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A patient is brought to the emergency department after falling down
two flights of stairs. The patient is suspected of having internal
bleeding. Which initial assessment of hypovolemic shock would the
nurse expect to find?
a. increased heart rate
b. decreased respiratory rate
c. increased urinary output
d. warm flushed skin ---------CORRECT ANSWER-----------------a.
A patient with a subarachnoid hemorrhage is being cared for in the ICU.
Which information about the patient is most important to
communicate about the patient to the health care provider?
a. the patient's blood pressure is 90/50
b. the patient complains of having a stiff neck
c. CSF report shows red blood cells
,d. the patient complains of a continuous headache ---------CORRECT
ANSWER-----------------a.
The nurse recognizes which clinical manifestations with the early stages
of cardiogenic shock (select all)
a. decreased respiratory rate
b. cool and clammy skin
c. decreased pulse rate
d. decreased blood pressure
e. elevated heart rate ---------CORRECT ANSWER-----------------b.
d.
e.
The nurse is caring for a patient diagnosed with septic shock. Which
pharmacological intervention should the nurse administer?
a. Amoxicillin 1000mg po every 8 hours
b. solu-cortef to reduce inflammation
c. 0.45% NS to increase intravascular volume
,d. norepinepherine (levophed) to increase blood pressure ---------
CORRECT ANSWER-----------------d.
A patient comes to the emergency room complaining of heartburn/ The
nurse connected the patient to telemetry. What would the nurse
identify the following strip as?
a. Ventricular tachycardia
b. Atrial fibrillation
c. sinus tachycardia
d. ventricular fibrillation ---------CORRECT ANSWER-----------------a.
The nurse is caring for a hispanic female. The nurse notices the
patient's husband is answering the questions the nurse is directing to
the patient. What should the nurse do?
a. request that the husband step out of the room
b. ask the patient to respond and not have the husband speak for her
c. leave the room and return when the husband leaves
d. recognize the couple is demonstrating a cultural behavior ---------
CORRECT ANSWER-----------------d.
, What relevant assessment data would the nurse observe when a
patient in acute respiratory failure has the complication of cerebral
hypercapnia?
a. decreased intracranial pressure
b. delerium
c. progressive somnolence and coma
d. restlessness and combative behavior ---------CORRECT ANSWER--------
---------c.
A new nurse appears to be unsure of nursing assessments. The nurse
asks co-workers to rehearse what needs to be reported to the
physician. This seems to be annoying to some of the nurse co-
workers.What is the nurse managers best response?
a. Tell the staff that all new nurses go through this phase and ignored
the behaviors
b. agree with the staff and have someone follow and work more closely
with a preceptor
c. Explain to coworkers that this is a characteristics of critical thinking
that is important.
d. Have a talk with the nurse and suggest asking fewer questions ---------
CORRECT ANSWER-----------------c.