1. Which is the most important goal of nursing care for a pt who is in shock?
a. Manage fluid overload
b. Manage increased CO
c. Manage inadequate tissue perfusion
d. Manage vasoconstrxn of vascular beds
2. Which nursing assessment finding indicates hypovolemic shock in a pt who has had a 15% blood loss?
a. Pulse <> 30mL/hr
b. Systolic bP > 110
c. Diastolic > 90
d. RR of 20 braeths/min
4. which is a risk factor for hypovolemic shock?
a. Hemorrhage
b. Antigen antibody rxn
c. Gram neg bacteria
d. vasodilation
5. what is a priority assessment for the pt in shock who is receiving an IV infusion of PRBC and NS?
a. Fluid balance
b. Anaphylactic rxn
c. Pain
d. ALOC
6. the pt who does not respond adequately to fluid replacement has an order for an IV infusion of dopamine hydrochloride at 5u/kg/min. the desired fx of the drug is
a. increased renal and mesenteric BF
b. increased CO
c. vasoconstrx
d. reduced preload and afterload
7. A male pt who has been taking coumadin has been admitted c severe acute rectal bleeding and the following lab results: INR 8, Hmg 11, hematocrit 33%. Which MD orders would the nurse expect to implement initially? Select all that apply.
a. IV D5 ½ NS
b. Schedule pt for sigmoidoscoy in the AM
c. Give 1 unit FF plasma
d. Admin vitamin K 2.5 mg PO
e. Begin polyethylene glycol-electrolyte solution in preparation for signoidoscopy
f. Admin fleet’s enema
8. the nurse in perop holding area keeps a pt c gastric bleeding in a dimly lit environment c one family member present. What is the primary rationale for these nursing interventions?
a. Stabilize fluid and lyte balance
b. Minimize O2 consumption
c. Increase pt and family comfort
d. Prevent infxn
9. when assessing a pt for early septic shock, the nurse observes for which of the following?
a. Cool clammy skin
b. Warm flushed skin
c. Decreased systolic bp
d. hemorrhage
10. a pt c toxic shock has been receiving ceftriaxone sodium, in add’n to culture and sensitivity studies. What other lab finding does the nurse monitor?
a. Serum creat
b. Spinal fluid analysis
c. ABG
d. Serum osmolality
11. what intervention is most important in preventing septic shock?
a. Admin IV fluid replacement therapy as orderd
b. Obtaining VS q 4 hrs for all pts
c. Monitoring RBC counts for elevation
d. Maintaining asepsis of indwelling urinary catheters
12. which is a indication of a complication of septic shock?
a. Anaphylaxis
b. ARDS
c. COPD
d. Mitral valve prolapse
a. Manage fluid overload
b. Manage increased CO
c. Manage inadequate tissue perfusion
d. Manage vasoconstrxn of vascular beds
2. Which nursing assessment finding indicates hypovolemic shock in a pt who has had a 15% blood loss?
a. Pulse <> 30mL/hr
b. Systolic bP > 110
c. Diastolic > 90
d. RR of 20 braeths/min
4. which is a risk factor for hypovolemic shock?
a. Hemorrhage
b. Antigen antibody rxn
c. Gram neg bacteria
d. vasodilation
5. what is a priority assessment for the pt in shock who is receiving an IV infusion of PRBC and NS?
a. Fluid balance
b. Anaphylactic rxn
c. Pain
d. ALOC
6. the pt who does not respond adequately to fluid replacement has an order for an IV infusion of dopamine hydrochloride at 5u/kg/min. the desired fx of the drug is
a. increased renal and mesenteric BF
b. increased CO
c. vasoconstrx
d. reduced preload and afterload
7. A male pt who has been taking coumadin has been admitted c severe acute rectal bleeding and the following lab results: INR 8, Hmg 11, hematocrit 33%. Which MD orders would the nurse expect to implement initially? Select all that apply.
a. IV D5 ½ NS
b. Schedule pt for sigmoidoscoy in the AM
c. Give 1 unit FF plasma
d. Admin vitamin K 2.5 mg PO
e. Begin polyethylene glycol-electrolyte solution in preparation for signoidoscopy
f. Admin fleet’s enema
8. the nurse in perop holding area keeps a pt c gastric bleeding in a dimly lit environment c one family member present. What is the primary rationale for these nursing interventions?
a. Stabilize fluid and lyte balance
b. Minimize O2 consumption
c. Increase pt and family comfort
d. Prevent infxn
9. when assessing a pt for early septic shock, the nurse observes for which of the following?
a. Cool clammy skin
b. Warm flushed skin
c. Decreased systolic bp
d. hemorrhage
10. a pt c toxic shock has been receiving ceftriaxone sodium, in add’n to culture and sensitivity studies. What other lab finding does the nurse monitor?
a. Serum creat
b. Spinal fluid analysis
c. ABG
d. Serum osmolality
11. what intervention is most important in preventing septic shock?
a. Admin IV fluid replacement therapy as orderd
b. Obtaining VS q 4 hrs for all pts
c. Monitoring RBC counts for elevation
d. Maintaining asepsis of indwelling urinary catheters
12. which is a indication of a complication of septic shock?
a. Anaphylaxis
b. ARDS
c. COPD
d. Mitral valve prolapse
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