Med-Surg 130 Final Exam 2024

Med-Surg 130 Final Exam The client is admitted into the ED with diaphoresis, pale, clammy skin, and BP of 90/70. Which intervention should the nurse implement first? a. start an IV w/ an 18-gauge catheter b. administer dopamine intravenous infusion c. obtain arterial blood gases (ABGs) d. Insert an indwelling urinary catheter - ANSWER a. start an IV w/ an 18 gauge catheter there are many types of shock but the one common intervention which should be done first in all types of shock is to establish an IV line with a large-bore catheter the nurse is caring for a client diagnosed with septic shock. which assessment data warrant immediate intervention by the nurse? a. vital signs T 100.4F, HR 104, RR 26, and BP 102/60 b. a white blood cell count of 18,000 c. a urinary output of 90 mL in the last 4 hours d. the client complains of being thirsty - ANSWER c. a urinary output of 90 mL in the last 4 hours 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. the vitals listed are expected in a client with septic shock. an elevated WBC count indicates an infection which is the definition of sepsis. the client being thirsty is not an uncommon complaint. the client diagnosed with septicemia has the following health-care provider orders. which HCP order has the highest priority? a. provide clear liquid diet b. initiate IV antibiotic therapy c. obtain STAT chest x-ray d. perform hourly glucometer checks - ANSWER b. initiate IV antibiotic therapy an IV antibiotic is the priority medication for the client with an infection, which is the definition of sepsis- a systemic bacterial infection of the blood. an IV antibiotic should be implemented within one hour of receiving the order. diagnostic tests are important but not priority over intervening in the potentially life-threatening situation such as septic shock