NCLEX questionNCLEX questions Midterm 1 Shock, Mods, SIRS, Sepsis Answered correctly
1. When analyzing assessment data, the nurse recognizes that
... [Show More] 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) 7.9
2. 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 - A. Hypotension
3. 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 - D. Check the airway and respiratory status
4. 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.
5. 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 - A. Compare these vital signs with the last several readings.
6. 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.
7. 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 - B. Measure hourly urine output
8. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.
9. The client with hemorrhagic shock has pulse 140 & thready, BP 60/40, respirations 40 & shallow, ABG showing respiratory acidosis, and lactate level 7mOsmol/L.
10. Which of the following orders would the nurse carry out first?
A. Notify anesthesia of need for endotracheal intubation
B. Give Plasmanate 1 unit now
C. Give normal saline 250mL/hr
D. Type and cross match for 4 units packed RBCs - A. Notify anesthesia of need for endotracheal intubation
s Midterm 1 Shock, Mods, SIRS, Sepsis Answered correctly [Show Less]