A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

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Question 1 of 5

A client admitted with a diagnosis of sepsis has a central venous pressure (CVP) of 15 mm Hg. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider immediately. A CVP of 15 mm Hg in a client with sepsis may indicate fluid overload or cardiac dysfunction, which require prompt medical intervention. Notifying the healthcare provider allows for timely assessment and appropriate management. Administering a fluid bolus (A) without further evaluation can exacerbate fluid overload. Administering a diuretic (C) without knowing the underlying cause can be harmful. Continuing to monitor the CVP (D) is important, but immediate action is required due to the high CVP level.

Question 2 of 5

A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states her pain has subsided. What is the legal status of the nurse?

Correct Answer: B

Rationale: The correct answer is B: The client would not be able to prove malpractice in court. In this scenario, although the nurse made an error in administering a higher dose of morphine, the client's condition improved, as evidenced by stable vital signs and pain relief. Therefore, there was no harm caused to the client due to the mistake. In malpractice cases, the client needs to prove that harm or injury resulted from the healthcare provider's actions. Since the client's condition improved, it would be difficult to establish malpractice in this situation. Choice A is incorrect because negligence requires harm or injury to occur, which is not the case here. Choice C is incorrect as the Good Samaritan Act typically applies to individuals providing emergency care in good faith at the scene of an emergency, not within a healthcare setting. Choice D is incorrect as the focus is on the nurse's error in administering the incorrect dose, not on the healthcare provider's responsibility in this context.

Question 3 of 5

A client with a cold is taking the antitussive benzonatate (Tessalon). Which assessment data indicates to the nurse that the medication is effective?

Correct Answer: B

Rationale: The correct answer is B: Denies having coughing spells. Benzonatate is an antitussive medication that suppresses cough reflex. If the client denies having coughing spells, it indicates that the medication is effectively suppressing the cough. This is the most direct indicator of the medication's effectiveness. A: Reports reduced nasal discharge - This is not directly related to the effectiveness of benzonatate in suppressing cough. C: Able to sleep through the night - While improved sleep may result from reduced coughing, it is not as specific an indicator of antitussive effectiveness as denying coughing spells. D: Expectorating bronchial secretions - This indicates productive coughing, which is not the intended effect of benzonatate.

Question 4 of 5

During a home visit, the nurse should evaluate the adequacy of a client's COPD treatment by assessing for which primary symptom?

Correct Answer: A

Rationale: The correct answer is A: Dyspnea. Dyspnea is a primary symptom of COPD due to impaired airflow. Assessing dyspnea helps determine the effectiveness of COPD treatment. Tachycardia (B) may occur but is not a primary symptom. Unilateral diminished breath sounds (C) suggest other conditions, not COPD. Edema of the ankles (D) is more indicative of heart failure.

Question 5 of 5

The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

Correct Answer: D

Rationale: The correct answer is D: Tachycardia, mental status change, and low urine output. In the early stages of shock, the body compensates by increasing heart rate (tachycardia) to maintain perfusion. Mental status change can indicate decreased cerebral perfusion. Low urine output is a sign of decreased renal perfusion. A: Warm skin, hypertension, and constricted pupils are not indicative of shock. In shock, skin becomes cool and clammy, blood pressure drops, and pupils dilate. B: Bradycardia, hypotension, and respiratory acidosis are not early signs of shock. Bradycardia and hypotension occur in the late stages of shock. Respiratory acidosis is a complication of shock, not an early symptom. C: Mottled skin, tachypnea, and hyperactive bowel sounds are signs of shock but not early indicators. Mottled skin appears in the late stages of shock, tach

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