ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 37 Questions
Question 1 of 5
A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the client's mean arterial pressure (MAP)?
Correct Answer: B
Rationale: Lower blood volume will decrease MAP because reduced blood volume leads to decreased cardiac output and subsequently lower pressure in the arterial system. The other answers are not accurate as they do not correctly describe the physiological response to blood loss.
Question 2 of 5
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)
Correct Answer: A,D,E
Rationale: The nurse can delegate bringing warm blankets, reorienting the client to decrease anxiety, and sitting with the client for reassurance. Providing hot tea is inappropriate as the client should be NPO. Massaging the legs is not recommended due to the risk of dislodging clots, which could lead to pulmonary embolism.
Question 3 of 5
A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
Correct Answer: B
Rationale: Preventing dehydration in older adults is critical because the age-related decrease in the thirst mechanism makes them prone to dehydration, a risk factor for shock. Drinking fluids on a regular schedule helps maintain hydration. The other options are relevant but less specific to preventing dehydration-related shock.
Question 4 of 5
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³, temperature 96.8°F, and weak pedal pulses. What action by the nurse takes priority?
Correct Answer: C
Rationale: This client has several indicators of sepsis with systemic inflammatory response, such as low white blood cell count, hypothermia, and poor perfusion (weak pulses). The nurse should notify the health care provider immediately to initiate prompt treatment. Documentation and comfort measures are important but not the priority. Insulin may not be needed in this scenario.
Question 5 of 5
A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
Correct Answer: A
Rationale: Normal cognitive function is a good indicator that the client is receiving the benefits of norepinephrine, which improves perfusion to vital organs, including the brain. Absence of chest pain, normal IV site, and minimal urine output do not specifically indicate the therapeutic effect of norepinephrine.