TEST BANK FOR ADULT
HEALTH NURSING COMPLEX
EXAM QUESTIONS
Themnursemismcaringmformampatientmadmittedmwithmhypovolemicmshock.mThemnursempalpatesmthreadymbr
achialmpulsesmbutmismunablemtomauscultatemambloodmpressure.mWhatmismthembestmnursingmaction?
A) AssessmthembloodmpressurembymDoppler
B) Estimatemthemsystolicmpressuremasm60mmmmHg
C) Obtainmanmelectronicmbloodmpressuremmonitor
D) RecordmthemBPmasm"notmassessable"m-mCORRECTmANSWERm-Am--
mAuscultatedmbloodmpressuresminmshockmmaymbemsignificantlyminaccuratemduemtomvasoconstriction.mIfmblo
odmpressuremismnotmaudible,mthemapproximatemvaluemcanmbemassessedmbympalpationmormultrasound.mIfmbr
achialmpulsesmarempalpable,mthemapproximatemmeasuremofmsystolicmbloodmpressuremism80mmmmHg.mThisma
ctionmhasmthempotentialmtomdelaymfurthermassessmentmofmamcompromisedmpatientminmshock.mDocumentin
gmambloodmpressuremasmnotmassessablemismnotmappropriatemwithoutmfurthermattemptsmusingmdifferentmmo
dalities.
Themnursemhasmjustmcompletedmanminfusionmofmam1000mmLmbolusmofm0.9%mnormalmsalineminmampatie
ntmwithmseveremsepsis.mOnemhourmlater,mwhichmlaboratorymresultmrequiresmimmediatemnursingmactio
n?
A) creatininem1.0mmg/dL
B) lactatem6mmmol/L
C) potassiumm3.8mmEq/L
D) sodiumm140mmEq/Lm-mCORRECTmANSWERm-Bm--
mLactatemlevelmhasmbeenmusedmasmanmindicatormofmdecreasedmoxygenmdeliverymtomthemcells,madequacymof
mresuscitationminmshock,mandmasmanmoutcomempredictor.mAllmothermlistedmvaluesmaremwithinmnormalmlimit
smandmdomnotmrequiremadditionalmfollow-up.
,Themnursemhasmbeenmadministeringm0.9%mnormalmsalinemintravenousmfluidsmasmpartmofmearlymgoal-
directedmtherapymprotocolsminmampatientmwithmseveremsepsis.mTomevaluatemthemeffectivenessmofmfluidmt
herapy,mwhichmphysiologicalmparametersmwouldmbemmostmimportantmformthemnursemtomassess?
A) breathmsoundsm&mcapmrefill
B) BPm&moralmtemp
C) oralmtempm&mcapmrefill
D) rightmatrialmpressurem&murinemoutputm-mCORRECTmANSWERm-Dm--mEarlymgoal-
directedmtherapymincludesmadministrationmofmIVmfluidsmtomkeepmcentralmvenousmpressurematm8mmmmHgmo
rmgreater.mCombinedmwithmurinemoutput,mfluidmtherapymeffectivenessmcanmbemadequatelymassessed.mEval
uationmofmbreathmsoundsmassistsmwithmdeterminingmfluidmoverloadminmampatientmbutmdoesmnotmevaluatemt
hemeffectivenessmofmfluidmtherapy.mCapillarymrefillmprovidesmamquickmassessmentmofmthempatient'smoverallm
cardiovascularmstatus,mbutmthismassessmentmismnotmreliableminmampatientmwhomismhypothermicmormhasmper
ipheralmcirculatorymproblems.mEvaluationmofmoralmtemperaturemdoesmnotmassessmthemeffectivenessmofmflu
idmtherapyminmpatientsminmshock.mEvaluationmofmoralmtemperaturemdoesmnotmassessmthemeffectivenessmofm
fluidmtherapyminmpatientsminmshock.mCapillarymrefillmprovidesmamquickmassessmentmofmthempatient'smoveral
lmcardiovascularmstatus,mbutmthismassessmentmismnotmreliableminmampatientmwhomismhypothermicmormhasmp
eripheralmcirculatorymproblems.
Ampatientmismadmittedmtomthemcriticalmcaremunitmfollowingmcoronarymarterymbypassmsurgery.mTwomhoursm
postoperatively,mthemnursemassessesmthemfollowingminformation:mpulsemism120mbeats/min;mbloodmpressu
remism70/50mmmmHg;mpulmonarymarterymdiastolicmpressuremism2mmmmHg;mcardiacmoutputmism4mL/min;murin
emoutputmism250mmL/hr;mchestmdrainagemism200mmL/hr.mWhatmismthembestminterpretationmbymthemnurse?
A) ThemassessedmvaluesmaremWNL
B) Themptmismatmriskmformdevelopingmcardiogenicmshock
C) Themptmismatmriskmformdevelopingmfluidmvolumemoverload
D) Themptmismatmriskmformdevelopingmhypovolemicmshockm-mCORRECTmANSWERm-Dm--
mVitalmsignsmandmhemodynamicmvaluesmassessedmcollectivelymincludemclassicmsignsmandmsymptomsmofm
hypovolemia.mBothmurinemoutputmandmchestmdrainagemvaluesmaremhigh,mcontributingmtomthemhypovole
mia.mAssessedmvaluesmaremnotmwithinmnormalmlimits.
Amcardiacmoutputmofm4mL/minmismnotmindicativemofmcardiogenicmshock.mThempatientmismatmriskmformhypovo
lemia,mnotmvolumemoverload,masmevidencedmbymexcessivemhourlymchestmdrainagemandmurinemoutput.
,Ampatientmismadmittedmaftermcollapsingmatmthemendmofmamsummermmarathon.mShemismlethargic,mwithma
mheartmratemofm110mbeats/min,mrespiratorymratemofm30mbreaths/min,mandmambloodmpressuremofm78/46m
mmmHg.mThemnursemanticipatesmadministeringmwhichmtherapeuticmintervention?
A) Humanmalbuminminfusion
B) Hypotonicmsalinemsolution
C) LactatedmRinger'smbolus
D) Packedmredmbloodmcellsm-mCORRECTmANSWERm-Cm--
mThempatientmismexperiencingmsymptomsmofmhypovolemicmshock.mIsotonicmcrystalloids,msuchmasmnormalm
salinemandmlactatedmRinger'smsolutions,maremthemprioritymintervention.mAlbuminmandmplasmamproteinmfra
ctionm(Plasmanate)maremnaturallymoccurringmcolloidmsolutionsmthatmareminfusedmwhenmthemvolumemlossmi
smcausedmbymamlossmofmplasmamrathermthanmblood,msuchmasminmburns,mperitonitis,mandmbowelmobstruction
.mHypotonicmsolutionsmrapidlymleavemthemintravascularmspace,mcausingminterstitialmandmintracellularmede
mamandmaremnotmusedmformfluidmresuscitation.mTheremismnomevidencemtomsupportmamtransfusionminmthemgi
venmscenario.
Themnursemismcaringmformampatientminmthemearlymstagesmofmsepticmshock.mThempatientmismslightlymconfusedma
ndmflushed,mwithmboundingmperipheralmpulses.mWhichmhemodynamicmvaluesmismthemnursemmostmlikelymtoma
ssess?
A) Highmpulmonarymarterymocclusivempressuremandmhighmcardiacmoutput
B) Highmsystemicmvascularmresistancemandmlowmcardiacmoutput
C) Lowmpulmonarymarterymocclusivempressuremandmlowmcardiacmoutput
D) Lowmsystemicmvascularmresistancemandmhighmcardiacmoutputm-mCORRECTmANSWERm-Dm--
mAsmamconsequencemofmthemmassivemvasodilationmassociatedmwithmsepticmshock,minmthemearlymstages,mcar
diacmoutputmismhighmwithmlowmsystemicmvascularmresistance.mInmsepticmshock,mpulmonarymarterymocclusio
nmpressuremismnotmelevated.mInmthemearlymstagesmofmsepticmshock,msystemicmvascularmresistancemismlowman
dmcardiacmoutputmismhigh.mInmthemearlymstagesmofmsepticmshock,mcardiacmoutputmismhigh.
Themnursemismcaringmformampatientmadmittedmwithmseveremsepsis.mVitalmsignsmassessedmbymthemnurseminc
ludembloodmpressurem80/50mmmmHg,mheartmratem120mbeats/min,mrespirationsm28mbreaths/min,moralmte
mperaturemofm102°mF,mandmamrightmatrialmpressurem(RAP)mofm1mmmmHg.mAssumingmphysicianmorders,mwhi
chminterventionmshouldmthemnursemcarrymoutmfirst?
, A) Acetaminophenmsuppository
B) Bloodmculturesmfromm2msites
C) IVmabxmadministration
D) Isotonicmfluidmchallengem-mCORRECTmANSWERm-Dm--mEarlymgoal-
directedmtherapyminmseveremsepsismincludesmadministrationmofmIVmfluidsmtomkeepmRAP/CVPmatm8mmmmHgm
ormgreaterm(butmnotmgreatermthanm15mmmmHg)mandmheartmratemlessmthanm110mbeats/min.mFluidmresuscita
tionmtomrestoremperfusionmismthemimmediatempriority.mBroad-
spectrummantibioticsmaremrecommendedmwithinmthemfirstmhour;mhowever,mvolumemresuscitationmismthem
priorityminmthismscenario.
Whichmpatientmbeingmcaredmforminmthememergencymdepartmentmismmostmatmriskmformdevelopingmhypovol
emicmshock?
A) Ampatientmadmittedmwithmabdominalmpainmandmanmelevatedmwhitembloodmcellmcount
B) Ampatientmwithmamtemperaturemofm102°mFmandmamgeneralmdermalmrash
C) Ampatientmwithmam2-daymhistorymofmnausea,mvomiting,mandmdiarrhea
D) Ampatientmwithmslightmrectalmbleedingmfromminflamedmhemorrhoidsm-mCORRECTmANSWERm-Cm--
mExcessivemexternalmlossmofmfluidmmaymoccurmthroughmthemgastrointestinalmtractmviamvomitingmandmdiarr
hea,mwhichmmaymleadmtomhypovolemia.mTheremismnomevidencemtomsupportmsignificantmfluidmlossminmthemr
emainingmpatientmscenarios.
Themnursemismcaringmformampatientmadmittedmwithmcardiogenicmshock.mHemodynamicmreadingsmobtained
mwithmampulmonarymarterymcathetermincludemampulmonarymarterymocclusionmpressurem(PAOP)mofm18mmmm
Hgmandmamcardiacmindexm(CI)mofm1.0mL/min/m2.mWhatmismthemprioritympharmacologicalmintervention?
A) Dobutaminem(Dobutrex)
B) Furosemidem(Lasix)
C) Phenylephrinem(Neo-Synephrine)
D) SodiummNitroprussidem(Nipride)m-mCORRECTmANSWERm-Am--
mPositiveminotropicmagentsm(e.g.,mdobutamine)maremgivenmtomincreasemthemcontractilemforcemofmthemheart
.mAsmcontractilitymincreases,mcardiacmoutputmandmindexmincreasemandmimprovemtissuemperfusion.mAdmini
strationmofmfurosemidemwillmassistmonlyminmmanagingmfluidmvolumemoverload.mPhenylephrinemadministra
tionmenhancesmvasoconstriction,mwhichmmaymincrease
HEALTH NURSING COMPLEX
EXAM QUESTIONS
Themnursemismcaringmformampatientmadmittedmwithmhypovolemicmshock.mThemnursempalpatesmthreadymbr
achialmpulsesmbutmismunablemtomauscultatemambloodmpressure.mWhatmismthembestmnursingmaction?
A) AssessmthembloodmpressurembymDoppler
B) Estimatemthemsystolicmpressuremasm60mmmmHg
C) Obtainmanmelectronicmbloodmpressuremmonitor
D) RecordmthemBPmasm"notmassessable"m-mCORRECTmANSWERm-Am--
mAuscultatedmbloodmpressuresminmshockmmaymbemsignificantlyminaccuratemduemtomvasoconstriction.mIfmblo
odmpressuremismnotmaudible,mthemapproximatemvaluemcanmbemassessedmbympalpationmormultrasound.mIfmbr
achialmpulsesmarempalpable,mthemapproximatemmeasuremofmsystolicmbloodmpressuremism80mmmmHg.mThisma
ctionmhasmthempotentialmtomdelaymfurthermassessmentmofmamcompromisedmpatientminmshock.mDocumentin
gmambloodmpressuremasmnotmassessablemismnotmappropriatemwithoutmfurthermattemptsmusingmdifferentmmo
dalities.
Themnursemhasmjustmcompletedmanminfusionmofmam1000mmLmbolusmofm0.9%mnormalmsalineminmampatie
ntmwithmseveremsepsis.mOnemhourmlater,mwhichmlaboratorymresultmrequiresmimmediatemnursingmactio
n?
A) creatininem1.0mmg/dL
B) lactatem6mmmol/L
C) potassiumm3.8mmEq/L
D) sodiumm140mmEq/Lm-mCORRECTmANSWERm-Bm--
mLactatemlevelmhasmbeenmusedmasmanmindicatormofmdecreasedmoxygenmdeliverymtomthemcells,madequacymof
mresuscitationminmshock,mandmasmanmoutcomempredictor.mAllmothermlistedmvaluesmaremwithinmnormalmlimit
smandmdomnotmrequiremadditionalmfollow-up.
,Themnursemhasmbeenmadministeringm0.9%mnormalmsalinemintravenousmfluidsmasmpartmofmearlymgoal-
directedmtherapymprotocolsminmampatientmwithmseveremsepsis.mTomevaluatemthemeffectivenessmofmfluidmt
herapy,mwhichmphysiologicalmparametersmwouldmbemmostmimportantmformthemnursemtomassess?
A) breathmsoundsm&mcapmrefill
B) BPm&moralmtemp
C) oralmtempm&mcapmrefill
D) rightmatrialmpressurem&murinemoutputm-mCORRECTmANSWERm-Dm--mEarlymgoal-
directedmtherapymincludesmadministrationmofmIVmfluidsmtomkeepmcentralmvenousmpressurematm8mmmmHgmo
rmgreater.mCombinedmwithmurinemoutput,mfluidmtherapymeffectivenessmcanmbemadequatelymassessed.mEval
uationmofmbreathmsoundsmassistsmwithmdeterminingmfluidmoverloadminmampatientmbutmdoesmnotmevaluatemt
hemeffectivenessmofmfluidmtherapy.mCapillarymrefillmprovidesmamquickmassessmentmofmthempatient'smoverallm
cardiovascularmstatus,mbutmthismassessmentmismnotmreliableminmampatientmwhomismhypothermicmormhasmper
ipheralmcirculatorymproblems.mEvaluationmofmoralmtemperaturemdoesmnotmassessmthemeffectivenessmofmflu
idmtherapyminmpatientsminmshock.mEvaluationmofmoralmtemperaturemdoesmnotmassessmthemeffectivenessmofm
fluidmtherapyminmpatientsminmshock.mCapillarymrefillmprovidesmamquickmassessmentmofmthempatient'smoveral
lmcardiovascularmstatus,mbutmthismassessmentmismnotmreliableminmampatientmwhomismhypothermicmormhasmp
eripheralmcirculatorymproblems.
Ampatientmismadmittedmtomthemcriticalmcaremunitmfollowingmcoronarymarterymbypassmsurgery.mTwomhoursm
postoperatively,mthemnursemassessesmthemfollowingminformation:mpulsemism120mbeats/min;mbloodmpressu
remism70/50mmmmHg;mpulmonarymarterymdiastolicmpressuremism2mmmmHg;mcardiacmoutputmism4mL/min;murin
emoutputmism250mmL/hr;mchestmdrainagemism200mmL/hr.mWhatmismthembestminterpretationmbymthemnurse?
A) ThemassessedmvaluesmaremWNL
B) Themptmismatmriskmformdevelopingmcardiogenicmshock
C) Themptmismatmriskmformdevelopingmfluidmvolumemoverload
D) Themptmismatmriskmformdevelopingmhypovolemicmshockm-mCORRECTmANSWERm-Dm--
mVitalmsignsmandmhemodynamicmvaluesmassessedmcollectivelymincludemclassicmsignsmandmsymptomsmofm
hypovolemia.mBothmurinemoutputmandmchestmdrainagemvaluesmaremhigh,mcontributingmtomthemhypovole
mia.mAssessedmvaluesmaremnotmwithinmnormalmlimits.
Amcardiacmoutputmofm4mL/minmismnotmindicativemofmcardiogenicmshock.mThempatientmismatmriskmformhypovo
lemia,mnotmvolumemoverload,masmevidencedmbymexcessivemhourlymchestmdrainagemandmurinemoutput.
,Ampatientmismadmittedmaftermcollapsingmatmthemendmofmamsummermmarathon.mShemismlethargic,mwithma
mheartmratemofm110mbeats/min,mrespiratorymratemofm30mbreaths/min,mandmambloodmpressuremofm78/46m
mmmHg.mThemnursemanticipatesmadministeringmwhichmtherapeuticmintervention?
A) Humanmalbuminminfusion
B) Hypotonicmsalinemsolution
C) LactatedmRinger'smbolus
D) Packedmredmbloodmcellsm-mCORRECTmANSWERm-Cm--
mThempatientmismexperiencingmsymptomsmofmhypovolemicmshock.mIsotonicmcrystalloids,msuchmasmnormalm
salinemandmlactatedmRinger'smsolutions,maremthemprioritymintervention.mAlbuminmandmplasmamproteinmfra
ctionm(Plasmanate)maremnaturallymoccurringmcolloidmsolutionsmthatmareminfusedmwhenmthemvolumemlossmi
smcausedmbymamlossmofmplasmamrathermthanmblood,msuchmasminmburns,mperitonitis,mandmbowelmobstruction
.mHypotonicmsolutionsmrapidlymleavemthemintravascularmspace,mcausingminterstitialmandmintracellularmede
mamandmaremnotmusedmformfluidmresuscitation.mTheremismnomevidencemtomsupportmamtransfusionminmthemgi
venmscenario.
Themnursemismcaringmformampatientminmthemearlymstagesmofmsepticmshock.mThempatientmismslightlymconfusedma
ndmflushed,mwithmboundingmperipheralmpulses.mWhichmhemodynamicmvaluesmismthemnursemmostmlikelymtoma
ssess?
A) Highmpulmonarymarterymocclusivempressuremandmhighmcardiacmoutput
B) Highmsystemicmvascularmresistancemandmlowmcardiacmoutput
C) Lowmpulmonarymarterymocclusivempressuremandmlowmcardiacmoutput
D) Lowmsystemicmvascularmresistancemandmhighmcardiacmoutputm-mCORRECTmANSWERm-Dm--
mAsmamconsequencemofmthemmassivemvasodilationmassociatedmwithmsepticmshock,minmthemearlymstages,mcar
diacmoutputmismhighmwithmlowmsystemicmvascularmresistance.mInmsepticmshock,mpulmonarymarterymocclusio
nmpressuremismnotmelevated.mInmthemearlymstagesmofmsepticmshock,msystemicmvascularmresistancemismlowman
dmcardiacmoutputmismhigh.mInmthemearlymstagesmofmsepticmshock,mcardiacmoutputmismhigh.
Themnursemismcaringmformampatientmadmittedmwithmseveremsepsis.mVitalmsignsmassessedmbymthemnurseminc
ludembloodmpressurem80/50mmmmHg,mheartmratem120mbeats/min,mrespirationsm28mbreaths/min,moralmte
mperaturemofm102°mF,mandmamrightmatrialmpressurem(RAP)mofm1mmmmHg.mAssumingmphysicianmorders,mwhi
chminterventionmshouldmthemnursemcarrymoutmfirst?
, A) Acetaminophenmsuppository
B) Bloodmculturesmfromm2msites
C) IVmabxmadministration
D) Isotonicmfluidmchallengem-mCORRECTmANSWERm-Dm--mEarlymgoal-
directedmtherapyminmseveremsepsismincludesmadministrationmofmIVmfluidsmtomkeepmRAP/CVPmatm8mmmmHgm
ormgreaterm(butmnotmgreatermthanm15mmmmHg)mandmheartmratemlessmthanm110mbeats/min.mFluidmresuscita
tionmtomrestoremperfusionmismthemimmediatempriority.mBroad-
spectrummantibioticsmaremrecommendedmwithinmthemfirstmhour;mhowever,mvolumemresuscitationmismthem
priorityminmthismscenario.
Whichmpatientmbeingmcaredmforminmthememergencymdepartmentmismmostmatmriskmformdevelopingmhypovol
emicmshock?
A) Ampatientmadmittedmwithmabdominalmpainmandmanmelevatedmwhitembloodmcellmcount
B) Ampatientmwithmamtemperaturemofm102°mFmandmamgeneralmdermalmrash
C) Ampatientmwithmam2-daymhistorymofmnausea,mvomiting,mandmdiarrhea
D) Ampatientmwithmslightmrectalmbleedingmfromminflamedmhemorrhoidsm-mCORRECTmANSWERm-Cm--
mExcessivemexternalmlossmofmfluidmmaymoccurmthroughmthemgastrointestinalmtractmviamvomitingmandmdiarr
hea,mwhichmmaymleadmtomhypovolemia.mTheremismnomevidencemtomsupportmsignificantmfluidmlossminmthemr
emainingmpatientmscenarios.
Themnursemismcaringmformampatientmadmittedmwithmcardiogenicmshock.mHemodynamicmreadingsmobtained
mwithmampulmonarymarterymcathetermincludemampulmonarymarterymocclusionmpressurem(PAOP)mofm18mmmm
Hgmandmamcardiacmindexm(CI)mofm1.0mL/min/m2.mWhatmismthemprioritympharmacologicalmintervention?
A) Dobutaminem(Dobutrex)
B) Furosemidem(Lasix)
C) Phenylephrinem(Neo-Synephrine)
D) SodiummNitroprussidem(Nipride)m-mCORRECTmANSWERm-Am--
mPositiveminotropicmagentsm(e.g.,mdobutamine)maremgivenmtomincreasemthemcontractilemforcemofmthemheart
.mAsmcontractilitymincreases,mcardiacmoutputmandmindexmincreasemandmimprovemtissuemperfusion.mAdmini
strationmofmfurosemidemwillmassistmonlyminmmanagingmfluidmvolumemoverload.mPhenylephrinemadministra
tionmenhancesmvasoconstriction,mwhichmmaymincrease
