Exam 3- NUR 221 Test Questions and Answers
The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates
thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing
action?
A. Assess the blood pressure palpation
B. Estimate the systolic pressure as 60 mm Hg.
C. Obtain an electronic blood pressure monitor.
D. Record the blood pressure as "not assessable." Correct-A. Assess the blood pressure
palpation
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a
patient with severe sepsis. One hour later, which laboratory result requires immediate nursing
action?
A. Creatinine 1.0 mg/dL
B. Lactate 6 mmol/L
, Exam 3- NUR 221 Test Questions and Answers
C. Potassium 3.8 mEq/L
D. Sodium 140 mEq/L Correct-B. Lactate 6 mmol/L
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-
directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of
fluid therapy, which physiological parameters would be most important for the nurse to
assess?
A. Breath sounds and capillary refill
B. Blood pressure and oral temperature
C. Oral temperature and capillary refill
D. Right atrial pressure and urine output Correct-D. Right atrial pressure and urine output
A patient is admitted to the critical care unit following coronary artery bypass surgery. Two
hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min;
blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac
, Exam 3- NUR 221 Test Questions and Answers
output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best
interpretation by the nurse?
A. The assessed values are within normal limits.
B. The patient is at risk for developing cardiogenic shock.
C. The patient is at risk for developing fluid volume overload.
D. The patient is at risk for developing hypovolemic shock. Correct-D. The patient is at risk
for developing hypovolemic shock.
A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with
a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of
78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?
A. Human albumin infusion
B. Hypotonic saline solution
C. Lactated Ringer's bolus
D. Packed red blood cells Correct-C. Lactated Ringer's bolus
, Exam 3- NUR 221 Test Questions and Answers
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly
confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the
nurse most likely to assess?
A. High pulmonary artery occlusive pressure and high cardiac output
B. High systemic vascular resistance and low cardiac output
C. Low pulmonary artery occlusive pressure and low cardiac output
D. Low systemic vascular resistance and high cardiac output Correct-D. Low systemic
vascular resistance and high cardiac output
The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse
include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min,
oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician
orders, which intervention should the nurse carry out first?
The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates
thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing
action?
A. Assess the blood pressure palpation
B. Estimate the systolic pressure as 60 mm Hg.
C. Obtain an electronic blood pressure monitor.
D. Record the blood pressure as "not assessable." Correct-A. Assess the blood pressure
palpation
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a
patient with severe sepsis. One hour later, which laboratory result requires immediate nursing
action?
A. Creatinine 1.0 mg/dL
B. Lactate 6 mmol/L
, Exam 3- NUR 221 Test Questions and Answers
C. Potassium 3.8 mEq/L
D. Sodium 140 mEq/L Correct-B. Lactate 6 mmol/L
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-
directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of
fluid therapy, which physiological parameters would be most important for the nurse to
assess?
A. Breath sounds and capillary refill
B. Blood pressure and oral temperature
C. Oral temperature and capillary refill
D. Right atrial pressure and urine output Correct-D. Right atrial pressure and urine output
A patient is admitted to the critical care unit following coronary artery bypass surgery. Two
hours postoperatively, the nurse assesses the following information: pulse is 120 beats/min;
blood pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac
, Exam 3- NUR 221 Test Questions and Answers
output is 4 L/min; urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best
interpretation by the nurse?
A. The assessed values are within normal limits.
B. The patient is at risk for developing cardiogenic shock.
C. The patient is at risk for developing fluid volume overload.
D. The patient is at risk for developing hypovolemic shock. Correct-D. The patient is at risk
for developing hypovolemic shock.
A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with
a heart rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of
78/46 mm Hg. The nurse anticipates administering which therapeutic intervention?
A. Human albumin infusion
B. Hypotonic saline solution
C. Lactated Ringer's bolus
D. Packed red blood cells Correct-C. Lactated Ringer's bolus
, Exam 3- NUR 221 Test Questions and Answers
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly
confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the
nurse most likely to assess?
A. High pulmonary artery occlusive pressure and high cardiac output
B. High systemic vascular resistance and low cardiac output
C. Low pulmonary artery occlusive pressure and low cardiac output
D. Low systemic vascular resistance and high cardiac output Correct-D. Low systemic
vascular resistance and high cardiac output
The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse
include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min,
oral temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician
orders, which intervention should the nurse carry out first?
