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, A nurse in the emergency department is preparing to administer naloxone 0.4mg IV bolus to a
client who has opiod-induced respiratory depression. Available is naloxone injection 0.2mg/mL.
How many mL should the nurse administer per dose? - ANS 2mL
After a change-of-shift report on a progressive care unit, who should the nurse see first? - ANS
Patient with suspected with urosepsis who has new orders for urine and blood cultures and
antibiotics
A nurse is caring for a patientwhose hemodynamic monitoring indicated BP 92/54, pulse 64,
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and an elevated pulmonary artery wedge pressure. Which collaborative measure ordered by the
HCP should the nurse question? - ANS infuse normal saline at 250 mL/hr
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To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic
inflammatory response syndrome (SIRS), which assessment will the nurse perform? - ANS
Check stools for occult blood
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A patient with cardiogenic shock has the following vital signs: BP 102/50, pulse 128, respirations
28. The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The
nurse will anticipate an order for which medication? - ANS furosemide (Lasix) IV
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A 78-kg patient with septic shock has a pulse rate is 120/minute and the central venous
pressure and pulmonary artery wedge pressure are low. Which order by the health care provider
will the nurse question? - ANS Give PRN furosemide (Lasix) 40mg IV
A nurse is caring for a female client in the emergency department who reports shortness of
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breath and pain the lung are. She states that she started taking birth control pills 3 weeks ago
and that she smokes. Her heart rate is 110/min, RR 40/min, BP 140/80. ABG are pH 7.50,
PaCO2 29, PaO2 60, HCO3 20mEq,L, SaO2 86%. which of the following is the priority nursing
intervention? - ANS Admin O2 via face mask
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A nurse in the emergency department is assessing a client who has internal injuries from a car
crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The
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nurse should anticipate which of the findings as an indication of hypovolemic shock? - ANS
increased heart rate
Which data collected by the nurse caring for a patient who has cardiogenic shock indicates that
the patient may be developing multiple organ dysfunction syndrome (MODS)? - ANS the
patient's serum creatinine level is elevated
A patient with septic shock has a BP of 70/46, pulse 136 beats/minute, respirations 32,
temperature 104F, and blood glucose 246 mg/dL. Which intervention ordered by the healthcare
provider should the nurse implement first? - ANS Give normal saline IV at 500 mL/hr