Advanced Med Surg. Exam 2 - Practice
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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. 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 - ANSWER✔✔d. Isotonic fluid challenge
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 by Doppler.
b.
Estimate the systolic pressure as 60 mm Hg.
c.
Obtain an electronic blood pressure monitor.
d.
Record the blood pressure as "not assessable." - ANSWER✔✔a.
Assess the blood pressure by Doppler.
Auscultated blood pressures in shock may be significantly inaccurate due to
vasoconstriction. If blood pressure is not audible, the approximate value can be
assessed by palpation or ultrasound. If brachial pulses are palpable, the
approximate measure of systolic blood pressure is 80 mm Hg. This action has the
potential to delay further assessment of a compromised patient in shock.
, Documenting a blood pressure as not assessable is inappropriate without further
attempts using different modalities.
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 - ANSWER✔✔B:
Lactate level has been used as an indicator of decreased oxygen delivery to the
cells, adequacy of resuscitation in shock, and as an outcome predictor
Other values are normal
The nurse has been administering 0.9% normal saline intravenous fluids 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 - 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.
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