Nursing Management: Shock & MODS (NCLEX) (4-2)

b. obtain an oxygen saturation.

Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is determined and addressed.

A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

a. check the blood pressure.

b. obtain an oxygen saturation.

c. attach a cardiac monitor.

d. check level of consciousness.

d. progressive stage of hypovolemic shock.

Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97° F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's neurologic status is not consistent with refractory shock.

2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that the patient is experiencing the

a. progressive stage of septic shock.

b. compensatory stage of diabetic shock.

c. refractory stage of cardiogenic shock.

d. progressive stage of hypovolemic shock.

c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.

Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into the interstitial space.

3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory physiologic mechanism that leads to altered urinary output is

a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.

b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output.

c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.

d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.

b. restlessness and apprehension.

Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities, cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.

4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of shock on finding

a. cold, mottled extremities.

b. restlessness and apprehension.

c. a heart rate of 120 and cool, clammy skin.

d. systolic BP less than 90 mm Hg.

a. cardiac output is increased and the central venous pressure (CVP) is low.

Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated. Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be infused cautiously.

5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the nurse will anticipate administration of large volumes of crystalloids when the

a. cardiac output is increased and the central venous pressure (CVP) is low.

b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low.

c. heart rate is decreased, and the systemic vascular resistance is low.

d. cardiac output is decreased and the PAWP is high.

b. Administer oxygen at 100% per non-rebreather mask.

Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only after actions to maximize oxygen delivery have been implemented.

6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

a. Insert two 14-gauge IV catheters.

b. Administer oxygen at 100% per non-rebreather mask.

c. Place the patient on continuous cardiac monitor.

d. Draw blood to type and crossmatch for transfusions.

c. heart rate of 48 beats/min

Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are consistent with hypovolemic shock.

7. A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of

a. cool, clammy skin.

b. shortness of breath.

c. heart rate of 48 beats/min

d. BP of 82/40 mm Hg.

b. pH 7.33, PaCO2 30 mm Hg.

Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.

8. The nurse caring for a patient in shock notifies the health care provider of the patient's deteriorating status when the patient's ABG results include

a. pH 7.48, PaCO2 33 mm Hg.

b. pH 7.33, PaCO2 30 mm Hg.

c. pH 7.41, PaCO2 50 mm Hg.

d. pH 7.38, PaCO2 45 mm Hg.

c. The patient's IV infusion site is cool and pale.

Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. The nurse should discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an immediate need for nursing intervention. A 28-ml output over 1 hour would require the nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin indicates that the patient is in early neurogenic shock.

9. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left-forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action?

a. The patient has an apical pulse rate of 58 beats/min.

b. The patient's urine output has been 28 ml over the last hour.

c. The patient's IV infusion site is cool and pale.

d. The patient has warm, dry skin on the extremities.

c. norepinephrine (Levophed).

Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an arterial vasodilator and would further decrease SVR.

10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac output. The nurse anticipates the administration of

a. nitroglycerine (Tridil).

b. dobutamine (Dobutrex).

c. norepinephrine (Levophed).

d. sodium nitroprusside (Nipride).

b. Place the patient in a private room.

Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.

11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?

a. Administer all medications through the patient's indwelling central line.

b. Place the patient in a private room.

c. Restrict the patient to foods that have been well-cooked or processed.

d. Insert a nasogastric (NG) tube for enteral feeding.

a. Epinephrine (Adrenalin)

Rationale: Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The other interventions are also appropriate but would not be the first ones administered.

12. All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who develops severe respiratory distress and faintness. Which one will the nurse administer first?

a. Epinephrine (Adrenalin)

b. Normal saline infusion

c. Dexamethasone (Decadron)

d. Diphenhydramine (Benadryl)

a. administration of furosemide (Lasix) IV.

Rationale: The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient requires endotracheal intubation.

13. A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse will anticipate

a. administration of furosemide (Lasix) IV.

b. titration of an epinephrine (Adrenalin) drip.

c. administration of a normal saline bolus.

d. assisting with endotracheal intubation.

c. two 14-gauge IV catheters.

Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain supplies, the IV catheters would take priority.

14. The triage nurse receives a call from a community member who is driving an unconscious friend with multiple injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In preparation for the patient's arrival, the nurse will obtain

a. a liter of lactated Ringer's solution.

b. 500 ml of 5% albumin.

c. two 14-gauge IV catheters.

d. a retention catheter.

a. urine output is 40 ml over the last hour.

Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.

15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patient's

a. urine output is 40 ml over the last hour.

b. hemoglobin is within normal limits.

c. CVP has decreased.

d. mean arterial pressure (MAP) is 65 mm Hg.

d. The patient has a temperature of 94.1° F.

Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent with compensated shock.

16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained in the assessment indicates a need for a change in therapy?

a. The patient is restless and anxious.

b. The patient has a heart rate of 134.

c. The patient has hypotonic bowel sounds.

d. The patient has a temperature of 94.1° F.

b. patient has received adequate fluid replacement.

Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs concurrently with Levophed.

17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the drug, the nurse ensures that the

a. patient's heart rate is less than 100.

b. patient has received adequate fluid replacement.

c. patient's urine output is within normal range.

d. patient is not receiving other sympathomimetic drugs.

c. PAWP drops to normal range.

Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK) levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.

18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the

a. systolic BP increases to greater than 100 mm Hg.

b. cardiac monitor shows sinus rhythm at 96 beats/min.

c. PAWP drops to normal range.

d. troponin and creatine kinase levels decrease.

a. additional fluid replacement.

Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions. There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.

19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP from 92 mm Hg to 76 mm Hg when the head of the patient's bed is elevated to 75 degrees. This finding indicates a need for

a. additional fluid replacement.

b. antibiotic administration.

c. infusion of a sympathomimetic drug.

d. administration of increased oxygen.

d. place the patient's call bell where it can be easily reached.

Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative administration is helpful but does not as directly address the patient's anxiety about dying.

20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived threat of death is to

a. arrange for the hospital pastoral care staff to visit the patient.

b. ask the health care provider to prescribe a sedative drug for the patient.

c. leave the patient alone with family members whenever possible.

d. place the patient's call bell where it can be easily reached.

a. urine output of 0.5 ml/kg/hr.

Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output. The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has improved.

21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac output related to relative hypovolemia is

a. urine output of 0.5 ml/kg/hr.

b. decreased peripheral edema.

c. decreased CVP.

d. oxygen saturation 90% or more.

b. Give normal saline IV at 500 ml/hr.

Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions are also appropriate and should be initiated quickly as well.

22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32, temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first?

a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.

b. Give normal saline IV at 500 ml/hr.

c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.

d. Infuse drotrecogin- (Xigris) 24 mcg/kg.

a. The cardiac output is elevated.

Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate that the patient had developed progressive or refractory septic shock.

23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory stage of shock?

a. The cardiac output is elevated.

b. The central venous pressure (CVP) is increased.

c. The systemic vascular resistance (SVR) is high.

d. The PAWP is high.

c. The patient has an elevated ammonia level and confusion.

Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles, chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in other major organ systems.

24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse will help confirm the diagnosis of MODS?

a. The patient has crackles throughout both lung fields.

b. The patient complains of 8/10 crushing chest pain.

c. The patient has an elevated ammonia level and confusion.

d. The patient has cool extremities and weak pedal pulses.

b. lung sounds and oxygenation status.

Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will not indicate the development of MODS as early.

25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most important assessments for the nurse to make are

a. stool guaiac and bowel sounds.

b. lung sounds and oxygenation status.

c. serum creatinine and urinary output.

d. serum bilirubin levels and skin color.

b. fixed urine specific gravity at 1.010.

Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.

26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS includes

a. respiratory rate of 10 breaths/min.

b. fixed urine specific gravity at 1.010.

c. MAP of 55 mm Hg.

d. 360-ml urine output in 8 hours.

c. Urine output 15 ml for 2 hours

Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2 saturation are more typical of compensated septic shock.

27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be of greatest concern to the nurse?

a. BP 88/56 mm Hg

b. Apical pulse 110 beats/min

c. Urine output 15 ml for 2 hours

d. Arterial oxygen saturation 90%

c. Tachycardia

.

The nurse is providing care for a client who is in shock after massive blood loss from a

workplace injury. The nurse recognizes that many of the findings from the most recent

assessment are due to compensatory mechanisms. What compensatory mechanism will

increase the client’s cardiac output during the hypovolemic state?

a. Third spacing of fluid

b. Dysrhythmias

c. Tachycardia

d. Gastric hypermotility

a. Addressing the client’s hypothermia

A homeless person is admitted the ED during a blizzard and is unable to feel the feet and

lower legs. Core temperature is noted at 33.2 C (91.8 F). The client is intoxicated with

alcohol at the time of admission and is visibly malnourished. What is the triage nurse’s

priority in the care of this client?

a. Addressing the client’s hypothermia

b. Addressing the client’s frostbite in his lower extremities

c. Addressing the client’s alcohol intoxication

d. Addressing the client’s malnutrition

b. The drug dose should be tapered down once vital signs improve.

A client who is in shock is receiving dopamine in addition to IV fluids. What principle

should inform the nurse’s care planning during the administration of a vasoactive drug?

a. The drug should be discontinued immediately after blood pressure increases.

b. The drug dose should be tapered down once vital signs improve.

c. The clients should have arterial blood gases drawn every 10 minutes during

treatment.

d. The infusion rate should be titrated according the client’s subjective sensation of

adequate perfusion.

b. neurogenic shock

A nurse in the intensive care unit (ICU) receives a report from the nurse in the

emergency department (ED) about a new client being admitted with a neck injury

received while diving into a lake. The ED nurse reports that the client’s blood pressure is

85/54, heart rate is 53 beats per minute, and skin is warm and dry. What does the ICU

nurse recognize that the client is probably experiencing?

a. anaphylactic shock

b. neurogenic shock

c. septic shock

d. hypovolemic shock

d. Maintenance of mean arterial pressure

5. The critical care nurse is preparing to initiate an infusion of vasoactive medication to a

client in shock. What goal of this treatment should the nurse identify?

a. Absence of infarcts or emboli

b. Reduced stroke volume and cardiac output

c. Absence of pulmonary and peripheral edema

d. Maintenance of mean arterial pressure

a. Two to three soft bowel movement daily

6. A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving

care on the medical unit. The client’s current medication regimen includes lactulose four

times daily. What desired outcome should the nurse relate to this pharmacologic

intervention?

a. Two to three soft bowel movement daily

b. Significant increase in appetite and food intake

c. Absence of nausea and vomiting

d. Absence of blood or mucus in stool

d. Inability of the liver to use vitamin K

A nurse is caring for a client with liver failure and is performing an assessment of the

client’s increased risk of bleeding. The nurse recognizes that this risk is related to the

client’s inability to synthesize prothrombin in the liver. What factor most likely

contributes to this loss of function?

a. Alterations in glucose metabolism

b. Retention of bile salts

c. Inadequate production of albumin by hepatocytes

d. Inability of the liver to use vitamin K

c. Daily weights and abdominal girth measurement

A client with portal hypertension has been admitted to the medical floor. The nurse

should prioritize what assessments?

a. Assessment of blood pressure and assessment for headaches and visual changes

b. Assessment for signs and symptoms of venous thromboembolism

c. Daily weights and abdominal girth measurement

d. Blood glucose monitoring q4h

a. “How many alcoholic drinks do you typically consume in a week?”

A triage nurse in the emergency department is assessing a client who presented with

reports of general malaise. Assessment reveals the presence of jaundice and increased

abdominal girth. What assessment question best addresses the possible etiology of this

client’s presentation?

a. “How many alcoholic drinks do you typically consume in a week?”

b. “To the best of your knowledge, are your immunizations up to date?”

c. “Have you ever worked in an occupation where you might have been exposed to

toxins?”

d. “Has anyone in your family ever experienced symptoms similar to yours?”

d. Administration of diuretics as prescribed

A nurse is amending a client’s plan of care in light of the fact that the client has recently

developed ascites. What should the nurse include in this client’s care plan?

a. Mobilization with assistance at least 4 times daily

b. Administration of beta-adrenergic blockers as prescribed

c. Vitamin B12 injections as prescribed

d. Administration of diuretics as prescribed

d. Understand the underlying mechanisms of shock, recognize the subtle and more

obvious signs, and then provide rapid assessment.

11. When caring for a client in shock, one of the major nursing goals is to reduce the risk

that the client will develop complications of shock. How can the nurse best achieve this

goal?

a. Provide a detailed diagnosis and plan of care in order to promote the client’s and

family’s coping.

b. Keep the health care provider updated with the most accurate information because

in cases of shock the nurse often cannot provide relevant interventions.

c. Monitor for significant changes and evaluate client outcomes on a scheduled basis

focusing on blood pressure and skin temperature.

d. Understand the underlying mechanisms of shock, recognize the subtle and more

obvious signs, and then provide rapid assessment.

c. Promoting communication with the client and family along with addressing

end-of-life issues

The nurse is caring for a client in the ICU who has been diagnosed with multiple organ

dysfunction syndrome (MODS). The nurse’s plan of care should include what

intervention?

a. Encouraging the family to stay hopeful and educating them to the fact that, in nearly

all cases, the prognosis is good.

b. Encouraging the family to leave the hospital and to take time for themselves as acute

care of MODS clients may last for several months.

c. Promoting communication with the client and family along with addressing

end-of-life issues

d. Discussing organ donation on a number of different occasions to allow the family

time to adjust to the idea.

a. A client-controlled analgesia (PCA) system

13. A client who is in the acute phase of recovery from a burn injury has yet to experience

adequate pain control. What pain management strategy is most likey to meet this

client’s needs?

a. A client-controlled analgesia (PCA) system

b. Oral opioids supplemented by NSAIDs

c. Distraction and relaxation techniques supplemented by NSAIDs

d. A combination of benzodiazepines and topical anesthetics

a. Respect the client’s privacy during assessment

The paramedics is bring a client who has suffered a sexual assault to the ED. What is

important for the sexual assault nurse examiner to do when assessing a sexual assault

victim?

a. Respect the client’s privacy during assessment

b. Shave all pubic hair for laboratory analysis

c. Place items for evidence in plastic bags

d. Bathe the client before the examination

b. The client with testicular cancer who is receiving intravenous chemothreaopy

15. A nurse is providing care to all of the following clients. Which client would be most at

risk for septic shock?

a. The client with pneumonia in the left lower love of the lung

b. The client with testicular cancer who is receiving intravenous chemothreaopy

c. The 45-year-old client with a sudden onset of frequent premature ventricular

contractions (PVCs)

d. The client with a BMI of 25 who has lost 3 pounds as the result of vomiting

b. Hypovolemic shock

16. The nurse admits a patient to the PACU with a blood pressure of 132/90 mmHg and a

pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47

mmHg, and the pulse is 110. The nurse documents that the patient’s skin is cold, moist,

and pale. The client is showing signs of what potential issue?

a. Hypothermia

b. Hypovolemic shock

c. Neurogenic shock

d. Malignant hyperthermia

b. Compensatory stage

The nurse obtained a blood pressure of 120/78 mmHg from a patient in hypovolemic

shock. Since the blood pressure is within normal range for this patient, what stage of

shock does the nurse realize this patient is experiencing?

a. Progressive stage

b. Compensatory stage

c. Irreversible stage

d. Intermediate stage

a. Give normal saline IV at 500 mL/hr.

18. A patient with septic shock has a BP of 80/46, heart rate of 136 bpm, respiration of 20,

oxygen at 94%, and temperature of 103, glucose of 246. Which intervention order by the

HCP should the nurse implement first?

a. Give normal saline IV at 500 mL/hr.

b. Give acetaminophen 650 mg rectally.

c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL

d. Start norepinephrine to keep systolic blood pressure above 90 mmHg

b. Urine output

A nurse is administering fluid IV as prescribed to a client who sustained superficial

partial thickness burn injuries of the back and the leg is evaluating the adequacy of the

fluid resuscitation, the nurse understands that which assessment would provide the

most reliable indicator for determining adequacy?

a. Vital signs

b. Urine output

c. Mental status

d. Peripheral pulses

d. Elevated hematocrit levels

20. The nurse is caring for a client who sustained superficial partial thickness burns on the

anterior lower legs and anterior thorax. Which finding does the nurse expect to note

during the resuscitation/emergent phase of the burn injury?

a. Decreased heart rate

b. Increased urinary output

c. Increased blood pressure

d. Elevated hematocrit levels

a. Lactated Ringers

A nurse is caring for a client with extensive full thickness burns 30% of his body. The

nurse is preparing for fluids administration. Which of the following fluids should the

nurse administer in the first 24 hours of the injury?

a. Lactated Ringers

b. Sodium chloride

c. 5% dextrose

d. Half normal saline

C. 36%

22. An adult client was burned as a result of an explosion. The burn initially affected the

client’s entire face (the anterior half of the head) and the upper half of the anterior

torse, and there were circumferential burns to the lower half of both of the arms. The

client’s clothes caught in fire, and the client ran, which caused subsequent burn injuries

of the posterior torso. According to the rule of nines, what is the extent of this client’s

burn injury?

A. 43%

B. 12%

C. 36%

D. 71%

d. Stay with him and encourage him to cough and continue monitor

23. Nurse in the med floor is taking an admission assessment of a client when the client

begins to choke on his lunch. The client coughing forcefully, what should be the nurse’s

intervention?

a. Stand him up and perform the abdominal thrust maneuver from behind

b. Lay him down, straddle him, and perform the abdominal thrust maneuver

c. Leave him to get assistance

d. Stay with him and encourage him to cough and continue monitor

c. 55 y/o with cirrhosis and ascites who has an oral temperature of 102 F

During change of shift report, the nurse learns about the following four patients. Which

patient required assessment first?

a. 40 y/o with chronic pancreatitis who has gnawing abdominal pain

b. 58 y/o who has compensated cirrhosis and is complaining of anorexia

c. 55 y/o with cirrhosis and ascites who has an oral temperature of 102 F

d. 36 y/o recovering from a laparoscopic cholecystectomy who has severe shoulder

a. Hematemesis, hypotension, cold, clammy skin (asterixis and lethargy)

25. A 45-year-old has been admitted with acute liver failure. Which assessment data are

most important for the nurse to communicate?

a. Hematemesis, hypotension, cold, clammy skin (asterixis and lethargy)

b. Jaundiced sclera and skin

c. Elevated total bilirubin level

d. Liver 3 cm below costal margin

A. use disposable needles and syringes

B. avoid sharing toothbrushes and razors

C. avoid unsafe sex with multiple partners and always use condoms

What points should a nurse emphasize while teaching a patient ways to protect oneself

from exposure to hepatitis B infection? SATA

A. use disposable needles and syringes

B. avoid sharing toothbrushes and razors

C. avoid unsafe sex with multiple partners and always use condoms

D. avoid earing food prepared in unhygienic ways

E. avoid touching or coming in contact with people with hepatitis

b. The patient used IV drugs about 20 years ago

27. Which information given by the 56-year-old client during a healthy history which

indicates to the nurse the client needs to be screened for hepatitis C.

a. The patient had a blood transfusion in 2005

b. The patient used IV drugs about 20 years ago

c. The patient frequently eats in fast food restaurants

d. The patient traveled to a country with poor sanitation.

c. Increasing the amount of intravenous (IV) lactated ringer’s solution administered per

hour

A client is undergoing fluid replacement after being burned 20% of her body 12 hrs ago.

The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110

bpm, and a urine output of 20 mL over the past hour. The nurse reports the finding to

the HCP and anticipates which prescription?

a. Transfusing 1 unit of PRBC

b. Administrating a diuretic to increase urine output

c. Increasing the amount of intravenous (IV) lactated ringer’s solution administered per

hour

d. Changing the IV lactated ringer’s solution to one that contain dextrose in water

d. 100% oxygen via a tight-fitting, nonrebreather face mask

The client arrives to the ER following a burn injury that occurred in the basement at

home and an inhalation injury is suspected. What would the nurse anticipate to be

prescribed for the client?

a. 100% oxygen via an aerosol mask

b. Oxygen via nasal cannula at 6 L/minute

c. Oxygen via nasal cannula at 15 L/minute

d. 100% oxygen via a tight-fitting, nonrebreather face mask

b. Maintain adequate nutrition

Which goal has the highest priority in the plan of care for a 26 y/o homeless patient

admitted with viral hepatitis who has severe anorexia and fatigue?

a. Increase activity level

b. Maintain adequate nutrition

c. Establish a stable environment

d. Identify source of hepatitis exposure

-check lactic acid levels

-blood cultures

-administer broad spectrum antibiotics

-rapid administration of crystalloids

-administer vasopressors

31. As a student doing clinical in a telemetry unit, how will you implement sepsis bundle in

order of priority?

-check lactic acid levels

-blood cultures

-administer broad spectrum antibiotics

-rapid administration of crystalloids

-administer vasopressors

-pressure-reducing mattress ( maintenance of skin integrity )

32. A nurse is developing a care plan for a client with DIC, which nursing intervention should the

nurse include?

-pressure-reducing mattress ( maintenance of skin integrity )

-lactate

33. A nurse is caring for multiple clients who are at risk for shock. Upon assessment patient

looks pale, cold, clammy skin, respiratory rate of 20, blood pressure 98/66. What following lab

values does the nurse require to communicate to the provider?

-lactate

-singed eyebrows, redness, and edema bilateral eyelids

34. Which of the following assessment findings leaves the nurse to believe the presenting client

has suffered an inhalation injury?

-singed eyebrows, redness, and edema bilateral eyelids

-750 ml first hr

35. An adult client has sustained severe deep partial and full thickness burns in approx. 35% of

his body. His family has provided historical information to emergency personnel, and it was

reported his preburn weight was approx. 75 kg. 1 hour has lapsed since the injury has occurred.

The nurse is now preparing for fluid resuscitation using the parkland formula. Calculate the

amount of fluid the client should receive?

-warm, flushed skin (shallow, rapid respirations)

36. A nurse is caring for a client whose worsening infection is placing her at high risk for septic

shock. When assessing the client for early septic shock the nurse should assess the client for

which of the following?

-warm, flushed skin (shallow, rapid respirations)

-psychosocial support and contraction prevention

37. The nurse is caring for a client who’s recovering from full thickness burns during the rehab

phase of the burn injury, what nursing intervention and health teaching education would be

beneficial to the client?

-psychosocial support and contraction prevention

-deflate the esophageal balloon.

38. A sengstaken-blakemore tube is inserted in an effort to stop the bleeding esophageal varices

in a patient with complicated liver cirrhosis. Upon insertion of the tube, the client complains of

the difficulty of breathing. The first action of the nurse is to:

-deflate the esophageal balloon.

-ammonia level

39. A supervising nurse receives a status report from the emergency charge nurse about four

patients that need an intensive care transfer. Which patient should be transferred to the ICU

first?

-ammonia level

-hemoglobin of 9

40. Which finding indicates to the nurse that the current therapies are the most effective for a

client with esophageal varices?

-hemoglobin of 9

-increased drowsiness

41 The nurse is assessing a client with hepatic encephalopathy. Which finding would the nurse

report for immediate follow-up?

-increased drowsiness

-assess airway

-administer oxygen

-elevate extremities if no fractures are present

42. A client was brought to the ER with partial thickness burns to his face, neck, arms, and chest

after trying to get out of a car fire. The nurse should implement which nursing actions for this

client? SATA

-assess airway

-administer oxygen

-elevate extremities if no fractures are present

-check BP, HR, and respirations

55 y/o patient admitted in the ICU with history of liver cirrhosis, which action should the

nurse in the ER take first with a new onset of hematemesis?

-check BP, HR, and respirations

-asterixis and lethargy

44. A 23 y/o has been admitted with acute liver failure. Which assessment date are most

important for the nurse to communicate to the HCP?

-asterixis and lethargy

-alcohol abuse and septic shock

Charge nurse is working in the ICU and assesses client reports for the progression. Which

client is at risk for developing DIC?

-alcohol abuse and septic shock

-the patient has adequate blood volume but is profoundly vasodilated.

46. A 24 y/o man has suffered extensive head and neck injuries in a motorcycle accident and has

been admitted to the ICU in apparent neurogenic shock. Which of the following are

characteristics of this patient’s diagnosis?

-the patient has adequate blood volume but is profoundly vasodilated.

-anticipate for possible intubation

47. A client is brought into the ER with partial thickness burns to his face, neck, arms, chest after

a car accident with an explosion with possible inhalation injury. The nurse should implement

which priority nursing action?

-anticipate for possible intubation

-blood transfusion

48. A nurse in the Er is caring for a patient who sustained a gunshot wound to the RT side of the

chest. Patient is intubated and receiving IV fluids for low BP. What should the nurse prioritize

to prevent hypovolemic shock?

-blood transfusion

-oxygen is administered until the carboxyhemoglobin level is less than 5%.

49. The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and

obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that

oxygen therapy can be discontinued?

-oxygen is administered until the carboxyhemoglobin level is less than 5%.

-releases burn tissue on the anterior chest freeing the chest for expansion with inspiration

50. A client presents with full thickness burn to the anterior chest. The leathery skin is tight,

making breathing difficult. The nurse anticipated a possible escharotomy management

technique to care for this client. What is the rationale for this procedure?

-releases burn tissue on the anterior chest freeing the chest for expansion with inspiration