exam 2

Pt has dehydration and hypotension after having vomiting and diarrhea for 3 days. Which is most important to tell dr?

Which of the following provides the correct description of a wound to the correct level of injury? SATA

Pts warfarin level is therapeutic when which of the following numbers is reported

Pt has fluid volume overload from cardiogenic shock. What symptom should the nurse expect?

Nurse is planning care for a pt who sustained severe burn injuries. Which interventions should the nurse include? SATA

The pathophysiology of acute respiratory distress syndrome is characterized by which of the following?

Pt has septic shock, urine output 20ml/hr, HR 120, low venous pressure. Which order would you question

Which of the following criteria would support the placement of a tracheostomy in this client?

Pt has neurogenic shock after a diving accident. He has a cervical collar. What should the nurse do? SATA

Which statement indicates the nurses correct understanding of DIC?

Pt has vitals: BP 90/60, 101F, 116 HR, 24 RR. Pt has post op incision warm and red. What type of shock are they in?

Nurse is helping dr to care for pt with a tension pneumothorax. Which actions should be performed first?

What should you assess to check if treatment for anaphylactic shock was effective

Based on report, the nurse will prioritize the clients to see which one first?

Calculate TBSA. Burns on half of front torso, entire left arm, front of left leg.

Calculate hourly rate during first 8 hrs. Pt has 55% TBSA and weighs 160 lbs.

which of the following would be a sign or symptom of acute respiratory distress syndrome?

The nurse should expect to note which finding for a fractured rib?

Nurse recognizes indication of respiratory distress includes all the following except?

Pt has shock, BP 92/54, HR 64, elevated pulmonary artery wedge pressure. Which order would you question?

Pt is severely bleeding and at risk for hypovolemic shock, the nurse anticipates which of the following?

A pt who in the nonprogressive compensatory stage of hypovolemic shock. Which should the nurse anticipate

Pt receiving phenylephrine iv. Which assessment obtained by the nurse indicates a need for immediate action?

Pt 1 day post op, having difficulty breathing, bilateral rales, confused and restless. What should the nurse do first?

Which finding would indicate the presence of pneumothorax in this client?

ICU is caring for a pt. The ventilator alarms are sounds. What should the nurse do first?

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

Which of the following pts should the nurse assess first?

Which of these is the best indicator that the fluid resuscitation for a pt with hypovolemic shock has been successful?

Which client is at least risk for developing acute respiratory distress syndrome?

Pt given silver sulfadiazine for a burn injury. Which finding would cause the nurse to question this order

nurse is caring for a ventilated client. Which intervention is appropriate for this client?

A client with a pulmonary embolism may have which of the following interventions?

After shock, the pt's sympathetic nervous symptom is correctly attempting to compensate when? SATA

Pt has sudden SOB, pleuritic chest pain, diaphoresis, low BP, 85% O2 sat, and crackles in left lower lung. What is it

identify which client is not experiencing distributive shock?

Pt treated for hypovolemic shock. Which shows the treatment is working?

Pt with spinal cord injury is in ER. Which finding by the nurse will comfirm neurogenic shock?

Pt diagnosed with a flail chest. After the pt is intubated, which treatment does the nurse expect to be implemented?

Pt with mod burns, SOB, elevated temp, urine 10/hr, increased WBC, GFR, ALT, and AST. What is this?

Pt with superficial partial thickness and deep partial thickness burns 38 hrs ago. What should be told to provider?

Which of the following would be the priority nursing dx with pt in acute phase of burn injury?

IV norepinephrine. The nurse expects the drug to have which effect on the clients mean arterial pressure?

Pt with a chest injury has suffered a flail chest. What is the most distinctive sign of flail chest?

Which med can cause hypertensive reaction?

What teaching is correct with hydrotherapy?

Which of the following is an indicator of adequate fluid resuscitation?

Pt has burns 37% of body. Pt is hoarse, brassy cough, and drooling. What does this indicate?

How do for a mechanically ventilated client to prevent ventricular acquired pneumonia? SATA

A nurse is caring for a group of clients. Which client is at most risk for a pulmonary embolism?

Pt is receiving mechanical ventilation via an endotracheal tube. Which actions should the nurse take?

which action by the new RN indicated a need for further education in the care of clients with shock?

Which pt is at highest risk for ARDS and MODS?

Pt 2 days post pneumonectomy has apical pulse 128 BP 80/50. What intervention should be done first?

Which if the following interventions is not appropriate for a client diagnosed with a pneumothorax?

Nurse is planning care for a pt who has severe (ARDS). Which actions should the nurse include?

Pt with pulmonary embolism. Which dx and treatment does nurse anticipate? SATA

The ventilator sounds a low pressure alarm. The nurse immediately assess for other signs of which condition?

Pt treated in the ER for shock of unknown etiology. The first action by the nurse is which of the following?

nurse is caring for pt with ABG pH 7.21, PaCO2 60 mmhg, PaO2 42 mmHg, HCO3 22mEq/L. What meds should you use to help

Pt with early sepsis. Which change in status is the most important to report?

Which of the following interventions would not be appropriate for hypovolemic shock?

client begins to show signs of shock. How should the client be positioned?

When assessing pt with a burn injury nurse classifies the burn as a full thickness burn based on observing what

Pt has full thickness burn, absent radial pulse, and fingers mottled. Pain 8/10. What do you do?

The nurse prepares IV tubing to infuse with which IV solution in preparation for a blood transfusion?

Nurse is caring for a pt who is in the progressive stage of shock. Which finding shouldthe nurse expect?

Calculate the mean arterial pressure in mmHg for a client with a blood pressure of 84/46 mmHg

Pt with severe burns is scheduled for an escharotomy. What does this procedure entail?

Nurse is evaluating the lab values of a pt in the resuscitation phase following amajor burn. Which should we expect?

Pt is in ER with sucking inward of chest. ABG shows hypoxemia and hypercarbia. What does nurse prepare for

Pt receiving dobutamine to treat septic shock. Which one is most important to notify dr