NMNC 4410 Exam 3 with Questions and Answers

NMNC 4410 Exam 3 with Questions and Answers A new nurse is having difficulty knowing which client should be seen first because they all seem important. The nurse preceptor helps and explains which of the following should be seen first? Hypotension, tachycardia, and lethargy Febrile, tachycardia, and vomiting Abdominal pain, hypertensive and constipated Dizziness with normal vital signs ANSWER Hypotension, tachycardia, and lethargy A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first Increase the rate of intravenous (IV) fluids Insert an indwelling urinary catheter Obtain arterial blood gas results Prepare to hang Heparin IV ANSWER Increase the rate of intravenous (IV) fluids After reviewing the information shown in the accompanying figure for a patient with pneumonia and sepsis, which information is most important to report to the healthcare provider? Petechiae noted on chest and legs· Crackles heard bilaterally in lung bases· No redness or swelling at central line IV site· Blood urea nitrogen (BUN) 34 mg/dL· Hematocrit 30%· Platelets 50,000/µL· Temperature 100° F (37.8° C)· Pulse 102/min· Respirations 26/min· BP 110/60 mm Hg· O2 saturation 93% on 2L O2 via nasal cannula Temperature and IV site appearance Oxygen saturation and breath sounds Platelet count and present of petechiae blood pressure, pulse rate, and respiratory rate ANSWER Platelet count and present of petechiae