The 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 elec...
NUR 221 exam 3 Questions and Answers
2024
The 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." -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔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.
NUR 221 exam 3
,NUR 221 exam 3
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. -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔C.
A patient with a 2-day history of nausea, vomiting, and diarrhea
NUR 221 exam 3
,NUR 221 exam 3
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 -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔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 -Correct Answer ✔D. Increased sympathetic
stimulation
NUR 221 exam 3
, NUR 221 exam 3
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 -Correct Answer ✔A. Central nervous system
The nurse is caring for a patient in cardiogenic shock who is being treated with an
intraaortic balloon pump (IABP). The family inquires about the primary reason for the
device. What is the best statement by the nurse to explain the IABP?
A. "The action of the machine will improve blood supply to the damaged heart."
B. "The machine will beat for the damaged heart with every beat until it heals."
C. "The machine will help cleanse the blood of impurities that might damage the
heart."
D. "The machine will remain in place until the patient is ready for a heart transplant." -
Correct Answer ✔A. "The action of the machine will improve blood supply to the
damaged heart."
The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP)
for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic
parameter best indicates an appropriate response to therapy?
A. Cardiac index (CI) of 2.5 L/min/m 2
B. Pulmonary artery diastolic pressure of 26 mm Hg
C. Pulmonary artery occlusion pressure (PAOP) of 22 mm Hg
D. Systemic vascular resistance (SVR) of 1600 dynes/sec/cm 5 -Correct Answer ✔A.
Cardiac index (CI) of 2.5 L/min/m 2
The nurse is caring for an 18-year-old athlete with a possible cervical spine (C5) injury
following a diving accident. The nurse assesses a blood pressure of 70/50 mm Hg,
heart rate of 45 beats/min, and respirations of 26 breaths/min. The patient's skin is
warm and flushed. What is the best interpretation of these findings by the nurse?
A. The patient is developing neurogenic shock.
B. The patient is experiencing an allergic reaction.
C. The patient most likely has an elevated temperature.
D. The vital signs are normal for this patient. -Correct Answer ✔A. The patient is
developing neurogenic shock.
NUR 221 exam 3
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