Nursing Prep

A patient is diagnosed with rupture of an aortic aneurysm in the ER, and surgery is imminent. What interventions should the nurse perform before surgery?

Select all that apply.

• Preparation for endotracheal intubation

• Administration of IV narcotic for pain

• Administration of blood

• Beginning fluid resuscitation

• Administration of anticoagulants

Which intervention will the nurse include in the plan of care for a patient who has cardiogenic shock?

• Monitor breath sounds frequently.

• Assess skin for flushing and itching.

• Maintain patient in supine position.

• Check temperature every 2 hours

Which data collected from the nurse for a patient with cardiogenic shock indicate that the patient may be developing multiple organ dysfunction syndrome (MODS)?

• The patient's serum creatinine level is elevated.

• The patient reports intermittent chest pressure.

• The patient's extremities are cool and the pulse is weak.

• The patient has bilateral crackles throughout lung fields.

The nurse is planning care for the infant with tetralogy of Fallot. The nurse identifies the following priority problem for the patient: inadequate nutrition: less than body weight requirements. Which intervention should the nurse include to best promote adequate nutrition?

• Encourage sips of juice between feedings

• Administer fortified breast milk every 3 hours

• Provide rest periods between meals to allow for digestion

• Administer prostaglandin E1 to keep fetal ducts open

The low exhaled volume alarm is sounding on a mechanical ventilator. Which action should the nurse take first?

• Extubate the patient and ventilate with a bag-valve device

• Contact the respiratory therapist to set the tidal volume at a higher level.

• Assess to see if the patient is biting the endotracheal tube.

• Assess to see that the ventilator is attached to the endotracheal tube.

After surgery, a patient's central venous pressure (CVP) monitor indicates low pressures. Which action would the nurse take?

• Increase the infusion rate of the IV vasodilators.

• Increase the IV fluid infusion per protocol

• Elevate the head of the bed to 45 degrees

• Administer IV diuretic medications

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention would the nurse implement first?

• Check potassium level

• Assess pain level

• Assess oral temperature.

• Place on heart monitor.

The nurse is caring for the child who has liver enlargement secondary to infective endocarditis. The nurse should assess the child for which complication associated with the condition.

• tetralogy of Fallot

• pulmonary embolism

• Check potassium level

• Right sided heart failure

A patient arrives in the emergency room with facial and chest burns caused by a house fire. Which action should the nurse take first?

• Give the prescribed hydromorphone

• Determine the depth of the burns

• Auscultate for breath sounds.

• Infuse the prescribed lactated solution.

A nurse is caring for a child who has liver enlargement secondary to infective endocarditis. The nurse should assess the child for which complication associated with the current condition.

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