Exam (elaborations)
NURS 209 MEDICAL SURGICAL EXAM 4 REVIEW QUESTIONS AND ANSWERS FORTIS COLLEGE
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NURS 209 MEDICAL SURGICAL EXAM 4 REVIEW QUESTIONS AND ANSWERS FORTIS COLLEGE
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NURS 209 MEDICAL SURGICAL EXAM4 REVIEW QUESTIONS AND
ANSWERS FORTIS COLLEGE.
,Anaphylactic shock
13. Which assessment information is most important for the nurse to obtain to evaluate whether
treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and breathing,
the oxygen saturation is the most critical assessment. Improvements in the other assessments will
also be expected with effective treatment of anaphylactic shock.
, Septic shock meds
Sepsis manifestations
ET secretions
Mechanical ventilation "fighting ventilator"
33. A patient who is orally intubated and receiving mechanical ventilation is anxious and is
fighting the ventilator. Which action should the nurse take next?
a. Verbally coach the patient to breathe with the ventilator.
b. Sedate the patient with the ordered PRN lorazepam (Ativan).
c. Manually ventilate the patient with a bag-valve-mask device.
d. Increase the rate for the ordered propofol (Diprivan) infusion.
ANS: A
The initial response by the nurse should be to try to decrease the patients anxiety by coaching the
patient about how to coordinate respirations with the ventilator. The other actions may also be
helpful if the verbal coaching is ineffective in reducing the patients anxiety.
ICP and JVD actions
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