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NUR 221 Exam 3 Questions And Correct Answers
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NUR 221 Exam 3 Questions And Correct Answers NUR 221 Exam 3 Questions And Correct Answers NUR 221 Exam 3 Questions And Correct Answers
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NUR 221 Exam 3The nurse is caring for a patient admitted with hypovolemic shock. The nurse palpates thready
brachial pulses but is unable to auscultate a blood pressure. What is the best nursing action?
A. Assess the blood pressure palpation
B. Estimate the systolic pressure as 60 mm Hg.
C. Obtain an electronic blood pressure monitor.
D. Record the blood pressure as "not assessable." - ANS A. Assess the blood pressure palpation
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% normal saline in a patient with
severe sepsis. One hour later, which laboratory result requires immediate nursing action?
A. Creatinine 1.0 mg/dL
B. Lactate 6 mmol/L
C. Potassium 3.8 mEq/L
D. Sodium 140 mEq/L - ANS B. Lactate 6 mmol/L
The nurse has been administering 0.9% normal saline intravenous fluids as part of early goal-
directed therapy protocols in a patient with severe sepsis. To evaluate the effectiveness of fluid
therapy, which physiological parameters would be most important for the nurse to assess?
A. Breath sounds and capillary refill
B. Blood pressure and oral temperature
C. Oral temperature and capillary refill
D. Right atrial pressure and urine output - ANS D. Right atrial pressure and urine output
A patient is admitted to the critical care unit following coronary artery bypass surgery. Two hours
postoperatively, the nurse assesses the following information: pulse is 120 beats/min; blood
pressure is 70/50 mm Hg; pulmonary artery diastolic pressure is 2 mm Hg; cardiac output is 4 L/min;
urine output is 250 mL/hr; chest drainage is 200 mL/hr. What is the best interpretation by the nurse?
,A. The assessed values are within normal limits.
B. The patient is at risk for developing cardiogenic shock.
C. The patient is at risk for developing fluid volume overload.
D. The patient is at risk for developing hypovolemic shock. - ANS D. The patient is at risk for
developing hypovolemic shock.
A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, with a heart
rate of 110 beats/min, respiratory rate of 30 breaths/min, and a blood pressure of 78/46 mm Hg.
The nurse anticipates administering which therapeutic intervention?
A. Human albumin infusion
B. Hypotonic saline solution
C. Lactated Ringer's bolus
D. Packed red blood cells - ANS C. Lactated Ringer's bolus
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused
and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to
assess?
A. High pulmonary artery occlusive pressure and high cardiac output
B. High systemic vascular resistance and low cardiac output
C. Low pulmonary artery occlusive pressure and low cardiac output
D. Low systemic vascular resistance and high cardiac output - ANS D. Low systemic vascular
resistance and high cardiac output
The nurse is caring for a patient admitted with severe sepsis. Vital signs assessed by the nurse
include blood pressure 80/50 mm Hg, heart rate 120 beats/min, respirations 28 breaths/min, oral
temperature of 102° F, and a right atrial pressure (RAP) of 1 mm Hg. Assuming physician orders,
which intervention should the nurse carry out first?
,A. Acetaminophen suppository
B. Blood cultures from two sites
C. IV antibiotic administration
D. Isotonic fluid challenge - ANS D. Isotonic fluid challenge
Which patient being cared for in the emergency department is most at risk for developing
hypovolemic shock?
A. A patient admitted with abdominal pain and an elevated white blood cell count
B. A patient with a temperature of 102° F and a general dermal rash
C. A patient with a 2-day history of nausea, vomiting, and diarrhea
D. A patient with slight rectal bleeding from inflamed hemorrhoids - ANS C. A patient with a 2-day
history of nausea, vomiting, and diarrhea
The nurse is caring for a patient admitted with cardiogenic shock. Hemodynamic readings obtained
with a pulmonary artery catheter include a pulmonary artery occlusion pressure (PAOP) of 18 mm
Hg and a cardiac index (CI) of 1.0 L/min/m 2 . What is the priority pharmacological intervention?
A. Dobutamine
B. Furosemide
C. Phenylephrine
D. Sodium nitroprusside - ANS A. Dobutamine
Ten minutes following administration of an antibiotic, the nurse assesses a patient to have
edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood
pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36 breaths/min. What is the
priority intervention?
A. Diphenhydramine 50 mg intravenously
B. Epinephrine 3 to 5 mL of a 1:10,000 solution intravenously
, C. Methylprednisolone 125 mg intravenously
D. Ranitidine 50 mg intravenously - ANS B. Epinephrine 3 to 5 mL of a 1:10,000 solution
intravenously
A patient is admitted to the cardiac care unit with an acute anterior myocardial infarction. The nurse
assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung
fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic
values is the nurse most likely to assess?
A. High pulmonary artery diastolic pressure and low cardiac output
B. Low pulmonary artery occlusive pressure and low cardiac output
C. Low systemic vascular resistance and high cardiac output
D. Normal cardiac output and low systemic vascular resistance - ANS A. High pulmonary artery
diastolic pressure and low cardiac output
During the initial stages of shock, what are the physiological effects of decreased cardiac output?
A. Arterial vasodilation
B. High urine output
C. Increased parasympathetic stimulation
D. Increased sympathetic stimulation - ANS D. Increased sympathetic stimulation
While monitoring a patient for signs of shock, the nurse understands which system assessment to be
of priority?
A. Central nervous system
B. Gastrointestinal system
C. Renal system
D. Respiratory system - ANS A. Central nervous system
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