Advanced Med Surg. Exam 2 - questions
1. The nurse is caring for a patient admitted with severe sepsis. Vital signs
assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120
beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a
right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse
carry out first?
a.Acetaminophen suppository
b.Blood cultures from two sites
c.IV antibiotic administration
d.Isotonic fluid challenge:
2. The nurse is caring for a patient admitted with hypovolemic shock. The
nurse palpates thready brachial pulses but is unable to auscultate a blood
pressure.
What is the best nursing action?
a.
Assess the blood pressure by Doppler.
b.
Estimate the systolic pressure as 60 mm Hg.
c.
Obtain an electronic blood pressure monitor.
d.
Record the blood pressure as "not assessable.":
Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be assessed
by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of
systolic blood pressure is 80 mm Hg. This action has the potential to delay further
assessment of a compromised patient in shock. Documenting a blood pressure as not
assessable is inappropriate without further attempts using different modalities.
, Advanced Med Surg. Exam 2 - questions
3. The nurse has just completed an infusion of a 1000 mL bolus of 0.9%
normal saline in a patient with severe sepsis. One hour later, which laboratory
result requires immediate nursing action?
a.
Creatinine 1.0 mg/dL
b.
Lactate 6 mmol/L
c.
Potassium 3.8 mEq/L
d.
Sodium 140 mEq/L:
B:
Lactate level has been used as an indicator of decreased oxygen delivery to the cells,
adequacy of resuscitation in shock, and as an outcome predictor
Other values are normal
4. The nurse has been administering 0.9% normal saline intravenous fluids
in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy,
which physiological parameters would be most important for the nurse to
assess?
a.
Breath sounds and capillary refill
b.
Blood pressure and oral temperature
c.
Oral temperature and capillary refill
d.
Right atrial pressure and urine output:
1. The nurse is caring for a patient admitted with severe sepsis. Vital signs
assessed by the nurse include blood pressure 80/50 mm Hg, heart rate 120
beats/min, respirations 28 breaths/min, oral temperature of 102° F, and a
right atrial pressure (RAP) of 1 mm Hg. Which intervention should the nurse
carry out first?
a.Acetaminophen suppository
b.Blood cultures from two sites
c.IV antibiotic administration
d.Isotonic fluid challenge:
2. The nurse is caring for a patient admitted with hypovolemic shock. The
nurse palpates thready brachial pulses but is unable to auscultate a blood
pressure.
What is the best nursing action?
a.
Assess the blood pressure by Doppler.
b.
Estimate the systolic pressure as 60 mm Hg.
c.
Obtain an electronic blood pressure monitor.
d.
Record the blood pressure as "not assessable.":
Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be assessed
by palpation or ultrasound. If brachial pulses are palpable, the approximate measure of
systolic blood pressure is 80 mm Hg. This action has the potential to delay further
assessment of a compromised patient in shock. Documenting a blood pressure as not
assessable is inappropriate without further attempts using different modalities.
, Advanced Med Surg. Exam 2 - questions
3. The nurse has just completed an infusion of a 1000 mL bolus of 0.9%
normal saline in a patient with severe sepsis. One hour later, which laboratory
result requires immediate nursing action?
a.
Creatinine 1.0 mg/dL
b.
Lactate 6 mmol/L
c.
Potassium 3.8 mEq/L
d.
Sodium 140 mEq/L:
B:
Lactate level has been used as an indicator of decreased oxygen delivery to the cells,
adequacy of resuscitation in shock, and as an outcome predictor
Other values are normal
4. The nurse has been administering 0.9% normal saline intravenous fluids
in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy,
which physiological parameters would be most important for the nurse to
assess?
a.
Breath sounds and capillary refill
b.
Blood pressure and oral temperature
c.
Oral temperature and capillary refill
d.
Right atrial pressure and urine output:
