ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 69 Questions
Question 1 of 5
The health care provider prescribes the following actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?
Order the Items
Source Container
Correct Answer: E,D,C,A,B
Rationale: The priority is to improve oxygenation (titrate oxygen), followed by fluid resuscitation (normal saline), vasopressor administration (vasopressin), obtaining cultures, and finally administering antibiotics (vancomycin) to ensure timely treatment while confirming the infection source.
Question 2 of 5
After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which of the following prescribed medications should the nurse administer?
Correct Answer: C
Rationale: Norepinephrine, a vasopressor, is appropriate to increase systemic vascular resistance and improve blood pressure when fluid resuscitation is insufficient in septic shock. Nitroglycerin and nitroprusside are vasodilators and would worsen hypotension, while drotrecogin-?± addresses inflammation but not blood pressure directly.
Question 3 of 5
Which of the following interventions should the nurse implement first when a patient in the emergency department develops anaphylactic shock?
Correct Answer: C
Rationale: Epinephrine is the first-line treatment for anaphylactic shock, as it rapidly reverses vasodilation, bronchoconstriction, and histamine effects. Fluid resuscitation, additional IV access, and vasopressors like dopamine are secondary actions after epinephrine administration.
Question 4 of 5
The nurse is caring for a patient in the emergency department (ED) with massive trauma and possible spinal cord injury. Which of the following findings by the nurse will help confirm a diagnosis of neurogenic shock?
Correct Answer: C
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of sympathetic tone, as seen with an apical heart rate of 48 beats/minute. Cool, clammy skin is more typical of hypovolemic or cardiogenic shock, inspiratory crackles suggest pulmonary edema, and fever is not specific to neurogenic shock.
Question 5 of 5
The nurse is caring for a patient with shock whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?
Correct Answer: A
Rationale: The patient's elevated pulmonary artery wedge pressure indicates volume excess, and infusing normal saline at 250 ml/hour could worsen this condition, potentially leading to pulmonary edema. The other actions are appropriate to support cardiac function and manage shock.