ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 17 : Caring for Clients in Shock Questions
Question 1 of 5
The nurse is obtaining physician orders which include a pulse pressure. The nurse is correct to report which of the following?
Correct Answer: C
Rationale: The nurse would report the difference between the systolic blood pressure number and the diastolic blood pressure number as the pulse pressure.
Question 2 of 5
The nurse is reporting the current nursing assessment to the physician. Vital signs: temperature, $97.2^{\circ} \mathrm{F}$; pulse, 68 beats/minute, thready; respiration, 28 breaths/minute, blood pressure, $102 / 78 \mathrm{~mm} \mathrm{Hg}$; and pedal pulses, palpable. The physician asks for the pulse pressure. Which would the nurse report?
Correct Answer: C
Rationale: The pulse pressure is the numeric difference between systolic and diastolic blood pressure. By subtracting the two numbers, the physician would be told 24 . The pulse pressure does not report quality of the pulse.
Question 3 of 5
The nurse is caring for a client with highly pigmented skin. Which assessment technique is used to evaluate cyanosis?
Correct Answer: B
Rationale: In clients with highly pigmented skin, cyanosis is more accurately detected by inspecting the conjunctiva and oral mucous membranes. The other options do not provide the best assessment for cyanosis.
Question 4 of 5
The seasoned nurse is instructing the new graduate on information obtained from central venous pressure and pulmonary artery pressure. Which statement, made by the seasoned nurse, reflects the most pertinent information regarding circulation?
Correct Answer: B
Rationale: The most pertinent information to share with a new nurse is the information that the pulmonary artery pressure provides essential information about the effectiveness of left ventricle. The left ventricle is most pertinent to circulation. The other information is correct but not as pertinent.
Question 5 of 5
The nurse is initiating intravenous therapy for a client who is in shock. Which ratio of fluid to fluid lost is anticipated?
Correct Answer: C
Rationale: Usually, a ratio of $3 \mathrm{~L}$ of fluid is administered for every $1 \mathrm{~L}$ of fluid lost.