HERZING UNIVERSITY MED-SURG 130 FINAL EXAM 2024
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 ar...
HERZING UNIVERSITY MED-SURG 130 FINAL EXAM 2024 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 - correct 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 - correct 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 - correct 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
the elderly female client with vertebral fractures who has been self-medicating with ibuprofen, an NSAID, presents to the ED complaining of abdominal pain, is pale and clammy, and has a HR of 110 and BP of 92/60. which type of shock should the nurse suspect? a. cardiogenic shock b. hypovolemic shock c. neurogenic shock d. septic shock - correct answer ✔✔ b. hypovolemic shock these signs make the nurse suspect that the client is losing blood which leads to hypovolemic shock, which is the most common type of shock and is characterized by decreased intravascular volume. the clients taking of NSAIDs put her at risk for hemorrhage because NSAIDs inhibit prostaglandin production in the stomach, which increases the risk of developing ulcers, which can erode the stomach lining and lead to hemorrhaging
the client diagnosed with a UTI has a blood pressure of 83/56 and a pulse of 122 bpm. which should the nurse implement first? a. notify the health care provider b. hang the IVPB antibiotic at the prescribed rate c. check the laboratory work to determine if the urine culture has been completed d. increase the normal saline IV fluids from keep vein open to 150 mL/hour on the IV pump - correct answer✔✔ d. increase the normal saline IV fluids from keep vein open to 150 mL/hour on the IV pump this is septic shock and not fluid volume shock but the circulatory system is still compromised. increasign
the fluid volume will support the client's BP until the IVPB is infused. The HCP should be notified but this delay could cost the client their life; this client is in septic shock. the IVPB will not treat the client as quickly as increasing the IVF. this would be the second action to be performed by the nurse. this is not the time to check the chart, it is the time for action/intervention.
the charge nurse is making shift assignments for the medical floor. which client should be assigned to the most experienced RN? a. the client diagnosed with congestive heart failure who is being discharged in the morning b. the client who is having frequent incontinent liquid, bowel movements and vomiting c. the client with an apical pulse rate of 116, a respiratory rate of 26 and a blood pressure of 94/62 d. the client who is complaining of chest pain on inspiration and a nonproductive cough - correct answer✔✔ c. the client with an apical pulse of 116, a respiratory rate of 26 and a blood pressure of 94/62 client c is experiencing s/s of shock which makes this client the most unstable. an experienced nurse should care for this client. client a is stable because they're being discharged. client b is more in need of custodial nursing care therefore can be given to a less experienced nurse. client d's complaints usually indicated muscular or pleuritic chest pain; cardiac chest pain does not fluctuate with inspiration.
a client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, board-like abdomen. after obtaining the client's vital signs, what should the nurse do next?
a. administer pain medication as prescribed b. raise the head of the bed c. prepare to insert a nasogastric tube d. notify the health care provider - correct answer ✔✔ d. notify the provider the client is experiencing a perforation of the ulcer, and the nurse should notify the HCP immediately. the body reacts to perforation of an ulcer by immobilizing the area as much as possible. this results in board-like abdominal rigidity, usually with extreme pain, perforation is a medical emergency requiring immediate surgical intervention because peritonitis develops quickly after perfs. administering pain meds is not the first action although nurses should institute measures to relieve pain. elevating the HOB will not minimize the perforation. a NGT may be used following surgery
when obtaining a nursing history from a client with a suspected gastric ulcer, which signs and symptoms should the nurse assess? Select all that apply. a. epigastric pain at night b. relief of epigastric pain after eating c. vomiting d. wt loss e. melena - correct answer ✔✔ c. vomiting d. wt loss e. melena vomiting and wt loss are common with gastric ulcers. the client may also have blood to the stools (melena) from gastric bleeding. clients with a gastric ulcer most likely to have a burning epigastric pain that occurs about 1 hour after eating. eating frequently aggravates the pain. clients with duodenal ulcers
are more likely to have pain that occurs during the night and is frequent relieved by eating.
a client with peptic ulcer disease is taking ranitidine. what is the expected outcome of this drug? a. heal the ulcer b. protect the ulcer surface from acids c. reduce acid concentration d. limit gastric acid secretion - correct answer ✔✔ d. limit gastric acid secretions Histamine-2 (H2) receptor antagonists, such as ranitidine, reduce gastric acid secretions. antisecretories or proton pump inhibitors, such as omeprazole, help ulcers heal quickly in 4 to 8 weeks. cytoprotective
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