exam 5 evolve UPDATED ACTUAL Exam
Questions and CORRECT Answers
the nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction.
Which clinical manifestations would be mostconcerning?
a. restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds
b. mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin
c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding
d. agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL - CORRECT
ANSWER -c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site
bleeding
a 64-yr-old woman is admitted to the emergency department vomiting bright red blood. the
patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of
28 breaths/min, and temperature of 97.2°F (36.2°C). which physician order should the nurse
complete first?
a. obtain a 12-lead ECG and arterial blood gases.
b. rapidly administer 1000 mL normal saline solution IV
c. administer norepinephrine (Levophed) by continuous IV infusion.
d. carefully insert a nasogastric tube and an indwelling bladder catheter. - CORRECT
ANSWER -b. rapidly administer 1000 mL normal saline solution IV
,a 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media.
the nurse notifies the physician that the patient reported an allergy to shellfish. which response
by the physician should the nurse question?
a. infuse IV diphenhydramine before the procedure.
b. administer lorazepam (Ativan) before the procedure.
c. complete the CT scan without the use of contrast media.
d. premedicate with hydrocortisone sodium succinate (Solu-Cortef). - CORRECT
ANSWER -b. administer lorazepam (Ativan) before the procedure.
the nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures,
pulmonary contusions, and a left femur fracture from a motor vehicle crash. the attending
physician states the patient has developed sepsis, and the family members have many questions.
which information should the nurse include when explaining the early stage of sepsis?
a. antibiotics are not useful when an infection has progressed to sepsis.
b. weaning the patient away from the ventilator is the top priority in sepsis.
c. large amounts of IV fluid are required in sepsis to fill dilated blood vessels.
d. the patient has recovered from sepsis if he has warm skin and ruddy cheeks. - CORRECT
ANSWER -c. large amounts of IV fluid are required in sepsis to fill dilated blood vessels.
the nurse is assisting in the care of several patients in the critical care unit. which patient is most
at risk for developing multiple organ dysfunction syndrome (MODS)?
a. a 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture
, b. a 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic
hormone and hyponatremia
c. a 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension
admitted for unstable angina
d. a 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for
peritonitis related to a peritoneal dialysis catheter infection - CORRECT ANSWER -d. a
82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for
peritonitis related to a peritoneal dialysis catheter infection
when caring for a patient in acute septic shock, what should the nurse anticipate?
a. infusing large amounts of IV fluids
b. administering osmotic and/or loop diuretics
c. administering IV diphenhydramine (Benadryl)
d. assisting with insertion of a ventricular assist device (VAD) - CORRECT ANSWER -a.
infusing large amounts of IV fluids
when caring for a critically ill patient who is being mechanically ventilated, the nurse will
monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?
a. Increased serum albumin
b. decreased respiratory compliance
Questions and CORRECT Answers
the nurse is caring for a 72-yr-old man in cardiogenic shock after an acute myocardial infarction.
Which clinical manifestations would be mostconcerning?
a. restlessness, heart rate of 124 beats/min, and hypoactive bowel sounds
b. mean arterial pressure of 54 mm Hg; increased jaundice; and cold, clammy skin
c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site bleeding
d. agitation, respiratory rate of 32 breaths/min, and serum creatinine of 2.6 mg/dL - CORRECT
ANSWER -c. PaO2 of 38 mm Hg, serum lactate level of 46.5 mcg/dL, and puncture site
bleeding
a 64-yr-old woman is admitted to the emergency department vomiting bright red blood. the
patient's vital signs are blood pressure of 78/58 mm Hg, pulse of 124 beats/min, respirations of
28 breaths/min, and temperature of 97.2°F (36.2°C). which physician order should the nurse
complete first?
a. obtain a 12-lead ECG and arterial blood gases.
b. rapidly administer 1000 mL normal saline solution IV
c. administer norepinephrine (Levophed) by continuous IV infusion.
d. carefully insert a nasogastric tube and an indwelling bladder catheter. - CORRECT
ANSWER -b. rapidly administer 1000 mL normal saline solution IV
,a 50-yr-old woman with a suspected brain tumor is scheduled for a CT scan with contrast media.
the nurse notifies the physician that the patient reported an allergy to shellfish. which response
by the physician should the nurse question?
a. infuse IV diphenhydramine before the procedure.
b. administer lorazepam (Ativan) before the procedure.
c. complete the CT scan without the use of contrast media.
d. premedicate with hydrocortisone sodium succinate (Solu-Cortef). - CORRECT
ANSWER -b. administer lorazepam (Ativan) before the procedure.
the nurse is caring for a 29-yr-old man who was admitted 1 week ago with multiple rib fractures,
pulmonary contusions, and a left femur fracture from a motor vehicle crash. the attending
physician states the patient has developed sepsis, and the family members have many questions.
which information should the nurse include when explaining the early stage of sepsis?
a. antibiotics are not useful when an infection has progressed to sepsis.
b. weaning the patient away from the ventilator is the top priority in sepsis.
c. large amounts of IV fluid are required in sepsis to fill dilated blood vessels.
d. the patient has recovered from sepsis if he has warm skin and ruddy cheeks. - CORRECT
ANSWER -c. large amounts of IV fluid are required in sepsis to fill dilated blood vessels.
the nurse is assisting in the care of several patients in the critical care unit. which patient is most
at risk for developing multiple organ dysfunction syndrome (MODS)?
a. a 22-yr-old patient with systemic lupus erythematosus admitted with a pelvic fracture
, b. a 48-yr-old patient with lung cancer admitted for syndrome of inappropriate antidiuretic
hormone and hyponatremia
c. a 65-yr-old patient with coronary artery disease, dyslipidemia, and primary hypertension
admitted for unstable angina
d. a 82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for
peritonitis related to a peritoneal dialysis catheter infection - CORRECT ANSWER -d. a
82-yr-old patient with type 2 diabetes mellitus and chronic kidney disease admitted for
peritonitis related to a peritoneal dialysis catheter infection
when caring for a patient in acute septic shock, what should the nurse anticipate?
a. infusing large amounts of IV fluids
b. administering osmotic and/or loop diuretics
c. administering IV diphenhydramine (Benadryl)
d. assisting with insertion of a ventricular assist device (VAD) - CORRECT ANSWER -a.
infusing large amounts of IV fluids
when caring for a critically ill patient who is being mechanically ventilated, the nurse will
monitor for which clinical manifestation of multiple organ dysfunction syndrome (MODS)?
a. Increased serum albumin
b. decreased respiratory compliance
