Immunity Exam Accurate 100%

The nurse has just completed administration of a 500 mL bolus of 0.9% normal saline in a patient with hypovolemic shock. The nurse assesses the patient to be slightly confused, with a mean arterial blood pressure (MAP) of 50 mm Hg, a heart rate of 110 beats/min, urine output of 10 mL for the past hour, and a central venous pressure (CVP/RAP) of 3 mm Hg. What is the best interpretation of these results by the nurse? a) Patient response to therapy is appropriate b) Additional interventions are indicated c) More time is needed to assess response d) Values are normal for the patient condition -ANSWER - Additional interventions are indicated The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? a) Documentation of insertion date b) Elevation of the HOB c) Assessment for weaning readiness d) Appropriate sedation management -ANSWER A The nurse is caring for a patient in septic shock. The nurse assesses the patient to have a blood pressure of 105/60 mm Hg, heart rate 110 beats/min, respiratory rate 32 breaths/min, oxygen saturation (SpO2) 95% on 45% supplemental oxygen via Venturi mask, and a temperature of 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a) Blood cultures b) Chest x-ray c) Foley insertion d) Serum electrolytes -ANSWER - Blood cultures A client brought to the emergency department after a motor vehicle accident is suspected of having internal bleeding. Which question does the nurse ask to determine whether the client is in the early stages of hypovolemic shock? a. "Are you more thirsty than normal?" b. "When was the last time you urinated?" c. "What is your normal heart rate?" d. "Is your skin usually cool and pale?" -ANSWER C The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action? a) Assess the blood pressure by Doppler b) Estimate the systolic pressure as 60 mmHg c) Obtain an electronic blood pressure monitor d) Record the blood pressure as "not assessable" -ANSWER A The nurse is assessing a client who has hypovolemic shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide -ANSWER B The nurse has been administering 0.9% normal saline intravenous fluids in a patient with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a) Breath sounds and capillary refill b) BP and oral temperature c) Oral temperature and capillary refill d) Right Arterial Pressure and urine output -ANSWER D The nurse is caring for an athlete with a possible cervical spine (C5) injury following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg, heart rate 45 beats/min, and respirations 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a) The patient is developing neurogenic shock. b) The patient is experiencing an allergic reaction. c) The patient most likely has an elevated temperature. d) The vital signs are normal for this patient. -ANSWER A The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of greater than or equal to 2.5 L/min/m2. The nurse measures a cardiac output, and the calculated cardiac index for the patient is 4.6 L/min/m2. What is the best action by the nurse? a) Obtain a stat serum potassium level b) Order a stat 12-lead electrocardiogram c) Reduce the rate of dobutamine d) Assess the patient's hourly urine output -ANSWER C The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5 L/min/m2, heart rate of 70 beats/min, and a systemic dynes/sec/cm−5. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a) Furosemide 20 mg intravenous (IV) every 4 hours as needed for CVP greater than or equal to ≥20 mm Hg b) Nitroglycerin infusion titrated at a rate of 5 to 10 mcg/min as needed for chest pain c) Dobutamine infusion at a rate of 2 to 20 mcg/kg/min as needed for CI less than 2 L/min/m2 d) Dopamine infusion at a rate of 5 to 10 mcg/kg/min to maintain a systolic BP of at least 90 mm Hg -ANSWER B The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm Hg and a cardiac index (CI) of 1.0 L/min/m2. What is the priority pharmacological intervention? a) Dobutamine b) Furosemide c) Phenylephrine d) Sodium nitroprusside -ANSWER A The charge nurse of a transplant unit is reviewing the clinical course of several transplant patients being cared for in the unit. Which patient assessed by the charge nurse requires immediate action? a. Renal transplant recipient, 1 day post op with a 3/10 pain level b. Lung transplant recipient, 1 day post op with a productive cough c. Heart transplant recipient, 1 day post op