3rd term week 2 3rd term Study guides, Class notes & Summaries

3rd term week 2 3rd term Study guides, Class notes & Summaries Question: The nurse is caring for the client in cardiogenic shock. The nurse knows that one of the earliest signs of cardiogenic shock is which of the following? Principle: 1. Restlessness or a change in mental status could indicate hypoxia ; Page# 448 2. Confusion may be a sign of early sepsis, fever or hypoxemia ; Page# 552 Question: The nurse observes signs that the post-surgical client may be going into hypovolemic shock. Which of the following assessment findings are consistent with hypovolemic shock? Select all that apply: Principle: 1. Signs of fluid volume deficit include changes in level of consciousness, decreased urinary output, dizziness, dry mucosal membranes, hypotension, tachycardia, ; Page# 247 2. Signs of fluid volume deficit include changes in level of consciousness, decreased urinary output, dizziness, dry mucosal membranes, hypotension, tachycardia, ; Page# 247 3. Shock creates a state where cells are not perfused (cardiogenic/heart pump fails; hypovolemic/intravascular volume drops; distributive/widespread vasodilation along with increased capillary permeability) ; Page# 442 4. Shock creates a state where cells are not perfused (cardiogenic/heart pump fails; hypovolemic/intravascular volume drops; distributive/widespread vasodilation along with increased capillary permeability) ; Page# 442 5. A weak thready pulse typically suggests a decrease in cardiac output ; Page# 443 Question: The nurse is caring for the post-surgical client who is restless and suddenly expresses a feeling of impending doom. Assessment findings also include dyspnea, tachypnea, and tachycardia. Which of the following best describes the underlying reason for the client's presentation? Principle: 1. Lung ventilation and perfusion mis-matches could result in hypoxia ; Page# 467 2. Signs of hypoxia include restlessness, confusion, pallor, tachycardia and tachypnea ; Page# 495 3. Restlessness or a change in mental status could indicate hypoxia ; Page# 805 4. Clinical manifestations of pulmonary embolism consist of chest pain, cough, dyspnea, hypoxemia, tachycardia, tachypnea, petechiae and restlessness ; Page# 813 Question: One day following surgery to the right knee, a client who has diabetes suddenly complains of chest pain and becomes pale and diaphoretic. Vital signs are, blood pressure 100/70 mm Hg, pulse 120 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? Principle: 1. Surgery increases ones risk for venous thromboembolism, surgical site infection, cardiovascular and respiratory complications. ; Page# 404 2. Tachypnea may be one of the first signs signaling a need for oxygen therapy ; Page# 494 3. Surgery increases ones Question: The nurse is completing an assessment on the pregnant client with a pulmonary embolus. The nurse identifies a nursing diagnosis of altered gas exchange. Which intervention should be included in the nursing plan of care? Principle: 1. Lung ventilation and perfusion mis-matches could result in hypoxia ; Page# 467 Question: The nurse is caring for a client who is receiving a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP). Which finding should be reported to the primary health care provider? Principle: 1. All surgical procedures have the risk of hemorrhage! ; Page# 407