SOLVED

Chapter 31 Question 1 A nurse is providing care to a patient diagnosed with urinary sepsis. Which symptoms would the nurse evaluate as indicating the patient has entered the flow stage of metabolic response to this physiologic stress? 1. The patient’s heart rate has increased to 125 bpm. 2. The patient’s respiratory rate has dropped from 24 to 18. 3. The patient’s cardiac output has increased. 4. The patient’s temperature is 101.6°F. 5. The patient’s blood pressure has been stable for 24 hours. Question 2 A patient has been tentatively diagnosed with adrenal insufficiency. Which findings would the nurse evaluate as supporting this diagnosis? 1. The patient’s low blood pressure is not responding to fluid infusion. 2. The patient’s heart rate is consistently lower than 60 bpm. 3. The patient has had a fever for a week. 4. Arterial blood gas results reveal acidosis. 5. The patient reports abdominal pain. Question 3 A patient is being tested for adrenal insufficiency with the rapid ACTH stimulation test. How will the nurse explain this test to the patient? 1. You will drink about a cup of a salty-tasting fluid during this test. 2. It will take several hours to complete this test. 3. We have to do this test first thing in the morning, just after you awaken. 4. A series of blood samples will be drawn during this test. Question 4 A critically ill patient’s plasma cortisol level is 2.6 mcg/dL. Which intervention does the nurse expect? 1. Treatment for adrenal insufficiency 2. Treatment for adrenal excess 3. Continued diagnostic testing of adrenal function. 4. Emergency dialysis Question 5 The nurse is advised that a patient diagnosed with hyperthyroid crisis will be admitted from the emergency department. The nurse prepares to care for a patient with which possible conditions? 1. Atrial fibrillation 2. High fever 3. Congestive heart failure 4. Constipation 5. Agitation Question 6 A patient diagnosed with hyperthyroid crisis is receiving propylthiouracil (PTU). The nurse will increase monitoring for which adverse reaction? 1. Tremors 2. Emotional outbursts 3. Elevation of WBC 4. Widening of pulse pressure Question 7 A critically ill patient requires IV insulin for persistent hyperglycemia. Current finger stick blood glucose is 68 mg/dL. According to international critical care guidelines, which nursing intervention is indicated? 1. Call for a laboratory glucose test. 2. Increase the rate of the insulin drip by 2 units per hour. 3. Administer 10 mL of D5W by bolus injection. 4. Administer 0.5 g sugar dissolved in orange juice by mouth. Question 8 A patient who has required an insulin drip is being transitioned to subcutaneous insulin. Which intervention would the nurse anticipate? 1. Administering NPH insulin subcutaneously every two hours according to finger stick blood sugar. 2. Administering the prescribed dose of NPH insulin two hours before discontinuing the insulin drip. 3. Tapering the insulin drip administration rate over the next several days. 4. Plan to administer twice the number of units of NPH insulin that the patient has been receiving per hour in regular insulin. Question 9 A patient is diagnosed with hyperglycemic hyperosmolar state (HHS). Which interventions would the nurse anticipate? 1. Potassium supplementation 2. Testing for sources of infection 3. Increasing amount of NPH insulin administered 4. Increasing IV fluid administration 5. Monitoring arterial blood gases Question 10 The patient whose lower extremities were crushed in a motor vehicle accident is likely experiencing “fight-or-flight.” Which finding would the nurse attribute to that neuroendocrine response? 1. Heart rate is 78. 2. Bowel sounds are diminished. 3. Very little bleeding from the injury 4. Decreased level of consciousness