Complex Exam 1 Test Bank Q's NEWEST ACTUAL EXAM TEST BANK COMPLETE QUESTIONS AND CORRECT DETAILED ANSWER

Complex Exam 1 Test Bank Q's NEWEST ACTUAL EXAM TEST BANK COMPLETE QUESTIONS AND CORRECT DETAILED ANSWER The emergency department nurse admits a patient following a motor vehicle collision. Vital signs include blood pressure 70/50 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min, temperature 101° F and oxygen saturation (SpO2) 95% on 3 L of oxygen per nasal cannula. Laboratory results include hemoglobin 6.0 g/dL, hematocrit 20%, and potassium 4.0 mEq/L. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? A) Insertion of an 18-gauge peripheral intravenous line B) Application of cushioned heel protectors C) Implementation of fall precautions D) Implementation of universal precautions - ANSWER-A – Rationale. Given the patient's diagnosis, laboratory results, and supporting vital signs, restoring circulating blood volume is a priority and can be accomplished following insertion of an appropriate gauge IV (18) to facilitate blood and fluid administration. Universal precautions, fall precautions, and application of heel protectors are appropriate interventions but are not the immediate priority. The nurse is starting to administer a unit of packed red blood cells (PRBCs) to a patient admitted in hypovolemic shock secondary to hemorrhage. Vital signs include blood pressure 60/40 mm Hg, heart rate 150 beats/min, respirations 42 breaths/min, and temperature 100.6° F. What is the best action by the nurse? A) Administer blood transfusion over at least 4 hours. B) Notify the physician of the elevated temperature. C) Titrate rate of blood administration to patient response. D) Notify the physician of the patient's heart rate. - ANSWER-C – Rationale. Given the acute nature of the patient's blood loss, the nurse should titrate the rate of the blood transfusion to an improvement in the patient's blood pressure. Administering the transfusion over 4 hours can lead to a prolonged state of hypoperfusion and endorgan damage. The heart rate will normalize as circulating blood volume is restored. A mildly elevated temperature does not take priority over restoring circulating blood volume.