Exam 2: NUR2755/ NUR 2755 (Latest 2023 / 2024): - Multidimensional Care/ MDC IV Rasmussen- 75 Questions and Verified Answers-Graded A- Rasmussen

Exam 2: NUR2755/ NUR 2755 (Latest 2023 / 2024): - Multidimensional Care/ MDC IV Rasmussen- 75 Questions and Verified Answers-Graded A- Rasmussen 1. A client with neurogenic shock is receiving phenylephrine infusion through a left forearm IV. Which assessment information obtained by the nurse indicates a need for immediate action? a. Client's IV infusion site is cool and pale b. Client has warm, dry skin on the extremities c. Client has an apical pulse rate of 58 beats/min d. Client's urine output has been 28 ml over the last hour ~ Answer: a. Client's IV infusion site is cool and pale 2. Which assessment is important for the nurse to evaluate whether the treatment of a client with anaphylactic shock has been effective? a. Pulse rate b. Orientation c. Blood pressure d. Oxygen saturation ~ Answer: d. Oxygen saturation 3. Nurse is planning care for an adult client who sustained severe burn injuries. Which interventions should the nurse include in the plan of care? SATA a. limit visitors in the clients room when immunosuppressed b. encourage raw foods to improve exposure to natural flora c. offer high calorie, high protein foods or supplemental feeding d. ambulate 2 or 3 times a day and progress in length each time e. apply compression dressings before the graft heals to prevent scar formation ~ Answer: ~ limit visitors in the clients room when immunosuppressed ~ offer high calorie, high protein foods or supplemental feeding 4. Nurse is caring for a client in shock. The nurse understands the client sympathetic nervous system is still correctly attempting to compensate when the following is assessed? a. Client has decreased peripheral pulses b. Client has an increase thirst c. Client has decreased heart rate d. Client has an increased respiratory rate e. Client has widening pulse pressure ~ Answer: ~ Client has an increased respiratory rate ~ Client has widening pulse pressure 5. Burn client is brought into the emergency department with the following burns: half of the front torso, entire left arm, front of the left leg. The nurse should record the total body surface area burn as? a. 27% b. 35% c. 20% d. 40% ~ Answer: A. 27% 6. Client is treated in the emergency department for shock of unknown etiology. The first action by the nurse is which of the following? a. Administer oxygen b. Attach a cardiac monitor c. Obtain a blood pressure d. Check level of consciousness ~ Answer: A. Administer oxygen 7. Client has been diagnosed with pulmonary embolism. Which diagnostics and treatments does the nurse anticipate will be ordered? SATA a. D dimer b. Thrombolytics c. Atropine d. Nitroglycerin e. CT angiogram ~ Answer: ~ D dimer ~ Thrombolytics ~ CT angiogram 8. Nurse is managing several IV medications to maintain the blood pressure of a client in hypovolemic shock. Which medication places the client at risk for a hypertensive reaction, requiring the nurse to assess the blood pressure at least every 15 minutes? a. Norephinephrine b. Sodium nitroprusside c. Adenosine d. Amiodarone ~ Answer: B. Sodium nitroprusside 9. Nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? a. Apply a vest restraint if self extubating is attempted b. Monitor daily ventilator settings c. Document tube placement in inches at the angle of the jaw