SOLVED

Chapter 36 Question 1 A patient is admitted to the emergency department with severe burn injuries. The nurse’s priority actions are to prevent development of which type of shock? 1. Cardiogenic 2. Hypovolemic 3. Distributive 4. Obstructive Question 2 A nurse is providing care to a patient with progressive shock. Which nursing diagnosis is priority in guiding the selection of interventions for this patient? 1. Ineffective Airway Clearance 2. Ineffective Tissue Perfusion 3. Stress Overload 4. Impaired Skin Integrity Question 3 A patient was admitted to the emergency department for treatment of a severe infection. Which subjective assessment would raise the nurse’s concern that this patient may be developing shock? 1. Hot, dry skin 2. Respiratory rate 11 3. Pulse rate 118 and weak 4. Anxiety Question 4 A patient was admitted to the emergency room for treatment of severe infection. Which objective parameters would increase the nurse’s concern that shock is developing? 1. Serum lactate level is 5.4 mmol/L. 2. Base deficit is -12 mmol/L. 3. SvO2 is 68%. 4. pHi is 6.9. 5. Arterial pH of 7.38. Question 5 A patient in shock has been sedated using a propofol (Diprivan) drip. How will the nurse assess this patient’s mental status? 1. Temporarily discontinue the drip and assess mental status within a few minutes. 2. Temporarily discontinue the drug and plan to assess mental status in an hour. 3. Use “train of four” testing while the medication is still infusing. 4. This assessment will have to wait until the sedating drug is no longer needed. Question 6 A patient is being treated with acetaminophen and a cooling blanket for persistent hyperthermia. Which assessment finding would the nurse evaluate as indicating therapy has been too aggressive? 1. The patient complains of a severe headache. 2. The patient’s urine output has dropped. 3. The patient begins to shiver. 4. The patient develops a cough. Question 7 The nurse is assessing a patient being treated for neurogenic shock after a spinal cord injury. Which assessment would the nurse evaluate as patient improvement? 1. Temperature of 97.8°F 2. Heart rate of 70 bmp 3. Resistance to ventilator-assisted breaths. 4. Pink skin tone Question 8 An adult patient is demonstrating anaphylaxis from an insect sting. What is the nurse’s priority intervention? 1. Benadryl (diphenhydramine) 50 mg intravenously 2. Oxygen at 3 liters via nasal cannula 3. Epinephrine 1:1000 0.5 mg sq 4. Normal saline at 150 mL/hr Question 9 A patient who has been receiving norepinephrine (Levophed) at a rate of 10 mcg/min will have the drug discontinued. How should the nurse plan to manage this intervention? 1. Stop the infusion, but leave normal saline infusing at a rate to keep the vein open. 2. Stop the infusion and place an intermittent infusion cap on the IV access device. 3. Decrease the rate to 5 mcg/min for 30 minutes before discontinuing the infusion. 4. Decrease the rate by 1 mcg/min every 30 minutes while monitoring the patient’s response Question 10 A patient in shock has just been started on IV Dopamine at 5 mcg/kg/min. Which findings would the nurse evaluate as indication of a possible adverse effect of this therapy? 1. Persistent hypotension 2. Heart rate 118 3. Development of a bundle branch block 4. Drop in urine output 5. Mottling of extremities