NRS 440 Unit 3 Questions with Correct Answers Rated A+

One of your patients begins to vomit large amounts of bright red blood. The patient is taking Warfarin. You call a rapid response. Which assessment findings indicate this patient is developing hypovolemic shock? Select all that apply: Urinary output 15 mL/hr Anxiety, restlessness Temperature 104.8 ‘F Heart rate 40 bpm Heart rate 140 bpm Pale, cool skin Blood pressure 220/106 Weak peripheral pulses Blood pressure 70/56 Urinary output 15 mL/hr Anxiety, restlessness Heart rate 140 bpm Pale, cool skin Weak peripheral pulses Blood pressure 70/56 You’re providing care to a patient who has experienced a 45% loss of their fluid volume and is experiencing hypovolemic shock. The patient has hemodynamic monitoring and fluid resuscitation is being attempted. Which finding indicates the patient is still in hypovolemic shock? High pulmonary artery wedge pressure Low central venous pressure Elevated mean arterial pressure Low systemic vascular resistance Low central venous pressure A 35-year-old male arrives to the emergency room with multiple long bone fractures and an internal abdominal injury. The patient is anxious. Patient’s vital signs are: Blood pressure 70/54, heart rate 125 bpm, respirations 30, oxygen saturation on 2 L nasal cannula 96%, temperature 99.3 ‘F, pain 6 on 1-10 scale. During assessment it is noted the skin is cool and clammy. The nurse will make it priority to? Obtain an EKG Place a warming blanket on the patient Establish 2 large-bore IV access sites Collect a urine sample Establish 2 large-bore IV access sites A patient in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which patient finding requires immediate nursing action? Patient experiences dyspnea and crackles in lung fields Patient heart rate is 115 bpm Patient is anxious Patient’s urinary output is 35 mL/hr Patient experiences dyspnea and crackles in lung fields Physical assessment of the patient with disseminated intravascular coagulation (DIC) may show which of the following? Increased urinary output, fluid overload Peripheral cyanosis, oozing from puncture sites Hypertension, headache Crackles throughout bilateral lung fields Peripheral cyanosis, oozing from puncture sites A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? Apply sterile dressings to the sites. Give prescribed proton-pump inhibitors. Avoid venipunctures. Notify the patient's physician. Notify the patient's physician. You’re working on a neuro unit. Which of your patients below are at risk for developing neurogenic shock? Select all that apply: A 25-year-old with a spinal cord injury above T6. A 36-year-old with a spinal cord injury at L4. A 42-year-old who has spinal anesthesia. A 55-year-old patient who is reporting seeing green halos while taking Digoxin. A 25-year-old with a spinal cord injury above T6. A 42-year-old who has spinal anesthesia. Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop the medication and call a rapid response. The patient's blood pressure is 80/52, heart rate 120, and oxygen saturation 87%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that the first initial treatment for this patient's condition is? IV Normal Saline Bolus Nebulized Albuterol IM Epinephrine IV Diphenhydramine IM Epinephrine