HESI RN EXIT NR293 EXAM 3
A patient with septic shock has a urine output of 20 mL/hr for the past
3 hours. The pulse rate is 120 and the central venous and pulmonary
artery wedge pressure are 4. Which of these orders by the health care
provider will the nurse question?
a.Give furosemide (Lasix) 40 mg IV
b. increase normal saline infusion to 150 mL/hr
c.Administer hydrocortisone (SoluCortef) 100 mg IV
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
After receiving 1000 mL of normal saline, the central venous pressure
for a patient who has septic shock is 10 mm Hg, but the blood pressure
is still 82/40 mmHg. The nurse will anticipate the administration of
which of the following?
a.Nitroglycerin (Tridil)
b.Sodium nitroprusside (Nipride)
c.Drotrecogin alpha (Xigris)
d.Norepinephrine (Levophed)
, Which of these findings is the best indicators that the fluid
resuscitation for apatient with hypovolemic shock has been
successful?
a.hemoglobin is within normal limits
b.Urine output is 60 mL over the last hour
c.Pulmonary artery wedge pressure (PAWP) is 10 mmHg
d.Mean arterial pressure (MAP) is 55 mm Hg
Which interventions will the nurse include in the plan of the care
for a patientwho has cardiogenic shock?
a.Avoid elevating head of bed
b.Check temperature every 2 hours
c.Monitor breath sounds frequently
d.Assess skin for flushing and itching
Which assessment is most important for the nurse to make in order
to evaluatewhether treatment of a patient with anaphylactic shock
has been effective?
a.Pulse rate
b.Orientation
c.Blood pressure
d.Oxygen saturation
When caring for the patient who has septic shock, which
assessment finding ismost important for the nurse to report to the
health care provider?
,e. BP 92/56 mm Hg
f. Skin cool and clammy
g. apical pulse 118 beats/min
, h. Arterial oxygen saturation 91%
38. During change-of-shift report, the nurse learns that a
patient has been admittedwith dehydration and hypotension after
having vomiting and diarrhea for 3 days. Which findings is most
important for the nurse to report to the HCP?
a.Decreased bowel sounds
b.Apical pulse 110 beats/min
c.Pale, cool, and dry extremities
d.New onset of confusion and agitation
39. A patient is admitted to the burn unit with burns the upper
body and head aftera garage fire. Initially, wheezes are heard, but
an hour later, the lung sounds are decreased ad no wheezes are
audible. What is the best action for the nurse to take?
a.encourage the patient to cough and auscultate the lungs again
b.Notify the HCP and prepare for endotracheal intubation
c.Document the results and continue to monitor the patient’s resp. rate
d.Reposition pt in high-Fowler’s position and reassess breath sounds
40. During the emergent phase of burn care, which nursing
action will be mostuseful in determining whether the patient is
receiving adequate fluid infusion?
a.Check skin turgor
b.Monitor daily weight
c.Assess mucous membranes
d.Measures hourly urine output
A patient with septic shock has a urine output of 20 mL/hr for the past
3 hours. The pulse rate is 120 and the central venous and pulmonary
artery wedge pressure are 4. Which of these orders by the health care
provider will the nurse question?
a.Give furosemide (Lasix) 40 mg IV
b. increase normal saline infusion to 150 mL/hr
c.Administer hydrocortisone (SoluCortef) 100 mg IV
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr
After receiving 1000 mL of normal saline, the central venous pressure
for a patient who has septic shock is 10 mm Hg, but the blood pressure
is still 82/40 mmHg. The nurse will anticipate the administration of
which of the following?
a.Nitroglycerin (Tridil)
b.Sodium nitroprusside (Nipride)
c.Drotrecogin alpha (Xigris)
d.Norepinephrine (Levophed)
, Which of these findings is the best indicators that the fluid
resuscitation for apatient with hypovolemic shock has been
successful?
a.hemoglobin is within normal limits
b.Urine output is 60 mL over the last hour
c.Pulmonary artery wedge pressure (PAWP) is 10 mmHg
d.Mean arterial pressure (MAP) is 55 mm Hg
Which interventions will the nurse include in the plan of the care
for a patientwho has cardiogenic shock?
a.Avoid elevating head of bed
b.Check temperature every 2 hours
c.Monitor breath sounds frequently
d.Assess skin for flushing and itching
Which assessment is most important for the nurse to make in order
to evaluatewhether treatment of a patient with anaphylactic shock
has been effective?
a.Pulse rate
b.Orientation
c.Blood pressure
d.Oxygen saturation
When caring for the patient who has septic shock, which
assessment finding ismost important for the nurse to report to the
health care provider?
,e. BP 92/56 mm Hg
f. Skin cool and clammy
g. apical pulse 118 beats/min
, h. Arterial oxygen saturation 91%
38. During change-of-shift report, the nurse learns that a
patient has been admittedwith dehydration and hypotension after
having vomiting and diarrhea for 3 days. Which findings is most
important for the nurse to report to the HCP?
a.Decreased bowel sounds
b.Apical pulse 110 beats/min
c.Pale, cool, and dry extremities
d.New onset of confusion and agitation
39. A patient is admitted to the burn unit with burns the upper
body and head aftera garage fire. Initially, wheezes are heard, but
an hour later, the lung sounds are decreased ad no wheezes are
audible. What is the best action for the nurse to take?
a.encourage the patient to cough and auscultate the lungs again
b.Notify the HCP and prepare for endotracheal intubation
c.Document the results and continue to monitor the patient’s resp. rate
d.Reposition pt in high-Fowler’s position and reassess breath sounds
40. During the emergent phase of burn care, which nursing
action will be mostuseful in determining whether the patient is
receiving adequate fluid infusion?
a.Check skin turgor
b.Monitor daily weight
c.Assess mucous membranes
d.Measures hourly urine output
