiac output and bronchodilation
C) Decreased heart rate and vasodilation
D) Reduction in urine output to preserve fluid balance

B) Increased cardiac output and bronchodilation
Rationale: Epinephrine stimulates alpha and beta receptors, leading to increased cardiac output, vasoconstriction (to improve BP), and bronchodilation (to improve breathing in anaphylaxis). (A, C, and D) do not accurately describe epinephrine's effects.

The nurse is caring for a patient in hypovolemic shock due to severe dehydration. Which assessment finding requires immediate intervention?

A) Urine output of 20 mL/hr
B) Blood pressure of 85/50 mmHg after fluid resuscitation
C) Heart rate of 120 bpm with weak peripheral pulses
D) Altered level of consciousness with confusion

D) Altered level of consciousness with confusion
Rationale: A change in mental status is an early sign of worsening shock and inadequate cerebral perfusion. (A) Low urine output and (B) hypotension are expected in shock but not the most immediate concern. (C) Tachycardia is a compensatory response but not as critical as a decline in neurological function.

A nurse is assessing a patient with suspected septic shock. Which laboratory value is most concerning?

A) White blood cell (WBC) count of 18,000/mm³
B) Blood glucose of 150 mg/dL
C) Serum lactate of 6.5 mmol/L
D) Creatinine of 1.2 mg/dL

C) Serum lactate of 6.5 mmol/L
Rationale: Elevated lactate levels (>4 mmol/L) indicate anaerobic metabolism due to poor tissue perfusion. This is a critical finding in shock. (A) Elevated WBC is expected in infection. (B) Slightly high glucose is common in stress responses. (D) A creatinine of 1.2 is within normal range.

A nurse is caring for a patient with cardiogenic shock. Which order should the nurse question?

A) Administer norepinephrine for hypotension
B) Give a 1000 mL normal saline bolus over 30 minutes
C) Start dobutamine to improve cardiac output
D) Provide oxygen via non-rebreather mask at 10 L/min

B) Give a 1000 mL normal saline bolus over 30 minutes
Rationale: Large fluid boluses are contraindicated in cardiogenic shock because they can worsen pulmonary edema. (A) Norepinephrine supports BP, (C) dobutamine improves contractility, and (D) oxygen therapy is essential in shock.

A patient in neurogenic shock has a BP of 85/50 mmHg and HR of 42 bpm. What is the nurse’s priority intervention?

A) Administer atropine IV
B) Elevate the patient’s legs
C) Give a rapid IV fluid bolus
D) Monitor the patient’s blood pressure every 30 minutes

A) Administer atropine IV
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to unopposed parasympathetic stimulation. Atropine blocks vagal stimulation and increases heart rate. (B) Leg elevation may help but is not the priority. (C) Fluids may be given but are less effective than vasopressors. (D) Monitoring alone does not address the issue

The nurse is assessing a patient with septic shock. Which findings indicate worsening shock? (Select all that apply.)

☑ Serum lactate level of 7.0 mmol/L
☑ MAP of 50 mmHg despite IV fluids
☑ Urine output of 5 mL/hr
☑ Altered mental status and restlessness
☑SpO₂ of 96% on room air 

☑Serum lactate level of 7.0 mmol/L
☑ MAP of 50 mmHg despite IV fluids
☑ Urine output of 5 mL/hr
☑ Altered mental status and restlessness

. A patient with anaphylactic shock is receiving treatment. Which interventions should the nurse implement? (Select all that apply.)

 ☑Administer intramuscular epinephrine immediately
 ☑Provide high-flow oxygen via non-rebreather mask
 ☑Start IV normal saline for fluid resuscitation
 ☑Prepare for possible intubation if airway swelling worsens
 ☑Give beta-blockers to control tachycardia 

☑Administer intramuscular epinephrine immediately
 ☑Provide high-flow oxygen via non-rebreather mask
 ☑Start IV normal saline for fluid resuscitation
 ☑Prepare for possible intubation if airway swelling worsens

A 65-year-old patient with pneumonia is admitted to the ICU with confusion, fever, and hypotension. The nurse suspects septic shock.

👉 What are the priority nursing interventions?

1. Initiate IV fluid resuscitation (crystalloids, 30 mL/kg) to improve perfusion.

2. Draw culture from 2 site 15 min apart

3. Start broad-spectrum IV antibiotics within 1 hour of recognition.

4. Administer norepinephrine if MAP remains <65 mmHg after fluids.

5. Monitor lactate levels to assess tissue perfusion.

6. Provide oxygen therapy and prepare for intubation if respiratory failure occurs.

A patient in septic shock has a prolonged activated partial thromboplastin time (aPTT) and platelet count of 50,000/mm³. The nurse suspects which complication?

A) Acute kidney injury (AKI)
B) Disseminated intravascular coagulation (DIC)
C) Acute respiratory distress syndrome (ARDS)
D) Myocardial infarction

B) Disseminated intravascular coagulation (DIC)
Rationale: DIC is a life-threatening complication of septic shock where widespread clotting leads to consumption of platelets and clotting factors, causing prolonged aPTT and thrombocytopenia. (A, C, and D) do not explain these coagulation abnormalities.

A patient in septic shock has an increasing serum creatinine level and urine output of 10 mL/hr. What complication is developing?

A) Acute kidney injury (AKI)
B) Myocardial infarction
C) Hepatic failure
D) Neurogenic shock

A) Acute kidney injury (AKI)
Rationale: Septic shock reduces perfusion to the kidneys, leading to AKI. Decreased urine output (< 30 mL/hr) and rising creatinine are key indicators of AKI. (B, C, and D) do not primarily affect kidney function in septic shock.

A patient with septic shock is at risk for multiple organ dysfunction syndrome (MODS). Which organs are most commonly affected first?

A) Brain and spinal cord
B) Liver and intestines
C) Lungs and kidneys
D) Pancreas and spleen

C) Lungs and kidneys
Rationale: MODS often begins with lung dysfunction (ARDS) followed by acute kidney injury (AKI) due to inadequate perfusion and inflammatory damage. (A, B, and D) are affected later in MODS progression.

A nurse is caring for a patient with septic shock and a mean arterial pressure (MAP) of 50 mmHg despite fluid resuscitation. Which intervention should the nurse anticipate?

A) Administer vasopressors such as norepinephrine
B) Give diuretics to reduce fluid overload
C) Initiate beta-blockers to control tachycardia
D) Increase the IV fluid rate until MAP normalizes

Administer vasopressors such as norepinephrine
Rationale: If fluid resuscitation fails to maintain MAP ≥ 65 mmHg, vasopressors (e.g., norepinephrine) are required to improve perfusion. (B) Diuretics could worsen hypotension. (C) Beta-blockers would lower heart rate, further reducing perfusion. (D) Excessive IV fluids can lead to pulmonary edema.

The nurse is assessing a patient in distributive shock. Which hemodynamic change is characteristic of this type of shock?

A) Increased systemic vascular resistance (SVR)
B) Decreased cardiac output (CO) and increased preload
C) Widespread vasodilation and decreased systemic vascular resistance (SVR)
D) Increased mean arterial pressure (MAP)

C) Widespread vasodilation and decreased systemic vascular resistance (SVR)
Rationale: Distributive shock (including septic, neurogenic, and anaphylactic shock) is characterized by massive vasodilation, leading to low SVR, reduced preload, and decreased perfusion. (A) SVR is actually decreased, not increased. (B) Preload is often reduced due to venous pooling. (D) MAP is decreased due to low vascular tone.

A nurse is reviewing the hemodynamic profile of a patient in septic shock. Which of the following would the nurse expect?

A) Increased preload and increased systemic vascular resistance
B) Decreased cardiac output and decreased systemic vascular resistance
C) Increased cardiac output and decreased systemic vascular resistance
D) Decreased cardiac output and increased preload

C) Increased cardiac output and decreased systemic vascular resistance
Rationale: In early septic shock, cardiac output is increased due to a hyperdynamic state, while systemic vascular resistance (SVR) is decreased due to widespread vasodilation. As shock progresses, cardiac output can decrease.

A patient in anaphylactic shock is experiencing profound hypotension. What is the primary cause of this hemodynamic instability?

A) Increased vascular permeability and vasodilation
B) Decreased heart rate and cardiac contractility
C) Blood loss due to capillary leakage
D) Increased systemic vascular resistance (SVR)

A) Increased vascular permeability and vasodilation
Rationale: Anaphylactic shock is caused by histamine release, leading to severe vasodilation and increased capillary permeability. This results in third-spacing of fluids, decreased preload, and profound hypotension

Which intervention is most important for improving perfusion in a patient with distributive shock?

A) Administering fluids and vasopressors
B) Performing Trendelenburg positioning
C) Administering beta-blockers to control tachycardia
D) Using diuretics to reduce fluid overload

A) Administering fluids and vasopressors
Rationale: Distributive shock leads to vasodilation and relative hypovolemia. IV fluids restore intravascular volume, and vasopressors (e.g., norepinephrine) constrict blood vessels to improve perfusion. (B) Trendelenburg is ineffective. (C) Beta-blockers would worsen hypotension. (D) Diuretics are not appropriate, as patients are already hypotensive.

The nurse is caring for a patient in neurogenic shock. Which hemodynamic change differentiates neurogenic shock from other forms of distributive shock?

A) Increased preload and systemic vascular resistance
B) Profound bradycardia and hypotension
C) Increased cardiac output and hypertension
D) Severe respiratory distress with hypoxia

B) Profound bradycardia and hypotension
Rationale: Neurogenic shock is unique among distributive shocks because it causes bradycardia (due to unopposed parasympathetic activity) along with hypotension from vasodilation. Other forms of distributive shock (e.g., septic, anaphylactic) usually present with tachycardia.

A patient with a spinal cord injury at T4 develops neurogenic shock. Which assessment finding is most characteristic of this condition?

A) Tachycardia and hypertension
B) Bradycardia and hypotension
C) Increased respiratory rate and crackles in lungs
D) Fever and tachycardia

B) Bradycardia and hypotension
Rationale: Neurogenic shock occurs due to loss of sympathetic tone, leading to unopposed parasympathetic stimulation. This results in bradycardia (due to vagal dominance) and hypotension (due to vasodilation). (A, C, and D) are more characteristic of other types of shock.

A patient with a cervical spinal cord injury is experiencing neurogenic shock. The nurse anticipates which medication to treat bradycardia?

A) Atropine
B) Propranolol
C) Epinephrine
D) Furosemide

A) Atropine
Rationale: Atropine is used to treat bradycardia in neurogenic shock by blocking parasympathetic stimulation. (B) Propranolol is a beta-blocker that would worsen bradycardia. (C) Epinephrine is not the first-line treatment, though it may be used for severe hypotension. (D) Furosemide is a diuretic and is not indicated in neurogenic shock.

A patient in neurogenic shock is experiencing severe hypotension. Which of the following interventions should be included in the patient’s care plan?

A) Administer large amounts of IV fluids rapidly
B) Use dopamine or norepinephrine to increase blood pressure
C) Position the patient supine with legs elevated
D) Withhold medications that increase heart rate

B) Use dopamine or norepinephrine to increase blood pressure
Rationale: Vasopressors like dopamine or norepinephrine are used to increase vascular tone and maintain perfusion in neurogenic shock. (A) Rapid fluid resuscitation is not always effective, as the issue is vasodilation rather than fluid loss. (C) Leg elevation may have minimal effect, and (D) withholding medications that increase heart rate would worsen bradycardia.

The nurse is educating a patient with a spinal cord injury about neurogenic shock. Which statement by the patient indicates a need for further teaching?

A) "My blood pressure might drop due to the loss of nervous system control."
B) "I could have a slower heart rate because my nervous system isn’t regulating it correctly."
C) "I should expect my body to shiver when I get cold."
D) "I may need medications to help my blood pressure stay normal."

C) "I should expect my body to shiver when I get cold."
Rationale: Patients in neurogenic shock lose their ability to regulate body temperature due to the loss of sympathetic nervous system function. They may experience poikilothermia (taking on the temperature of their environment) rather than shivering.

A patient in septic shock has a mean arterial pressure (MAP) of 50 mmHg despite fluid resuscitation. Which vasoactive drug should the nurse anticipate administering?

A) Dobutamine
B) Norepinephrine
C) Metoprolol
D) Furosemide

B) Norepinephrine
Rationale: Norepinephrine is a first-line vasopressor used in septic shock to increase MAP and maintain organ perfusion. (A) Dobutamine is used for cardiogenic shock, while (C) Metoprolol (a beta-blocker) would worsen hypotension, and (D) Furosemide is a diuretic, not a vasopressor.

A patient receiving a continuous epinephrine infusion for shock is experiencing chest pain and an irregular heart rate. What is the nurse’s priority action?

A) Stop the infusion immediately
B) Notify the healthcare provider and monitor for arrhythmias
C) Increase the infusion rate to improve perfusion
D) Reassure the patient that this is an expected effect

B) Notify the healthcare provider and monitor for arrhythmias
Rationale: Epinephrine can cause tachycardia, arrhythmias, and myocardial ischemia due to increased myocardial oxygen demand. The nurse should notify the provider and monitor cardiac function closely. (A) Stopping the infusion abruptly may cause hemodynamic instability.

A nurse is administering vasopressin to a patient in shock. What is the primary action of this drug?

A) Increases myocardial contractility
B) Causes peripheral vasoconstriction
C) Lowers systemic vascular resistance
D) Increases urine output

B) Causes peripheral vasoconstriction
Rationale: Vasopressin is a potent vasoconstrictor that helps increase blood pressure in shock. (A) It does not affect contractility (like dobutamine). (C) It increases, rather than lowers, vascular resistance. (D) It decreases urine output due to its antidiuretic effects

A patient in cardiogenic shock is receiving dobutamine. Which assessment finding indicates that the medication is effective?

A) Increased urine output
B) Decreased blood pressure
C) Increased pulmonary artery wedge pressure (PAWP)
D) Development of new arrhythmias

A) Increased urine output
Rationale: Dobutamine is an inotropic agent that increases cardiac output, leading to improved renal perfusion and urine output. (B) A decrease in blood pressure may indicate worsening shock. (C) PAWP should decrease, not increase, if the drug is effective. (D) Arrhythmias can be a side effect of dobutamine, but they are not a sign of effectiveness

The nurse is assessing a patient in the progressive stage of shock. Which clinical manifestations should the nurse expect? (Select all that apply.)

 ☑ Cold, clammy skin
 ☑ Weak or absent peripheral pulses
 ☑ Altered level of consciousness (confusion or agitation)
 ☑ Hypotension and tachycardia
☑ Bradycardia with hypertension 
 ☑Increased urine output

In the progressive stage of shock, decreased perfusion leads to hypotension, tachycardia, cold skin, weak pulses, altered mentation, and decreased urine output due to worsening organ dysfunction.

Bradycardia with hypertension (Incorrect - Progressive shock is characterized by tachycardia and hypotension, not bradycardia with hypertension.)
 ☑Increased urine output (Incorrect - In progressive shock, renal perfusion decreases, leading to oliguria (low urine output).)

A patient in the progressive stage of shock is being assessed. Which findings indicate worsening perfusion and organ dysfunction? (Select all that apply.)

 ☑ Increased lactic acid levels (>4 mmol/L) )
☑ Mottled skin and cyanosis 
 ☑ MAP (Mean Arterial Pressure) < 60 mmHg
 ☑ Respiratory acidosis with worsening hypoxemia 
☑ Compensatory tachypnea with stable ABG values 

The progressive stage of shock involves worsening cellular hypoxia, metabolic acidosis, multi-organ dysfunction, and hypotension.

Increased lactic acid levels (>4 mmol/L) (Sign of anaerobic metabolism and worsening hypoxia.)
☑ Mottled skin and cyanosis (Sign of inadequate perfusion.)
 ☑ MAP (Mean Arterial Pressure) < 60 mmHg (Indicates poor perfusion to vital organs.)
 ☑ Respiratory acidosis with worsening hypoxemia (Lung function deteriorates, leading to increased CO₂ retention.)
☑ Compensatory tachypnea with stable ABG values (Incorrect - In the progressive stage, ABGs worsen, and the patient may develop metabolic acidosis and respiratory failure.)

The nurse is monitoring a patient in the progressive stage of septic shock. Which interventions should be included in the plan of care? (Select all that apply.)

 ☑Administer vasopressors (e.g., norepinephrine) to maintain MAP > 65 mmHg
☑Monitor urine output closely for signs of acute kidney injury
 ☑Provide mechanical ventilation if respiratory distress worsens
 ☑Monitor for signs of disseminated intravascular coagulation (DIC)
 ☑Administer large volumes of IV fluids without assessment

• The progressive stage of shock requires vasopressors, respiratory support, organ perfusion monitoring, and early detection of complications like DIC.

• Administer vasopressors (e.g., norepinephrine) to maintain MAP > 65 mmHg
  ✅ ☑ Monitor urine output closely for signs of acute kidney injury
  ✅ ☑ Provide mechanical ventilation if respiratory distress worsens
  ✅ ☑ Monitor for signs of disseminated intravascular coagulation (DIC)
  ❌ Administer large volumes of IV fluids without assessment (Incorrect - Fluid resuscitation is important, but it must be carefully monitored to avoid pulmonary edema and fluid overload.)

·       A patient is in cardiogenic shock following a myocardial infarction. Which finding should the nurse expect?

  A) Warm, flushed skin with a bounding pulse
B) Hypotension, tachycardia, and cool, clammy skin
C) Hypertension, bradycardia, and peripheral edema
D) Increased urine output with normal blood pressure

B) Hypotension, tachycardia, and cool, clammy skin
Rationale: Cardiogenic shock results in decreased cardiac output, leading to hypotension, tachycardia (compensatory mechanism), and poor tissue perfusion (cool, clammy skin).

Which intervention is the priority for a patient in cardiogenic shock?

A) Administer IV fluids rapidly
B) Initiate high-dose corticosteroids
C) Provide supplemental oxygen and administer vasopressors as needed
D) Position the patient in the Trendelenburg position

C) Provide supplemental oxygen and administer vasopressors as needed
Rationale: In cardiogenic shock, the heart is unable to pump effectively. Oxygen supports myocardial oxygenation, and vasopressors (e.g., norepinephrine, dopamine) help maintain perfusion. (A) is incorrect because aggressive fluid resuscitation can worsen pulmonary congestion. (D) is incorrect because Trendelenburg can worsen respiratory distress.

   A nurse is caring for a patient in cardiogenic shock with pulmonary edema. Which medication should the nurse anticipate administering?

A) 0.9% Normal saline bolus
B) Furosemide (Lasix)
C) Dopamine at a high dose
D) Hydrocortisone

B) Furosemide (Lasix)
Rationale: Pulmonary edema is a common complication of cardiogenic shock due to fluid overload from decreased cardiac function. Furosemide (Lasix) is a loop diuretic that reduces preload and decreases pulmonary congestion.(A) is incorrect because fluid boluses can worsen pulmonary edema. (C) Dopamine at high doses increases afterload and may worsen the heart’s workload.

A patient in cardiogenic shock has a blood pressure of 78/50 mmHg, crackles in the lungs, and urine output of 10 mL/hr. The nurse should anticipate an order for which medication?

A) Norepinephrine
B) Beta-blockers
C) Normal saline bolus
D) Calcium channel blockers

A) Norepinephrine
Rationale: Norepinephrine (a vasopressor) helps increase blood pressure and improve organ perfusion. Beta-blockers (B) and calcium channel blockers (D) should be avoided in acute cardiogenic shock as they decrease cardiac contractility. (C) Normal saline bolus is not appropriate due to the risk of fluid overload and pulmonary edema.

A patient with bacterial meningitis is receiving treatment. The nurse notices a sudden drop in blood pressure, tachycardia, and cool, clammy skin. What complication is the patient most likely experiencing?

A) Seizure activity
B) Septic shock
C) Increased intracranial pressure (ICP)
D) Status epilepticus

B) ) Septic shock
Rationale: Septic shock is a life-threatening complication of bacterial meningitis caused by systemic infection. Signs include hypotension, tachycardia, and poor perfusion (cool, clammy skin).

A patient diagnosed with bacterial meningitis is prescribed IV antibiotics and dexamethasone. What is the purpose of the corticosteroid?

A) Reduce seizure risk
B) Lower blood pressure
C) Reduce meningeal inflammation
D) Increase CSF glucose levels

C) Reduce meningeal inflammation
Rationale: Dexamethasone (a corticosteroid) is often given with antibiotics to reduce inflammation in the meninges, decrease ICP, and prevent neurological complications.

The nurse is teaching a student nurse about lumbar punctures in bacterial meningitis patients. Which statement by the student indicates a need for further teaching?

A) "A lumbar puncture is performed to analyze CSF and confirm the diagnosis."
B) "If increased ICP is suspected, a CT scan should be done before the LP."
C) "CSF findings in bacterial meningitis include high protein, high WBCs, and low glucose."
D) "Lumbar puncture should always be performed before starting IV antibiotics."

D) "Lumbar puncture should always be performed before starting IV antibiotics."
Rationale: If bacterial meningitis is suspected, IV antibiotics must be started immediately and should NOT be delayed for an LP. A CT scan is needed before LP if increased ICP is suspected.

A patient with bacterial meningitis has a Glasgow Coma Scale (GCS) score of 7. What is the nurse’s priority action?

A) Monitor vital signs closely
B) Assess pupillary response
C) Prepare for possible intubation
D) Administer IV fluids

C) Prepare for possible intubation
Rationale: A GCS of ≤8 indicates a high risk of airway compromise. The nurse should anticipate intubation and mechanical ventilation to protect the airway.

A patient with suspected bacterial meningitis has a fever of 102°F, a stiff neck, and a new onset of confusion. What is the first priority nursing action?

A) Administer IV acetaminophen
B) Draw blood cultures and start IV antibiotics
C) Perform a lumbar puncture
D) Obtain a CT scan of the head

B) Draw blood cultures and start IV antibiotics
Rationale: Early administration of IV antibiotics is critical to prevent worsening infection and complications. Blood cultures should be obtained before antibiotics but should not delay treatment.

The nurse is monitoring a patient with bacterial meningitis. Which findings indicate worsening increased intracranial pressure (ICP)? (Select all that apply.)

☑Altered level of consciousness 

 ☑Cushing’s triad
☑Dilated, non-reactive pupils 
 ☑Tachycardia 
 ☑Hypotension 

☑ Altered level of consciousness (Earliest sign of increased ICP.)
✅ ☑ Cushing’s triad (hypertension, bradycardia, irregular respirations) (Late sign of increased ICP.)
✅ ☑ Dilated, non-reactive pupils (Sign of brain herniation.)
❌ Tachycardia (Incorrect - Bradycardia is more typical in increased ICP.)
❌ Hypotension (Incorrect - Increased ICP is usually associated with hypertension.)

A nurse is preparing to admit a patient with suspected bacterial meningitis. What are the priority nursing actions? (Select all that apply.)

✅ ☑ Initiate droplet precautions (Bacterial meningitis is spread via respiratory droplets.)
✅ ☑ Start IV fluids and antibiotics immediately (Prompt treatment is critical.)
✅ ☑ Monitor for increased ICP (frequent neuro checks, Glasgow Coma Scale) (To detect early complications.)
❌ Place the patient in Trendelenburg position (Incorrect - This can increase ICP.)
❌ Encourage fluid intake to maintain hydration (Incorrect - Fluid management should be cautious to prevent cerebral edema.)

The most common long-term neurological complication of bacterial meningitis is hearing loss due to damage to cranial nerve VIII (vestibulocochlear nerve).

Hearing loss is a frequent residual effect due to nerve inflammation and damage.

The nurse is reviewing cerebrospinal fluid (CSF) results for a patient with suspected meningitis. The findings of high WBCs, low glucose, and high protein are indicative of bacterial meningitis.

Bacterial meningitis typically presents with:

• High WBCs (mostly neutrophils)

• Low glucose (bacteria consume it for energy)

• High protein (due to increased inflammation and breakdown of the blood-brain barrier)

Which of the following interventions is contraindicated in a patient with increased intracranial pressure (ICP) due to bacterial meningitis?

Performing a lumbar puncture before a CT scan
Rationale: If increased ICP is suspected, a lumbar puncture (LP) is contraindicated due to the risk of brain herniation. A CT scan must be performed first to assess ICP. (B, C, and D) are appropriate interventions.

A patient with bacterial meningitis is prescribed acetaminophen (Tylenol) for fever. The nurse should question which route

Rectal
Rationale: In patients with increased ICP, nothing should be given rectally as it can increase intracranial pressure further. Oral, IV, and NG tube administration are acceptable if the patient can tolerate them.

The nurse is assessing a patient with suspected bacterial meningitis. Which of the following are classic signs and symptoms?

✅ ☑ Nuchal rigidity
✅ ☑ Photophobia
✅ ☑ Positive Brudzinski’s sign
✅ ☑ Petechial rash
❌ Hyperglycemia (Incorrect - Bacterial meningitis typically causes low CSF glucose due to bacterial metabolism.)

A patient with increased intracranial pressure (ICP) due to meningitis is being managed in the ICU. Which interventions are appropriate?

✅ ☑ Maintain a quiet, dark environment (Reduces stimulation and prevents worsening ICP.)
✅ ☑ Administer IV mannitol to reduce cerebral edema (Osmotic diuretics help lower ICP.)
✅ ☑ Limit visitors to reduce stimulation but provide them with that one person(Minimizes stress and ICP spikes.)
❌ Place the patient in the Trendelenburg position (Incorrect - This can worsen ICP.)
❌ Encourage oral fluids to maintain hydration (Incorrect - Fluids should be carefully monitored to prevent worsening cerebral edema.)

Which complications may occur in a patient recovering from bacterial meningitis?

✅ ☑ Hearing loss (Vestibulocochlear nerve damage is common.)
✅ ☑ Seizures (Due to inflammation and increased ICP.)
✅ ☑ Facial paralysis (Cranial nerve involvement.)
✅ ☑ Diabetes insipidus (Can occur if the hypothalamus or pituitary is affected.)
❌ Pulmonary embolism (Incorrect - Not a direct complication of bacterial meningitis.)

Which complications may occur in a patient recovering from bacterial meningitis?

Brudzinski’s sign involves involuntary hip and knee flexion when the neck is flexed. Kernig’s sign is pain when extending the knee while the hip is flexed.

If increased ICP is suspected in a patient with bacterial meningitis, a CT scan should be performed before a lumbar puncture to prevent brain herniation.

A lumbar puncture in the presence of increased ICP can cause brain herniation due to pressure shifts. A CT scan is done first to assess for ICP before performing an LP.

The nurse is teaching a group of college students about bacterial meningitis prevention. Which points should be included? (Select all that apply.)

✅ ☑ Get the meningococcal vaccine before college enrollment
✅ ☑ Avoid sharing drinks, utensils, or personal items
✅ ☑ Seek medical attention if experiencing severe headache, neck stiffness, or photophobia
❌ Take antibiotics daily to prevent meningitis (Incorrect - Antibiotics are only given prophylactically if exposed to a confirmed case.)
❌ Bacterial meningitis is not contagious, so precautions are unnecessary (Incorrect - It is spread via respiratory droplets.)

The nurse is monitoring a patient with bacterial meningitis. Which findings indicate worsening increased ICP? (Select all that apply.)

✅ ☑ Bradycardia (Part of Cushing’s triad)
✅ ☑ Irregular respirations (Sign of brainstem compression)
✅ ☑ Widened pulse pressure (Cushing’s triad: Hypertension, bradycardia, irregular breathing)
❌ Tachycardia (Incorrect - Bradycardia is expected in ICP.)
❌ Hypotension (Incorrect - Hypertension is a key sign of worsening ICP.)

A patient is diagnosed with meningococcal meningitis. What precautions should the nurse take? (Select all that apply.)

✅ ☑Place the patient in droplet isolation
✅ ☑Wear a surgical mask when within 3 feet of the patient
✅ ☑Encourage close contacts to receive prophylactic antibiotics
❌ Use contact precautions instead of droplet precautions (Incorrect - Droplet precautions are required, not contact precautions.)
❌ Keep the patient in isolation for 10 days after starting antibiotics (Incorrect - Isolation is usually discontinued after 24 hours of antibiotic therapy if symptoms

What are the hallmark signs of bacterial meningitis.

The classic triad of symptoms in bacterial meningitis includes fever, nuchal rigidity (stiff neck), and altered mental status.

1.     A patient with suspected brain herniation exhibits Cushing’s triad. Which set of vital signs would the nurse expect?

2.     A) BP 180/60 mmHg, HR 45 bpm, irregular respirations
B) BP 90/50 mmHg, HR 120 bpm, rapid respirations
C) BP 110/70 mmHg, HR 100 bpm, normal respirations
D) BP 150/90 mmHg, HR 80 bpm, bradypnea

  A) BP 180/60 mmHg, HR 45 bpm, irregular respirations
Rationale: Cushing’s triad (widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased ICP and impending brain herniation. (B) These findings suggest hypovolemic shock. (C) These are normal vitals. (D) Hypertension is present, but the heart rate and respiratory pattern do not fit Cushing’s triad.

A 72-year-old patient with a history of hypertension and coronary artery disease is admitted to the ICU with a diagnosis of cardiogenic shock following an acute myocardial infarction. The patient presents with tachypnea, bilateral crackles in the lungs, cool and clammy skin, delayed capillary refill, and a blood pressure of 78/52 mmHg. The cardiac index is 1.8 L/min/m², and the pulmonary artery wedge pressure (PAWP) is 22 mmHg.

Which of the following interventions should the nurse anticipate? (Select all that apply.)

A. Administer a vasopressor such as norepinephrine.
B. Provide aggressive IV fluid resuscitation with normal saline at 250 mL/hr.
C. Prepare the patient for possible intubation and mechanical ventilation.
D. Administer an inotropic agent such as dobutamine.
E. Initiate beta-blocker therapy immediately.
F. Monitor urine output and renal function closely.

Correct Answers: A, C, D, F

Rationale:

• A. Correct: Norepinephrine is a vasopressor that increases systemic vascular resistance (SVR) and blood pressure, which is essential for maintaining perfusion in cardiogenic shock.

• B. Incorrect: Large-volume fluid resuscitation is not appropriate in cardiogenic shock due to the risk of pulmonary congestion and worsening heart failure.

• C. Correct: Due to pulmonary congestion and respiratory distress, the patient may require intubation and mechanical ventilation.

• D. Correct: Dobutamine, an inotropic agent, is often used to enhance myocardial contractility and improve cardiac output.

• E. Incorrect: Beta-blockers are contraindicated in acute cardiogenic shock because they can further depress myocardial contractility.

• F. Correct: Monitoring urine output and renal function is essential because reduced cardiac output can lead to renal hypoperfusion and acute kidney injury.

A patient in the progressive stage of hypovolemic shock presents with hypotension, weak pulses, and cold, clammy skin. Which of the following interventions should the nurse anticipate? (Select all that apply.)

• A. Administer IV fluids rapidly

• B. Administer norepinephrine

• C. Place the patient in Trendelenburg position

• D. Monitor for metabolic acidosis

• E. Assess for signs of organ failure

Rationale:

• A & B: Rapid IV fluid administration (usually crystalloids) is the first-line treatment to restore intravascular volume. If hypotension persists after fluids, vasopressors (e.g., norepinephrine) may be needed to maintain perfusion.

• C: Trendelenburg position is not recommended as it does not improve circulation and may worsen cerebral edema.

• D & E: Metabolic acidosis occurs due to tissue hypoxia, and organ failure is a concern in progressive shock.

A patient with septic shock has a BP of 82/50 mmHg, HR of 120, and an elevated lactate level. What is the first priority intervention?

• A. Start norepinephrine infusion

• B. Administer a 30 mL/kg fluid bolus

• C. Obtain blood cultures

• D. Administer broad-spectrum antibiotics

• A. Start norepinephrine infusion

• B. Administer a 30 mL/kg fluid bolus ✅

• C. Obtain blood cultures

• D. Administer broad-spectrum antibiotics

Rationale: The priority in septic shock is fluid resuscitation to improve perfusion. Blood cultures and antibiotics are essential but should not delay fluid administration. Vasopressors are used only if fluids fail to restore BP

Which patient is at highest risk of developing neurogenic shock?

• A. A patient with a C5 spinal cord injury

• B. A patient with a myocardial infarction

• C. A patient with a pelvic fracture

• D. A patient with hypovolemia

• A. A patient with a C5 spinal cord injury ✅

• B. A patient with a myocardial infarction

• C. A patient with a pelvic fracture

• D. A patient with hypovolemia

Rationale: Neurogenic shock results from loss of sympathetic tone, typically seen in high spinal cord injuries (above T6).

A patient in anaphylactic shock is experiencing stridor and severe respiratory distress. Which action should the nurse take first?

• A. Administer IV diphenhydramine

• B. Prepare for emergency intubation

• C. Apply a non-rebreather mask

• D. Administer epinephrine IM

• A. Administer IV diphenhydramine

• B. Prepare for emergency intubation

• C. Apply a non-rebreather mask

• D. Administer epinephrine IM ✅

Rationale: Epinephrine is the first-line treatment for anaphylaxis as it reverses airway obstruction and hypotension.

A patient with cardiogenic shock has a PAWP of 25 mmHg and crackles in the lungs. Which order should the nurse question?

• A. Administer dopamine

• B. Give a 500 mL fluid bolus

• C. Start dobutamine infusion

• D. Monitor urine output

• A. Administer dopamine

• B. Give a 500 mL fluid bolus ✅

• C. Start dobutamine infusion

• D. Monitor urine output

Rationale: In cardiogenic shock, fluid boluses can worsen pulmonary edema. Dopamine and dobutamine improve cardiac output but should be used cautiously.

A patient with increased intracranial pressure (ICP) is receiving mechanical ventilation. Which parameter should the nurse adjust to help decrease ICP?

• A. Increase CO₂ levels

• B. Lower respiratory rate

• C. Maintain PaCO₂ between 30-35 mmHg

• D. Increase fluid intak

• A. Increase CO₂ levels

• B. Lower respiratory rate

• C. Maintain PaCO₂ between 30-35 mmHg ✅

• D. Increase fluid intake

Rationale: Mild hyperventilation reduces PaCO₂, causing cerebral vasoconstriction, which helps decrease ICP.

Which Glasgow Coma Scale (GCS) score would indicate a need for intubation?

• A. 15

• B. 12

• C. 8

• D. 5

• A. 15

• B. 12

• C. 8 ✅

• D. 5

Rationale: A GCS score of ≤8 indicates severe neurological impairment, requiring airway protection via intubation.

A patient with a basilar skull fracture is suspected of having cerebrospinal fluid (CSF) leakage. What is the most appropriate nursing action?

• A. Insert a nasogastric tube

• B. Encourage the patient to blow their nose

• C. Place the patient in the Trendelenburg position

• D. Test the drainage for glucose

• A. Insert a nasogastric tube

• B. Encourage the patient to blow their nose

• C. Place the patient in the Trendelenburg position

• D. Test the drainage for glucose ✅

Rationale: CSF tests positive for glucose and should not be confused with other nasal drainage. NG tube insertion is contraindicated due to the risk of intracranial placement.

A patient with autonomic dysreflexia presents with severe hypertension and a throbbing headache. What is the nurse’s priority action?

• A. Lower the head of the bed

• B. Check for bladder distention

• C. Administer hydralazine

• D. Apply compression stockings

• A. Lower the head of the bed

• B. Check for bladder distention ✅

• C. Administer hydralazine

• D. Apply compression stockings

Rationale: Autonomic dysreflexia is often triggered by bladder distention. Relieving the cause (e.g., emptying the bladder) is the priority.

A patient with a spinal cord injury at T2 complains of a pounding headache and nausea. The nurse finds their BP is 190/100. What action should be taken first?

• A. Increase IV fluids

• B. Assess for bowel impaction

• C. Administer labetalol

• D. Notify the provider immediately

• A. Increase IV fluids

• B. Assess for bowel impaction ✅

• C. Administer labetalol

• D. Notify the provider immediately

Rationale: Autonomic dysreflexia is commonly caused by bladder or bowel distention. The underlying cause should be addressed before medications are given.

A patient with syndrome of inappropriate antidiuretic hormone (SIADH) has a serum sodium level of 118 mEq/L. Which intervention is most appropriate?

• A. Encourage oral fluids

• B. Administer 3% saline IV

• C. Administer an IV bolus of normal saline

• D. Give furosemide

• A. Encourage oral fluids

• B. Administer 3% saline IV ✅

• C. Administer an IV bolus of normal saline

• D. Give furosemide

Rationale: Severe hyponatremia (<120 mEq/L) requires hypertonic saline to correct sodium levels.

A patient with diabetic insipidus (DI) has a urine specific gravity of 1.002 and reports excessive thirst. Which medication should the nurse anticipate?

• A. Furosemide

• B. Desmopressin

• C. Hydrocortisone

• D. Metformin

• A. Furosemide

• B. Desmopressin ✅

• C. Hydrocortisone

• D. Metformin

Rationale: DI is caused by a deficiency of ADH, and desmopressin is used to replace it.

Which of the following findings is expected in a patient with Addisonian crisis? (Select all that apply.)

• A. Hypoglycemia

• B. Hypertension

• C. Hyperkalemia

• D. Hyponatremia

• E. Hypovolemia

• A. Hypoglycemia ✅

• B. Hypertension ❌

• C. Hyperkalemia ✅

• D. Hyponatremia ✅

• E. Hypovolemia ✅

Rationale: Addisonian crisis results in hypotension, electrolyte imbalances (low sodium, high potassium), and hypoglycemia due to cortisol deficiency.

A patient with pheochromocytoma presents with a BP of 210/110 mmHg. What medication should be administered first?

• A. Labetalol

• B. Sodium nitroprusside

• C. Hydralazine

• D. Furosemide

• A. Labetalol

• B. Sodium nitroprusside ✅

• C. Hydralazine

• D. Furosemide

Rationale: Sodium nitroprusside is a potent vasodilator used to quickly lower BP in hypertensive emergencies.

Which dietary recommendation is most appropriate for a patient with Cushing’s disease?

• A. High protein, low sodium

• B. High sodium, high potassium

• C. Low potassium, low protein

• D. High carbohydrate, low calcium

• A. High protein, low sodium ✅

• B. High sodium, high potassium

• C. Low potassium, low protein

• D. High carbohydrate, low calcium

Rationale: A high-protein, low-sodium diet helps counteract muscle wasting and fluid retention in Cushing’s.

A patient with hypovolemic shock is receiving a rapid infusion of normal saline. Which finding would indicate that the treatment is effective?

• A. Heart rate decreases from 130 to 90 bpm

• B. Urine output drops to 10 mL/hr

• C. Respiratory rate increases from 18 to 26 breaths/min

• D. Central venous pressure (CVP) decreases

✅ A. Heart rate decreases from 130 to 90 bpm

Rationale: A decreasing heart rate indicates improved perfusion and stabilization of vital signs. In hypovolemic shock, the body compensates with tachycardia, so a reduction in HR suggests fluid resuscitation is effective.

• B (Urine output drops to 10 mL/hr): This suggests worsening perfusion.

• C (Respiratory rate increases from 18 to 26 breaths/min): Increased RR can indicate ongoing shock.

• D (CVP decreases): A decrease in CVP suggests continued volume depletion, not improvement.

A patient in septic shock is receiving norepinephrine. Which assessment finding requires immediate intervention?

• A. MAP of 67 mmHg

• B. Urine output of 20 mL/hr

• C. Heart rate of 105 bpm

• D. Capillary refill of 2 seconds

✅ B. Urine output of 20 mL/hr

Rationale: Low urine output (<30 mL/hr) indicates poor perfusion and possible kidney dysfunction despite vasopressor support. Immediate intervention is needed, such as increasing fluids or adjusting medication.

• A (MAP of 67 mmHg): This is adequate (goal in septic shock: MAP ≥ 65 mmHg).

• C (HR of 105 bpm): Mild tachycardia is expected in septic shock.

• D (Capillary refill of 2 seconds): Normal capillary refill suggests adequate perfusion.

A patient with cardiogenic shock is receiving dobutamine. Which finding indicates the medication is having its desired effect?

• A. Increased cardiac output

• B. Decreased blood pressure

• C. Decreased urine output

• D. Worsening crackles in the lungs

✅ A. Increased cardiac output

Rationale: Dobutamine is an inotropic agent that increases myocardial contractility and cardiac output. This improves perfusion, oxygen delivery, and tissue function.

• B (Decreased BP): This could indicate worsening shock.

• C (Decreased urine output): Suggests inadequate perfusion.

• D (Worsening crackles in lungs): Suggests fluid overload, which is a concern in cardiogenic shock.