MEDSURG FINAL EXAM with 100% perfect answers 2024

A client who has septic shock is admitted to the hospital. What priority intervention does the nurse implement first? a. Obtain two sets of blood cultures. b. Administer the prescribed IV vancomycin (Vancocin). c. Obtain central venous pressure (CVP) measurements. d. Administer the prescribed IV norepinephrine (Levophed) correct answersa. Obtain two sets of blood cultures. Blood cultures should be obtained before IV antibiotics are started. If hypotension occurs, fluid resuscitation is used first. CVP monitoring and vasopressor therapy are started if hypotension persists. The emergency department nurse is triaging clients. Which client does the nurse assess most carefully for hypovolemic shock? a. 15-year-old adolescent who plays high school basketball b. 24-year-old computer specialist who has bulimia c. 48-year-old truck driver who has a 40-pack-year history of smoking d. 62-year-old business executive who travels frequently correct answersb. 24-year-old computer specialist who has bulimia Hypovolemic shock can be caused by dehydration. A client who has bulimia is at highest risk for dehydration owing to excessive vomiting. Basketball, smoking, and traveling do not put the client at risk for hypovolemic shock. A client with epilepsy develops stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How does the nurse document this seizure activity? a. Atonic seizure b. Absence seizure c. Myoclonic seizure d. Tonic-clonic seizure correct answersd. Tonic-clonic seizure Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. The other seizures do not manifest in this manner. The nurse is assessing a client with a history of absence seizures. Which clinical manifestation does the nurse assess for?