Emergency Nursing Practice Questions and Answers with Verified Solutions

Emergency Nursing Practice Questions and Answers with Verified Solutions The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings? Answer: 16 mmHg pulse pressure The pulse pressure is the systolic BP minus the diastolic BP. 100 - 60 = 40 mmHg pulse pressure in first BP reading 88 - 64 = 24 mmHg pulse pressure in second reading 40 - 24 = 16 mmHg pulse pressure narrowing. A narrowing or decreased pulse pressure is an earlier indicator of shock than a decrease in systolic blood pressure. TEST-TAKING HINT: If the test taker is not aware of how to obtain a pulse pressure, the only numbers provided in the stem are systolic and diastolic blood pressures. The test taker should do something with the numbers. The client is admitted into the emergency department with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter. 2. Administer intravenous dopamine infusion. 3. Obtain arterial blood gases (ABGs). 4. Insert an indwelling urinary catheter. Answer: 1 1. There are many types of shock, but the one common intervention that should be done first in all types of shock is to establish an intravenous line with a large-bore catheter. The low blood pressure and cold, clammy skin indicate shock. 2. This blood pressure does not require dopamine; fluid resuscitation is first. 3. The client may need ABGs monitored, but this is not the first intervention. 4. An indwelling catheter may need to be inserted for accurate measurement of output, but it is not the first intervention. TEST-TAKING HINT: This question asks for the first intervention, which means all options may be appropriate interventions for the client, but only one should be implemented first. Remember: When the client is in distress, do not assess. The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4°F, P 104, R 26, and BP 102/60. 2. A white blood cell count of 18,000/mm^3. 3. Urinary output of 90 mL in the last 4 hours. 4. The client reports being thirsty. Answer: 3 1. These vital signs are expected in a client diagnosed with septic shock. 2. An elevated WBC count indicates an infection, which is the definition of sepsis. 3. The client must have a urinary output of at least 30 mL/hr, so 90 mL in the last 4 hours indicates impaired renal perfusion, which is a sign of worsening shock. 4. The client being thirsty is not an uncommon issue for a client diagnosed with septic shock. This warrants immediate intervention. TEST-TAKING HINT: The words "warrant immediate intervention" mean the nurse must do something, which frequently can be notifying the HCP. Any client diagnosed with shock will have clinical manifestations requiring the nurse to intervene. In this question, the test taker must determine priority and which data require immediate intervention. The client diagnosed with septicemia has the following health-care provider (HCP) orders. Which HCP order has the highest priority? 1. Provide clear liquid diet. 2. Initiate IV antibiotic therapy. 3. Obtain a STAT chest x-ray. 4. Perform hourly glucometer checks. Answer: 2 1. The client's diet is not a priority when transcribing orders. 2. An IV antibiotic is the priority medication for the client diagnosed with an infection, which is the definition of sepsis—a systemic bacterial infection of the blood. A new order for an IV antibiotic should be implemented within 1 hour of receiving the o