Review Med/Surg

The emergency nurse is admitting a client experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

• cool, clammy skin

• hyperactive bowel sounds

• increased urine output

• decreased heart rate

• decreased blood pressure

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident. In addition to normal saline, which crystalloid fluid should the nurse prepare to administer?

• lactated ringers

• albumin

• D5 1/2 Normal Saline

• .45 Normal Saline

A client who is in shock is receiving dopamine in addition to IV fluids. What principle should inform the nurse’s care planning during the administration of a vasoactive drug?

• The drug should be discontinued immediately after blood pressure increases.

• The drug dose should be tapered down once vital signs improve.

• The client should have arterial blood gases drawn every 10 minutes during treatment.

• The infusion rate should be titrated according the client's subjective sensation of adequate perfusion.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement?

• Administer norepinephrine as prescribed.

• Initiate enteral feedings as prescribed.

• Begin a continuous IV infusion of insulin per protocol.

• Administer recombinant human activated protein C (rhAPC) as prescribed.

The nurse is writing a plan of care for a client with a cardiac dysrhythmia. What would be the priority goal for the client?

• Maintain a resting heart rate below 70 bpm.

• Maintain adequate control of chest pain.

• Maintain adequate cardiac output.

• Maintain normal cardiac structure.

A nurse is caring for a client who is exhibiting ventricular tachycardia (VT). Because the client is pulseless, the nurse should prepare for what intervention?

• angioplasty

• ECG monitoring

• implantation of a cardioverter defibrillator

• Defibrillation

Which assessment finding would put a patient at risk for hemorrhagic stroke?

• blood glucose of 480

• right sided carotid bruit

• BP of 220/105

• small cell lung cancer

A patient with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the ICU nurse implement

• encourage patient to cough each hour

• administer a stool softener

• maintain the dopamine drip to keep BP at 160/90

• Monitor neurological status every shift

Your patient is experiencing status epilepticus which collaborative intervention should you anticipate

• Assess Neuro status every hour

• monitor the client's heart rhythm via telemetry

• Administer Solumedrol IV

• Administer IV push anticonvulsants

You see the following rhythm on the monitor what is your first intervention

• Defibrillation

• Assess the patient to see if they are symptomatic

• Administer Atropine

• Initiate Transcutaneous Pacing