Midterm 1 Shock, Mods, SIRS, Sepsis NCLEX questions and answers
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Course
Shock, Sepsis & Multiple Organ Dysfunction NCLEX
Institution
Shock, Sepsis & Multiple Organ Dysfunction NCLEX
When analyzing assessment data, the nurse recognizes that which of the following puts client at risk for hemorrhagic shock?
A. International normalized ratio (INR) 7.9
B. Partial thromboplastin time (PTT) 12.5
C. Platelets 170,000
D. Hemoglobin 8.2 g
A. International normalized ratio (INR) 7...
Midterm 1 Shock, Mods, SIRS,
Sepsis NCLEX questions and
answers
When analyzing assessment data, the nurse recognizes that which
of the following puts client at risk for hemorrhagic shock?
A. International normalized ratio (INR) 7.9
B. Partial thromboplastin time (PTT) 12.5
C. Platelets 170,000
D. Hemoglobin 8.2 g - answer A. International normalized ratio (INR)
7.9
The nurse is caring for postoperative clients at risk for hypovolemic
shock. Which of the following would cause the nurse to suspect that
the client has early shock?
A. Hypotension
B. Bradypnea
C. Irregular heart rhythm
D. Tachycardia - answer A. Hypotension
When caring for an obtunded ED client with shock of unknown
origin, which action should the nurse take first?
A. Establish IV access and hang prescribed infusion
B. Apply the automatic BP cuff
C. Assess level of consciousness and pupil response to light
, D. Check the airway and respiratory status - answer D. Check the
airway and respiratory status
When caring for any client, determining airway and respiratory
status is the priority. The airway takes priority over obtaining IV
access, applying the blood pressure cuff, and assessing for changes
in the client's mental status.
The nursing assistant reports concerns about the postoperative
client who has BP 90/60, HR 80, R 22. What should the RN do?
A. Compare these VS with last several readings
B. Request that the surgeon come see the client
C. Increase the rate of IV fluids
D. Reassess VS using different equipment - answer A. Compare
these vital signs with the last several readings.
Vital sign trends must be taken into consideration; a BP of 90/60
mm Hg may be normal for this client. Calling the surgeon is not
necessary at this point, and increasing IV fluids is not indicated. The
same equipment should be used when vital signs are taken
postoperatively.
A postoperative client is admitted to the ICU with hypovolemic
shock. Which nursing action should the nurse delegate to the
experienced nursing assistant?
A. Obtain vital signs every 15 minutes
B. Measure hourly urine output
C. Check oxygen saturation
D. Assess level of alertness - answer B. Measure hourly urine output
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