Term II Unit III Questions

A client with MODS has a SOFA score of 12. What does this suggest?

The nurse assesses a client with mitral valve disease. Which clinical manifestation is expected?

The nurse is educating a client post-valve replacement. Which statement indicates a need for further teaching?

A client in the refractory stage of shock is unresponsive to interventions. What should the nurse prepare for?

A client with AAA reports abdominal pain and hypotension. What is the nurse’s priority?

A client with cardiac tamponade has an echocardiogram ordered. What is the purpose of this diagnostic test?

A client with a suspected AAA reports sudden back pain and hypotension. What should the nurse prepare for?

A client with valve replacement reports chest pain. What should the nurse assess first?

The nurse is providing discharge teaching to a client post-CABG. Which instruction is most important?

A client with DIC has a PT of 20 seconds. What does this indicate?

The nurse assesses a client with SIRS and tachycardia. Which additional finding confirms SIRS?

A client with a history of myocardial infarction suddenly collapses. What rhythm should the nurse anticipate?

A client with AAA has a BP of 80/50 mmHg and severe back pain. What is the priority?

The nurse is titrating norepinephrine for a client in shock. Which parameter should guide the titration?

The nurse assesses a client with valve disease and edema. What is the likely cause?

The nurse is caring for a client with septic shock and an arterial line. What is the benefit of this device?

The nurse is caring for a client with MODS and anuria. What is the likely cause?

The nurse is monitoring a client post-CABG with a chest tube. What finding indicates a complication?

A client with aortic valve replacement reports shortness of breath. What should the nurse assess first?

A client meets SIRS criteria with a temperature of 39°C and heart rate of 100 bpm. What should the nurse assess next?

A client post-splenectomy develops SIRS with a temperature of 101.7°F and BP 78/46. What is the nurse’s priority?

The nurse assesses a client in the initial stage of shock. Which finding is expected?

A client post-endovascular aneurysm repair (EVAR) has decreased pedal pulses. What should the nurse do first?

A client with DIC has a fibrinogen level of 100 mg/dL. What does this indicate?

The nurse assesses a client with SIRS and a WBC of 15,000/mm³. What should be done next?

The nurse is caring for a client with cardiac tamponade. Which finding indicates worsening condition?

The nurse is caring for a client with SIRS due to pancreatitis. Which intervention is most appropriate?

The nurse is caring for a client with hypovolemic shock and a BP of 70/40 mmHg. What is the priority?

A client with neurogenic shock has a spinal cord injury at T4. Which finding should the nurse expect?

The nurse is caring for a client with DIC and bleeding from IV sites. What should be prioritized?

A client in hypovolemic shock has lost 30% of their circulating blood volume. What is the nurse’s priority intervention?

A client with DIC has a decreased platelet count and increased D-dimer. What should the nurse monitor for?

A client in pulseless electrical activity (PEA) arrest is receiving CPR. What should the nurse prioritize?

The nurse is caring for a client with cardiac tamponade awaiting surgery. Which position is most appropriate?

A client with cardiac tamponade has a BP of 90/60 mmHg. What should the nurse prepare for?

The nurse is caring for a client post-CABG with a dry suction chest drainage system. What indicates proper function?

The nurse assesses a client in septic shock. Which clinical manifestation should the nurse expect?

A client post-valve replacement develops an irregular heartbeat. What is the nurse’s priority action?

A client with hypovolemic shock receives albumin. What should the nurse monitor?

A client with SIRS has a temperature of 39°C and RR 24 breaths/min. What should the nurse assess?

A client with valve replacement has an INR of 3.5. What should the nurse do?

A client with cardiac tamponade has a BP drop during inspiration. What is this called?

A client with valve replacement and endocarditis. What is the priority?

A client in cardiac arrest has ROSC after CPR. What should the nurse monitor next?

The nurse is reflecting on caring for a client with altered perfusion. What is the most important nursing role?

A client with DIC develops epistaxis and petechiae. What should the nurse do first?

A client post-CABG reports throat pain. What should the nurse explain?

A client with MODS has a rising creatinine level and anuria. What should the nurse anticipate?

The nurse is defibrillating a client in ventricular fibrillation. What is the initial energy setting?

A client post-CABG reports incisional pain. Which intervention should the nurse implement first?

A 4-year-old requiring cardiac surgery is anxious. How should the nurse adjust the assessment?

A client post-CABG has a chest tube with 200 mL of bloody drainage in 1 hour. What should the nurse do?

The nurse is defibrillating a client in ventricular fibrillation. What should be ensured?

The nurse assesses a client with MODS using the SOFA score. Which organ system is evaluated?

A client with sepsis develops MODS. What is the nurse’s priority intervention?

The nurse is performing CPR on a client in cardiac arrest. How often should epinephrine be administered?

The nurse hears an audible bruit over a client’s abdomen. What should be suspected?

A client with anaphylactic shock receives epinephrine. What should the nurse monitor for?

A client with MODS is receiving dopamine 10 mcg/kg/min. What is the rationale for this therapy?

A client post-CABG develops tachycardia and hypotension. What should the nurse suspect?

The nurse palpates a pulsating mass in a client with hypertension. What should be done first?

A client with valve replacement develops endocarditis. What should the nurse teach the client?

The nurse is caring for a client with MODS and mechanical ventilation. What indicates respiratory improvement?

A client in cardiopulmonary arrest has asystole. What is the nurse’s priority?

The nurse is caring for a client with DIC due to sepsis. Which laboratory result indicates improvement?

The nurse is administering heparin to a client with DIC. What is the goal of this therapy?

The nurse notes return of spontaneous circulation (ROSC) post-arrest. What is the next priority?

A client post-central line placement develops cardiac tamponade. What should the nurse monitor for?

The nurse is administering fresh frozen plasma to a client with DIC. What is the purpose of this therapy?

The nurse is educating a client post-CABG. Which activity should be avoided?

The nurse palpates a pulsating abdominal mass in a client. What is the most likely diagnosis?

A client with a ruptured AAA exhibits Cullen’s sign. What does this indicate?

The nurse assesses a client with suspected cardiac tamponade. Which finding supports pulsus paradoxus?

The nurse hears muffled heart sounds in a client post-MI. What should be suspected?

A client with AAA is scheduled for open repair. What preoperative teaching is essential?

A client with septic shock has a lactate level of 4 mmol/L. What does this indicate?

A client with DIC is at risk for organ damage. What should the nurse prioritize?

The nurse is caring for a client with a ruptured spleen and hypovolemic shock. Which vital sign finding is expected?

The nurse is teaching a client post-CABG about cardiac rehabilitation. What is the primary goal?

A client with SIRS has a heart rate of 95 bpm and temperature of 38.5°C. What additional finding confirms SIRS?

The nurse is teaching a client with an AAA about risk factor modification. Which statement should be included?

A client with MODS has a decreased cardiac output. What should the nurse anticipate?

The nurse monitors a client with SIRS for progression to sepsis. Which finding is most concerning?

A client with septic shock has a BP of 85/50 mmHg. What should the nurse administer first?

The nurse is performing CPR on a client in ventricular tachycardia. What should be done next?

The nurse is caring for a client with cardiogenic shock. Which laboratory result should the nurse monitor closely?

A client with SIRS develops tachypnea and a PaCO2 of 30 mmHg. What does this indicate?

The nurse is monitoring a client with toxic shock syndrome. Which intervention is most appropriate?

A client with a wound infection post-surgery has improved vital signs (BP 109/64, pulse 88). What does this indicate?

A client with SIRS is receiving antibiotics. What should the nurse evaluate to assess treatment effectiveness?