NUR 417 EXAM 1 QUESTIONS AND
ANSWERS
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136
beats/min, respirations of 32 breaths/min, temperature of 104 F, and
blood glucose of 246 mg/dL. Which intervention ordered by the health
care provider would the nurse implement first?
1. Acetaminophen (Tylenol) 650 mg rectally.
2. Administer normal saline IV at 500 mL/hr.
3. Start norepinephrine to keep blood pressure above 90 mm Hg.
4. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. -
CORRECT ANSWER- 2. Administer normal saline IV at 500 mL/hr.
Because of the decreased preload associated with septic shock, fluid
resuscitation is the initial therapy. The other actions also are appropriate,
and should be initiated quickly as well.
The nurse is caring for a patient who has septic shock. Which
assessment finding is most important for the nurse to report to the health
care provider?
1. Skin cool and clammy
2. Heart rate of 118 beats/min
3. Blood pressure of 92/56 mm Hg
4. O2 saturation of 93% on room air - CORRECT ANSWER- 1. Skin
cool and clammy
Because patients in the early stage of septic shock have warm and dry
skin, the patient's cool and clammy skin indicates that shock is
progressing. The other information will also be reported, but does not
indicate deterioration of the patient's status.
, Which preventive actions by the nurse will help limit the development of
systemic inflammatory response syndrome (SIRS) in patients admitted
to the hospital? (Select all that apply.)
1. Ambulate postoperative patients as soon as possible after surgery.
2. Use aseptic technique when manipulating invasive lines or devices.
3. Remove indwelling urinary catheters as soon as possible after
surgery.
4. Administer prescribed antibiotics within 1 hour for patients with
possible sepsis.
5. Advocate for parenteral nutrition for patients who cannot eat adequate
calories. - CORRECT ANSWER- 1. Ambulate postoperative patients
as soon as possible after surgery.
2. Use aseptic technique when manipulating invasive lines or devices.
3. Remove indwelling urinary catheters as soon as possible after
surgery.
4. Administer prescribed antibiotics within 1 hour for patients with
possible sepsis.
The standard policy on the cardiac unit states, "Notify the health care
provider for mean arterial pressure (MAP) less than 70 mm Hg." Which
patient's status would the nurse report to the health care provider?
1. Postoperative patient with a BP of 116/42 mm Hg.
2. Newly admitted patient with a BP of 150/87 mm Hg.
3. Patient with left ventricular failure who has a BP of 110/70 mm Hg.
4. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.
- CORRECT ANSWER- 1. Postoperative patient with a BP of 116/42
mm Hg.
The mean arterial pressure (MAP) is calculated using the formula MAP =
(systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient is
67. The MAP in the other three patients is higher than 70 mm Hg.
Which hemodynamic parameter most directly reflects the effectiveness
of drugs given to reduce a patient's left ventricular afterload?
1. Cardiac output (CO)
ANSWERS
A patient with septic shock has a BP of 70/46 mm Hg, pulse of 136
beats/min, respirations of 32 breaths/min, temperature of 104 F, and
blood glucose of 246 mg/dL. Which intervention ordered by the health
care provider would the nurse implement first?
1. Acetaminophen (Tylenol) 650 mg rectally.
2. Administer normal saline IV at 500 mL/hr.
3. Start norepinephrine to keep blood pressure above 90 mm Hg.
4. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL. -
CORRECT ANSWER- 2. Administer normal saline IV at 500 mL/hr.
Because of the decreased preload associated with septic shock, fluid
resuscitation is the initial therapy. The other actions also are appropriate,
and should be initiated quickly as well.
The nurse is caring for a patient who has septic shock. Which
assessment finding is most important for the nurse to report to the health
care provider?
1. Skin cool and clammy
2. Heart rate of 118 beats/min
3. Blood pressure of 92/56 mm Hg
4. O2 saturation of 93% on room air - CORRECT ANSWER- 1. Skin
cool and clammy
Because patients in the early stage of septic shock have warm and dry
skin, the patient's cool and clammy skin indicates that shock is
progressing. The other information will also be reported, but does not
indicate deterioration of the patient's status.
, Which preventive actions by the nurse will help limit the development of
systemic inflammatory response syndrome (SIRS) in patients admitted
to the hospital? (Select all that apply.)
1. Ambulate postoperative patients as soon as possible after surgery.
2. Use aseptic technique when manipulating invasive lines or devices.
3. Remove indwelling urinary catheters as soon as possible after
surgery.
4. Administer prescribed antibiotics within 1 hour for patients with
possible sepsis.
5. Advocate for parenteral nutrition for patients who cannot eat adequate
calories. - CORRECT ANSWER- 1. Ambulate postoperative patients
as soon as possible after surgery.
2. Use aseptic technique when manipulating invasive lines or devices.
3. Remove indwelling urinary catheters as soon as possible after
surgery.
4. Administer prescribed antibiotics within 1 hour for patients with
possible sepsis.
The standard policy on the cardiac unit states, "Notify the health care
provider for mean arterial pressure (MAP) less than 70 mm Hg." Which
patient's status would the nurse report to the health care provider?
1. Postoperative patient with a BP of 116/42 mm Hg.
2. Newly admitted patient with a BP of 150/87 mm Hg.
3. Patient with left ventricular failure who has a BP of 110/70 mm Hg.
4. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.
- CORRECT ANSWER- 1. Postoperative patient with a BP of 116/42
mm Hg.
The mean arterial pressure (MAP) is calculated using the formula MAP =
(systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient is
67. The MAP in the other three patients is higher than 70 mm Hg.
Which hemodynamic parameter most directly reflects the effectiveness
of drugs given to reduce a patient's left ventricular afterload?
1. Cardiac output (CO)
