FINAL EXAM &
VERIFIED CORRECT
ANSWERS JUST
,Which Of The Following Assessments Is Done To Detect Complications Of Iv Fluid
Administration Question
a) Lungs Sounds
b) Cap Refill
c) Pupil Size
d) Temp -Ans:A) Lungs Sounds
*Fve Often Manifests As Acute Hf And Causes Crackles In The Lungs
* Other Body Systems That Can Be Negatively Impacted By Iv Fluids Is The Brain
Because If Give Fluids Too Fast Can Cause Increase In Icp So Look At Loc
Your Patient Has An Intake Of 1050 Ml In The Last Eight Hours And An Output Of 900
Ml. What Is His Food Balance In Ml?
A) +150 Ml
2) -150 Ml -Ans:A) +150 Ml
*More In Then Out
Your Patience Cvp Has Changed From 7 To 2 In The Last Two Hours. Which Of The
Following Could Explain This Change?
a) Acute Hf
b) Diuresis Of 1000 Ml
c) Intake 700, Output 750
d) Administration Of Two Units Prbc -Ans:B) Diuresis Of 1000 Ml
* With Acute Hf Expect Cbp To Be Increased. C Is Wrong Because Only 50 Ml
Difference. And D Is Wrong Because 1000 Ml Of The Fluid Would Increase Cvp
The Nurse Is Caring For A Patient Who Has Been Admitted Because Pt Is 56 And Inr Is
8.2. He Is Receiving Vitamin K. His Wife Puts On The Call Light And The Patients On
The Commode Saying "I Don't Feel Good" In The Commode Is A Large Amount Of
Bright Red Bloody Stool.
The Patient Is Ashen, Diaphoretic, Heart Rate Of 112 And A Bp Of 89/69. What Is The
Nurses Best Action To Take?
,a) Listen To Lung Sounds, Check Spo2
b) Call The Lab To Come Draw A Stat Hgb/Hct
c) Increase The Iv Rate, Call For Help
d) Prepare The Patient For Emergency Surgery -Ans:C) Increase The Iv Rate, Call For
Help
* Lab Will Come Later To Draw Blood Values And Patient May Go In For Emergency
Surgery But The Nurses Initial Action Is To Restore Perfusion For The Patient
A Nurse Is Taking The Morning Bp Of A Postop Patient And The Reading Is 96/60. What
Does The Nurse Do Next
a) Report The Reading To The Physician
b) Assess The Patient's Hr, Rr, And Loc
c) Check The Patient's Chart For Vs Trends
d) Make Note To Check The Patients Bp In An Hour -Ans:B) Assess The Patient's Hr,
Rr, And Loc
* Don't Have Enough Data So These Assessments Will Tell Us How The Patient Is Perfusing
And Patient Was Admitted After Vomiting Up Large Amounts Of Blood. Bp Is 92/70, Hr
Is 116, Rr Is 28, Abg Is Ph 7.31, Pco2 32, Hco3 Is 18, Serum Lactate Is 2.1.
1) Calculate The Pulse Pressure. Is This Normal?
1) Calculate Map. Is This Normal? -Ans:1) 92-70= 22; Normal Is 1/3 X 98=31. This Is
Narrowed
2) (2x70)+92 /3 =77; Normal Is 70-110 So This Is Normal But Trend!
*Tells Us That The Compensatory Mechanisms Are Adequately Allowing For Perfusion
Which Is A Good
What Is The Formula For Determining Pulse Pressure? What Is Considered Normal? -
Ans:Systolic Bp - Diastolic Bp
* Normal Is 1/3 Of The Systolic
Patient Was Admitted With Hypovolemic Shock As A Result Of Vomiting Up A Large
Amount Of Blood. The Following Is The Patients Abg, What Is The Interpretation Of This?
Ph 7.31, Pco2 Is 32, Hco3 Is 18 -Ans:Metabolic Acidosis With Partial Respiratory
Compensation
* Not Just Dka Causes This, Lactic Acidosis Can Result In This Because Anaerobic
Metabolism Is Occurring At The Cellular Level Because In Adequate Amount Of
Oxygenation To The Cells
* Respiratory System Is Trying To Compensate By Increasing Rr To Blow Off Co2
, The Physician Ordered Iv Fluid To Run At 200 Ml/Hr. Which Iv Solution Will You
Expect Him To Order For Pt With Hypovolemic Shock?
a) D5w W 20 Meq/K
b) D10w
c) 0.45% Saline
d) 0.9% Saline -Ans:D) 0.9% Saline
What Are The Clinical Manifestations For The Different Stages Of Sepsis:
1) Sepsis
2) Severe Sepsis
3) Septic Shock -Ans:Sepsis (Infection + Inflammation):
-Lactate >1
-Hr >90
-Temp >101 Or <96.8
-Altered Mental Status
-Significant Edema Or + Fluid
-Hyperglycemia
-Wbc .>12,000 Or <4,000
-Increase Bands
-Increase Crp
Severe Sepsis:
-Lactate >2
-Severe Hypotension
-Lung (Ards), Kidney (Creat >2), Liver (Bili >2), & Coag (<100,000) Involvement
Septic Shock:
-Lactate >4
-Multi Organ Failure
-End Of Life
What Are The Nursing Actions For The Different Stages Of Sepsis
1) Sepsis
2) Severe Sepsis
3) Septic Shock -Ans:*Sepsis*:
-Blood Cultures (W/In 1st Hr)
-Atb (W/In 1st Hr)
-S/S Of Organ Dysfunction
>>Ex: Kidneys W Bun/Creat, Urine Output
>>Ex: Lungs W Loc, Rr, Resp Effort, Abg
VERIFIED CORRECT
ANSWERS JUST
,Which Of The Following Assessments Is Done To Detect Complications Of Iv Fluid
Administration Question
a) Lungs Sounds
b) Cap Refill
c) Pupil Size
d) Temp -Ans:A) Lungs Sounds
*Fve Often Manifests As Acute Hf And Causes Crackles In The Lungs
* Other Body Systems That Can Be Negatively Impacted By Iv Fluids Is The Brain
Because If Give Fluids Too Fast Can Cause Increase In Icp So Look At Loc
Your Patient Has An Intake Of 1050 Ml In The Last Eight Hours And An Output Of 900
Ml. What Is His Food Balance In Ml?
A) +150 Ml
2) -150 Ml -Ans:A) +150 Ml
*More In Then Out
Your Patience Cvp Has Changed From 7 To 2 In The Last Two Hours. Which Of The
Following Could Explain This Change?
a) Acute Hf
b) Diuresis Of 1000 Ml
c) Intake 700, Output 750
d) Administration Of Two Units Prbc -Ans:B) Diuresis Of 1000 Ml
* With Acute Hf Expect Cbp To Be Increased. C Is Wrong Because Only 50 Ml
Difference. And D Is Wrong Because 1000 Ml Of The Fluid Would Increase Cvp
The Nurse Is Caring For A Patient Who Has Been Admitted Because Pt Is 56 And Inr Is
8.2. He Is Receiving Vitamin K. His Wife Puts On The Call Light And The Patients On
The Commode Saying "I Don't Feel Good" In The Commode Is A Large Amount Of
Bright Red Bloody Stool.
The Patient Is Ashen, Diaphoretic, Heart Rate Of 112 And A Bp Of 89/69. What Is The
Nurses Best Action To Take?
,a) Listen To Lung Sounds, Check Spo2
b) Call The Lab To Come Draw A Stat Hgb/Hct
c) Increase The Iv Rate, Call For Help
d) Prepare The Patient For Emergency Surgery -Ans:C) Increase The Iv Rate, Call For
Help
* Lab Will Come Later To Draw Blood Values And Patient May Go In For Emergency
Surgery But The Nurses Initial Action Is To Restore Perfusion For The Patient
A Nurse Is Taking The Morning Bp Of A Postop Patient And The Reading Is 96/60. What
Does The Nurse Do Next
a) Report The Reading To The Physician
b) Assess The Patient's Hr, Rr, And Loc
c) Check The Patient's Chart For Vs Trends
d) Make Note To Check The Patients Bp In An Hour -Ans:B) Assess The Patient's Hr,
Rr, And Loc
* Don't Have Enough Data So These Assessments Will Tell Us How The Patient Is Perfusing
And Patient Was Admitted After Vomiting Up Large Amounts Of Blood. Bp Is 92/70, Hr
Is 116, Rr Is 28, Abg Is Ph 7.31, Pco2 32, Hco3 Is 18, Serum Lactate Is 2.1.
1) Calculate The Pulse Pressure. Is This Normal?
1) Calculate Map. Is This Normal? -Ans:1) 92-70= 22; Normal Is 1/3 X 98=31. This Is
Narrowed
2) (2x70)+92 /3 =77; Normal Is 70-110 So This Is Normal But Trend!
*Tells Us That The Compensatory Mechanisms Are Adequately Allowing For Perfusion
Which Is A Good
What Is The Formula For Determining Pulse Pressure? What Is Considered Normal? -
Ans:Systolic Bp - Diastolic Bp
* Normal Is 1/3 Of The Systolic
Patient Was Admitted With Hypovolemic Shock As A Result Of Vomiting Up A Large
Amount Of Blood. The Following Is The Patients Abg, What Is The Interpretation Of This?
Ph 7.31, Pco2 Is 32, Hco3 Is 18 -Ans:Metabolic Acidosis With Partial Respiratory
Compensation
* Not Just Dka Causes This, Lactic Acidosis Can Result In This Because Anaerobic
Metabolism Is Occurring At The Cellular Level Because In Adequate Amount Of
Oxygenation To The Cells
* Respiratory System Is Trying To Compensate By Increasing Rr To Blow Off Co2
, The Physician Ordered Iv Fluid To Run At 200 Ml/Hr. Which Iv Solution Will You
Expect Him To Order For Pt With Hypovolemic Shock?
a) D5w W 20 Meq/K
b) D10w
c) 0.45% Saline
d) 0.9% Saline -Ans:D) 0.9% Saline
What Are The Clinical Manifestations For The Different Stages Of Sepsis:
1) Sepsis
2) Severe Sepsis
3) Septic Shock -Ans:Sepsis (Infection + Inflammation):
-Lactate >1
-Hr >90
-Temp >101 Or <96.8
-Altered Mental Status
-Significant Edema Or + Fluid
-Hyperglycemia
-Wbc .>12,000 Or <4,000
-Increase Bands
-Increase Crp
Severe Sepsis:
-Lactate >2
-Severe Hypotension
-Lung (Ards), Kidney (Creat >2), Liver (Bili >2), & Coag (<100,000) Involvement
Septic Shock:
-Lactate >4
-Multi Organ Failure
-End Of Life
What Are The Nursing Actions For The Different Stages Of Sepsis
1) Sepsis
2) Severe Sepsis
3) Septic Shock -Ans:*Sepsis*:
-Blood Cultures (W/In 1st Hr)
-Atb (W/In 1st Hr)
-S/S Of Organ Dysfunction
>>Ex: Kidneys W Bun/Creat, Urine Output
>>Ex: Lungs W Loc, Rr, Resp Effort, Abg
