Chapter 54 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 54

Question 1

Type: MCSA

The nurse would be most alert for assessment findings of hypovolemic shock in which patient?

1. Patient who had a DVT after a surgical procedure 2 years ago

2. Patient 6 hours postmastectomy

3. Patient with coronary atherosclerosis who takes 81 mg of aspirin daily

4. Patient sustaining a transmural myocardial infarction 2 days ago

Correct Answer: 2

Rationale 1: A past history of DVT is not pertinent to hemorrhage, as DVT is caused by a clot.

Rationale 2: Postoperative patients are at risk for hemorrhage; mastectomy patients typically have drains whose output should be carefully documented.

Rationale 3: The antiplatelet properties of aspirin may predispose the patient to bleeding; however, there is no indication of trauma or bleeding.

Rationale 4: A myocardial infarction may lead to cardiogenic shock, not hemorrhage.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-1

Question 2

Type: MCSA

The nurse is caring for a patient with papillary muscle rupture. The nurse would be most alert to the development of which type of shock?

1. Septic

2. Cardiogenic

3. Anaphylactic

4. Neurogenic

Correct Answer: 2

Rationale 1: The most common etiology of septic shock is an overwhelming infection.

Rationale 2: The papillary muscle holds the valves in place and may be damaged during MI, the most common reason for cardiogenic shock.

Rationale 3: Anaphylactic shock develops from hypersensitivity reactions.

Rationale 4: Neurogenic shock results from spinal cord injury or vasodilatation below the level of spinal anesthesia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-1

Question 3

Type: MCSA

The nurse is caring for a patient with endocarditis who is receiving penicillin. The nurse should be particularly attentive to recognize early symptoms of which type of shock?

1. Hypovolemic

2. Cardiogenic

3. Septic

4. Anaphylactic

Correct Answer: 4

Rationale 1: Hypovolemic shock results from decreased vascular fluid volume, which would not be a primary concern in this situation.

Rationale 2: Cardiogenic shock results from loss of pumping ability due to damage to the left ventricle, such as after MI. Cardiogenic shock could result from endocarditis, but this is not the primary concern in this situation.

Rationale 3: Septic shock results from overwhelming infections.

Rationale 4: A hypersensitivity to medications, particularly penicillins, may occur at any time during initial or subsequent treatments with the drug. This hypersensitivity may result in anaphylactic shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-1

Question 4

Type: MCSA

A patient developed septic shock related to cancer chemotherapy. This morning the nurse assessed a change in the patients mental status. The nurses primary concern would focus on which possible etiology for this change?

1. Anxiety about and fear of death

2. Metastasis of underlying cancer

3. A result of chemotherapy

4. Decreased tissue oxygenation

Correct Answer: 4

Rationale 1: Anxiety and fear can lead to confusion, but this is not the nurses primary concern in this situation.

Rationale 2: Metastasis to the brain could cause confusion, but this is not the nurses primary concern in this situation.

Rationale 3: Chemotherapy can cause chemo brain, which is a cause of confusion, but this is not the nurses primary concern in this situation.

Rationale 4: One of the physiologic changes associated with septic shock is decreased tissue and organ perfusion. Decreased perfusion of the brain results in changes in mental status. The nurse should be alert for these changes as they could indicate worsening of the shock state.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-2

Question 5

Type: MCSA

A patient has developed severe cardiogenic shock and is on a mechanical ventilator. The family asks why the patients hands feel so cold. What is the nurses best response?

1. We keep the intensive care unit cool to reduce patients metabolic rates.

2. The patient has developed a fever and chills.

3. This happens frequently to patients in shock states.

4. Blood vessels constrict in shock, which takes the blood away from hands and feet.

Correct Answer: 4

Rationale 1: The ICU is not deliberately chilled; this is not the reason the patients hands are cold.

Rationale 2: Fever and chills would not result in cold hands.

Rationale 3: This response does not answer the familys question.

Rationale 4: Vasoconstriction results from catecholamine release, which is a compensatory mechanism in shock. The diversion of warm blood away from the extremities results in cold hands and feet.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-2

Question 6

Type: MCSA

A patient who takes a beta adrenergic blocker is at risk of developing shock after an accident. The nurse is aware that the patients medication use may alter which assessment finding associated with shock?

1. Tachycardia

2. Declining mental status

3. Cyanosis

4. Tachypnea

Correct Answer: 1

Rationale 1: Beta adrenergic blockers inhibit the sympathetic nervous system, causing bradycardia. Because the patient is taking a beta blocker, the normal response of tachycardia may be blunted.

Rationale 2: The use of a beta blocker should not alter the neurological symptoms of shock.

Rationale 3: Cyanosis will still occur in a shock state, as beta blockers do not interfere with symptoms of poor oxygenation.

Rationale 4: Increase in respiratory rate is related to the bodys need for more oxygenation. Beta blockers would not affect this finding.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-2

Question 7

Type: MCMA

The nurse would identify which patients as being at increased risk for development of sepsis and septic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient admitted from a nursing home for treatment of a stage 4 pressure ulcer

2. A patient with a ruptured viscus who is vomiting bright red blood

3. A patient who takes methotrexate for rheumatoid arthritis

4. A patient who sustained blunt trauma to the spinal cord

5. A patient being treated for aplastic anemia

Correct Answer: 1,3,5

Rationale 1: Breaches in skin integrity such as pressure ulcers are a risk for sepsis and septic shock.

Rationale 2: Fluid-volume deficit secondary to hematemesis may lead to hypovolemic shock.

Rationale 3: Patients taking methotrexate for chemotherapy or immune modulation are at risk for sepsis and septic shock.

Rationale 4: Blunt spinal cord injury may lead to spinal or neurogenic shock.

Rationale 5: Aplastic anemia is characterized by the suppression of all cellular elements of the bone marrow, including WBCs, which raises the risk of infection and sepsis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-3

Question 8

Type: MCMA

Which patients would the nurse identify as being at increased risk for the development of hypovolemic shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient with systemic lupus erythematosus

2. A patient who had a myocardial infarction

3. A patient with cirrhosis, ascites, and anasarca

4. A patient who was the unrestrained front-seat passenger in a multivehicle car crash

5. Patient with ruptured abdominal aortic aneurysm

Correct Answer: 3,4,5

Rationale 1: A patient treated for lupus typically takes immunosuppressing drugs such as corticosteroids, which place the patient at risk for septic shock.

Rationale 2: A myocardial infarction may lead to cardiogenic, not hypovolemic, shock.

Rationale 3: Patients at risk for hypovolemic shock include those with hemorrhage, GI bleeding, third spacing, and unreplaced fluid loss. Ascites and anasarca are examples of third spacing.

Rationale 4: Patients at risk for hypovolemic shock include those with chest and abdominal trauma.

Rationale 5: Patients at risk for hypovolemic shock include those with hemorrhage and GI bleeding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-3

Question 9

Type: MCSA

An 80-year-old patient is being admitted from a nursing home for treatment of septic shock. Which assessment finding should the nurse investigate as the most likely source of the sepsis?

1. A red, flat rash in the perineal area

2. History of exposure to a daughter who is receiving chemotherapy

3. Report that several patients at the nursing home have scabies

4. An indwelling urinary catheter inserted 3 days ago by nursing home personnel

Correct Answer: 4

Rationale 1: A perineal rash without open skin would not contribute to sepsis.

Rationale 2: The patients daughter is at risk for infection and sepsis, not the patient.

Rationale 3: Scabies is not the most likely source of this sepsis.

Rationale 4: A major cause of sepsis is indwelling urinary catheters.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-3

Question 10

Type: MCSA

A patient who was stabbed in the abdomen has received fluid resuscitation of 2 liters over the last hour. Which finding would the nurse evaluate as indicating this intervention has been ineffective?

1. Patient complaints of abdominal pain

2. Patients request to see a priest

3. Urine output of 45 mL for this hour

4. Heart rate 142 and regular

Correct Answer: 4

Rationale 1: The patient will likely continue to have abdominal pain even if shock is reversed.

Rationale 2: Level of consciousness is an indicator of the effectiveness of fluid resuscitation. If the patient is alert enough to ask for a priest, it is likely that mental status is more or less normal.

Rationale 3: A urine output of 30 to 50 mL per hour indicates adequate fluid resuscitation.

Rationale 4: Elevation of the heart rate indicates that fluid resuscitation has not been effective.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 54-5

Question 11

Type: MCSA

A patient admitted to the emergency department after a traumatic injury is becoming more and more lethargic and hard to arouse. Periods of apnea are increasing. To protect the patients airway, the nurse should prepare to assist with which intervention?

1. Monitoring oxygen saturation

2. Endotracheal intubation

3. Assessment of breath sounds

4. Asking the patient if it is becoming difficult to breathe

Correct Answer: 2

Rationale 1: Simply monitoring oxygen saturation is not sufficient protection for this patient.

Rationale 2: Endotracheal intubation is necessary for a trauma patient who is becoming lethargic and hard to arouse.

Rationale 3: Breath sound assessment is important but will not help protect the airway.

Rationale 4: The patients perception of breathing difficulty is not important in this situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-5

Question 12

Type: MCSA

A patient in shock is receiving norepinephrine by continuous infusion. For which outcome would the nurse monitor to evaluate the effectiveness of this medication?

1. Cardiac enzymes

2. Reduced apical heart rate

3. Reduction in bleeding

4. Blood pressure

Correct Answer: 4

Rationale 1: Norepinephrine is not given to change cardiac enzymes.

Rationale 2: The apical pulse would increase related to the catecholamine effects; therefore, reduced heart rate is not the intended outcome.

Rationale 3: Norepinephrine is not given to reduce bleeding and may have the opposite effect.

Rationale 4: Norepinephrine is a vasopressor used in shock to raise blood pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 54-5

Question 13

Type: MCSA

According to standard definitions, which patient would the nurse describe as being in septic shock?

1. A patient with community-acquired pneumonia who has developed respiratory failure

2. A patient who has burns over 40% of the body and is febrile

3. A patient with an infection whose blood pressure is 84/52 after 4 liters of saline were administered intravenously

4. A patient with a WBC count of 22,000 and fever

Correct Answer: 3

Rationale 1: Because the patients acute respiratory failure was caused by an infectious process, the definition of sepsis is not met.

Rationale 2: Burn injury with fever more closely meets the definition of systemic inflammatory response syndrome.

Rationale 3: Septic shock exists when acute circulatory failure and hypotension are refractory to fluid administration.

Rationale 4: A high WBC count and fever may be present in an uncomplicated infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-6

Question 14

Type: MCSA

The nurse is reviewing the diagnostic tests for a patient with an infection. Which test result would the nurse attribute to this diagnosis?

1. Potassium 2.9 mEq/L

2. Hemoglobin 8.5 gm/dL/ Hematocrit 25.2%

3. Decreased activated protein C

4. WBCs 5,000 cells/cubic mm

Correct Answer: 3

Rationale 1: Potassium levels are not specific to the diagnosis of sepsis.

Rationale 2: A low H & H indicates hemorrhage or destruction of cells.

Rationale 3: A decreased activated protein C level is associated with sepsis, coagulopathy, MODS, and increased mortality.

Rationale 4: A WBC count of 5,000 is normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-6

Question 15

Type: MCSA

The nurse plans to administer normal saline to a patient with systemic inflammatory response syndrome (SIRS) and hypotension. At which rate would the nurse anticipate administering this fluid?

1. 20 mL/hr

2. 500 mL/hr

3. 100 mL/hr

4. 0.05 mL/kg/hr

Correct Answer: 2

Rationale 1: A rate of 20 mL/hr is too slow.

Rationale 2: Isotonic solutions are administered in 5001000mL bolus while monitoring vital signs and urinary output.

Rationale 3: Initial fluid administration should be faster than 100 mL/hr.

Rationale 4: The goal is to maintain urine output at 0.4 to 1.0 mL/kg/hr. This is not the IV rate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 54-7

Question 16

Type: MCSA

The critical care nurse is delivering a peer lecture on guidelines for the management of SIRS and severe sepsis. Which intervention would the nurse describe as improving outcomes in septic shock?

1. Use bicarbonate for pH of 7.30.

2. Keep mechanically ventilated patients flat in bed.

3. Maintain blood glucose lower than 150 mg/dL.

4. Initiate antibiotic therapy within 4 hours of diagnosis.

Correct Answer: 3

Rationale 1: Bicarbonate therapy is not recommended for treatment of hypoperfusion-induced lactic acidemia with a pH greater than 7.15.

Rationale 2: Mechanically ventilated patients should be maintained in a semirecumbent position.

Rationale 3: Current evidence indicates that maintaining blood glucose <150 mg/dL improves lipid levels and has anti-inflammatory and anticoagulant effects, improving the chances of survival.

Rationale 4: Antibiotic therapy should be initiated within the first hour of identifying sepsis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-7

Question 17

Type: MCSA

The nurse anticipates assisting with which therapy to achieve improved outcomes for a patient who is in septic shock?

1. Vasopressin instead of dopamine for hypotension

2. Early use of neuromuscular blocking agents

3. Limiting fluids to 3 liters per day

4. Mechanical ventilation with a tidal volume of 4 to 6 ml/kg

Correct Answer: 4

Rationale 1: Norephinephrine and dopamine are the first-line vasopressors to support perfusion.

Rationale 2: Neuromuscular blocking agents should be avoided if possible due to the complications of immobility.

Rationale 3: Fluids should be administered as needed to support perfusion. Fluids are limited if the patient is in cardiogenic shock.

Rationale 4: Current evidence suggests that maintaining mechanical ventilation with lower-than-traditional tidal volumes of 4 to 6 ml/kg results in improved outcomes.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-7

Question 18

Type: MCSA

The nurse will plan which interventions to reduce metabolic demands in a patient with multiple organ dysfunction syndrome (MODS)?

1. Provide skin care and positioning to prevent breakdown.

2. Use meticulous hand hygiene and aseptic technique for procedures.

3. Place the patient on a high-fat diet to increase energy.

4. Administer antipyretics for fever

Correct Answer: 4

Rationale 1: Skin care and positioning are essential to prevent breakdown and further entry of bacteria into the body, but they would not reduce oxygen demands.

Rationale 2: Asepsis and hand washing are essential to prevent further infection but would not reduce oxygen demand.

Rationale 3: A high-fat diet is not indicated in shock; however, attention to nutrition and adequate calories is necessary.

Rationale 4: Reducing fever will decrease metabolic rate and oxygen demand.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-8

Question 19

Type: MCSA

The nurse is caring for a patient with septic shock and MODS. A family member tearfully tells the nurse, The doctor said my mothers organs are shutting down. How did that happen? What is the nurses best response?

1. The infection attacks and destroys each organ, causing it to fail.

2. Fever damages the brain, which controls all organs.

3. Deprivation of oxygen during shock causes organs to fail to function properly.

4. The stress of illness has overwhelmed your loved one.

Correct Answer: 3

Rationale 1: Infection does not strike each organ; rather, an inflammatory process begins a cascade of events that impair tissue perfusion and cause organs to fail.

Rationale 2: Fever may cause brain damage if exceedingly high and increase metabolic demand, thereby increasing oxygen demand, but it is not the primary cause of MODS.

Rationale 3: The cascade of events in shock states results in inadequate tissue perfusion and hypoxia, leading to organ failure.

Rationale 4: The stress response is activated as a compensatory mechanism; however, it is not the primary cause of MODS.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-8

Question 20

Type: MCSA

The nurse is caring for a patient with MODS secondary to septic shock whose urine output was 10 mL for the last 2 hours. Temperature is 97 degrees, pulse is 124 and thready, and BP is 88/48. Which order is the current priority?

1. Place the patient on a warming blanket.

2. Administer isotonic fluids at 20 mL/kg/hr.

3. Draw blood for BUN and creatinine.

4. Place the patient in a kinetic bed.

Correct Answer: 2

Rationale 1: The patient in septic shock who is hypothermic is in an advanced stage of sepsis. Warming may be indicated but should be done so very carefully. This is not the current priority.

Rationale 2: Fluids are indicated to improve blood pressure and blood flow through the kidney. Fluid administration should be monitored carefully, but this is the current priority intervention.

Rationale 3: BUN and creatinine may be evaluated to determine the consequence of renal blood flow, but this would be done after the ABCs have been addressed.

Rationale 4: A kinetic bed will decrease pressure on the skin and prevent breakdown secondary to decreased tissue perfusion, but this would be done after the ABCs have been addressed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-8

Question 21

Type: MCSA

A patient has MODS secondary to severe sepsis. The nurse would prioritize interventions to address which finding in this patient?

1. WBC count of 28,000 cell/cubic mm

2. Blood glucose of 245 mg/dL

3. pO2 of 54 mmHg

4. Serum lactate level of 2.1 mmol/L

Correct Answer: 3

Rationale 1: A WBC count of 28,000 cells indicates infection; antibiotics are begun within the first hour of identifying severe sepsis, but not before other findings are addressed.

Rationale 2: Interventions to address the blood glucose level should be implemented, but not before other, more urgent findings are addressed.

Rationale 3: The nurse follows the ABCs for priority; a pO2 of 54 mmHg reflects hypoxemia and is the priority.

Rationale 4: A serum lactate level of 2.1 mmol/L is barely above the normal range and is not the priority in this situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-8

Question 22

Type: MCMA

The nurse would be most alert for assessment findings of obstructive shock in which patients?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient who has tumor mass in the vena cava

2. A patient who sustained a gunshot wound to the abdomen

3. A patient who suffered a severe cardiac contusion

4. The patient who sustained several fractured ribs in a fall

5. A patient who has pneumonia caused by a multiple-drug-resistant organism

Correct Answer: 1,3,4

Rationale 1: Obstruction of the vena cava can slow blood flow into the heart, resulting in obstructive shock.

Rationale 2: This patient is at risk for hypovolemic shock from volume loss.

Rationale 3: This injury could result in cardiac tamponade, which would lead to obstructive shock.

Rationale 4: Rib fragments might damage the lung, causing a tension pneumothorax and possibly obstructive shock.

Rationale 5: This patient is at risk of septic shock than obstructive shock.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-1

Question 23

Type: MCMA

Which statements by the paramedic who brought a patient to the emergency department would indicate correct field treatment of a patient suspected of being in shock?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. An endotracheal tube was inserted prior to transport.

2. Secondary assessment took place during transport.

3. The IV was started while we were at the scene.

4. My partner applied direct pressure to the bleeding wound as we moved the patient to the ambulance.

5. Blood was drawn for blood cultures before we left the scene.

Correct Answer: 1,2,4

Rationale 1: Only critical interventions, such as airway management, should be executed before transport.

Rationale 2: The patient should be transported as soon as possible. Secondary assessment is done en route.

Rationale 3: Intravenous access should be obtained en route to the emergency department.

Rationale 4: Bleeding should be controlled as soon as possible but should not delay transport.

Rationale 5: Drawing blood should not delay transport. If a blood draw is necessary, it should be performed en route.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 54-4

Question 24

Type: MCMA

The emergency department nurse would expect which patients to arrive by ambulance with pneumatic antishock garments (PASGs) in place?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient with part of a fence post impaled in the abdomen

2. A patient whose intestines have eviscerated through an infected surgical wound

3. A patient whose blood pressure is 84/58 mmHg and who has suspected pelvic fractures

4. A patient suspected of intraperitoneal hemorrhage with systolic blood pressure of 58 mmHg

5. A patient who has a compound fracture of the left lower leg.

Correct Answer: 3,4

Rationale 1: PASGs are contraindicated if there is an object impaled in the abdomen.

Rationale 2: Evisceration of abdominal organs is a contraindication for the use of PASGs.

Rationale 3: Suspected pelvic fractures with hypotension are an indication for the use of PASGs.

Rationale 4: A patient with a suspected intraperitoneal hemorrhage or with a systolic BP of less than 60 mmHg is a candidate for PASGs.

Rationale 5: Isolated lower extremity fractures are not indications for use of PASGs.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-4

Question 25

Type: MCMA

A 20-year-old male was seriously wounded in a shooting incident and is not expected to survive the resulting hypovolemic shock. Which nursing statements to the family are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The rules allow only two visitors for 5 minutes.

2. Your sons color is very gray.

3. Your son will not be able to talk to you, but he will know you are there.

4. Your son has a big bandage around his head and his face is swollen and bruised.

5. We have given your son pain medication for his wounds.

Correct Answer: 2,3,4,5

Rationale 1: This patient is about to die. Family should be allowed as much time with the patient as possible, even if the rules are not followed.

Rationale 2: Describing the patients appearance is important in this situation.

Rationale 3: The family should be alerted to the fact that the patient is unconscious or otherwise unable to talk. Assuring them that their loved one will know they are there is comforting.

Rationale 4: The family should be apprised of the patients appearance prior to visiting.

Rationale 5: It is important to let the family know what comfort measures have been provided for their loved one.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 54-4

Question 26

Type: MCSA

A patient is brought to the emergency department with injuries sustained in a gang fight. The patients blood pressure is 80/50 mmHg with a pulse of 120 and thready. The nurse will prepare the patient for which test to provide the fastest diagnostic information?

1. Sonogram

2. Complete blood count

3. Urinalysis

4. Serum electrolyte levels

Correct Answer: 1

Rationale 1: The focused assessment by sonography in trauma or FAST identifies blood in body cavities where it is not supposed to be. The primary focus is on the peritoneum. The patient was in a fight and has a low blood pressure and thready pulse; this diagnostic test would provide the fastest information to help guide care.

Rationale 2: A complete blood count would provide information about blood loss but not about the location of blood loss.

Rationale 3: Urinalysis would provide information about whether there is bleeding in the urinary tract but would be limited to that system.

Rationale 4: Serum electrolyte levels will likely be drawn for baseline but will not provide diagnostic information about the source of bleeding.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 54-4

Question 27

Type: MCMA

A 60-year-old woman with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is insufficient time for type and crossmatch, the patient could receive which types of blood?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. O-positive

2. AB-positive

3. A-negative

4. O-negative

5. A-positive

Correct Answer: 1,4

Rationale 1: Male patients and women past childbearing age may receive O-positive blood if needed immediately.

Rationale 2: The patient may have antibodies against this blood.

Rationale 3: The patient may have antibodies against this blood.

Rationale 4: Any patient can receive O-negative blood.

Rationale 5: The patient may have antibodies against this blood.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 54-4

Question 28

Type: MCSA

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). The nurse would evaluate which finding as indicating the medication has had the desired effect?

1. Increased cardiac output

2. Decreased temperature

3. Decreased respiratory rate

4. Decreased blood pressure

Correct Answer: 1

Rationale 1: Dobutamine improves cardiac contractility and cardiac output.

Rationale 2: Dobutamine is not an antipyretic or antibiotic and will have no effect on fever.

Rationale 3: Dobutamine will not have a direct effect on respiratory rate.

Rationale 4: Dobutamine is more likely to increase blood pressure due to increased cardiac contractility.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 54-5

Question 29

Type: FIB

A patient was diagnosed with sepsis 5 hours ago. To meet the criteria of the Sepsis Resuscitation Bundle, the nurse and health care team must complete the bundle within ______ hour(s).

Standard Text:

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