The nurse is caring for a patient with severe sepsis. Vital signs assessed by the nurse include BP 88/60 mm Hg, HR 145 beats/min, RR 28 breaths/min, temperature 101°F, CVP 1 mm Hg, and SpO2 94% on 3 L/cannula. Which physician order should the nurse initiate first?

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Question 1 of 5

The nurse is caring for a patient with severe sepsis. Vital signs assessed by the nurse include BP 88/60 mm Hg, HR 145 beats/min, RR 28 breaths/min, temperature 101°F, CVP 1 mm Hg, and SpO2 94% on 3 L/cannula. Which physician order should the nurse initiate first?

Correct Answer: D

Rationale: Low BP and CVP in sepsis require fluid resuscitation (D) first to restore perfusion.

Question 2 of 5

How many pairs of cranial nerves originate within the brain?

Correct Answer: D

Rationale: 12 pairs of cranial nerves originate from the brain. [Level: Knowledge]

Question 3 of 5

A male client is admitted to the rehabilitation unit following a cerebrovascular (CVA), which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best response from the nurse?

Correct Answer: C

Rationale: Empathy acknowledges frustration, building rapport. A delays, B escalates, D is instructional but not immediate. [Level: Application]

Question 4 of 5

While performing a neurovascular assessment distal to a client’s fracture site, the nurse determines that the client’s pulse is present, regular, and full. Which nursing action should be taken next?

Correct Answer: D

Rationale: Normal pulse is reassuring, but full neurovascular check (color, sensation, pain, movement) ensures no compromise. B follows D. [Level: Application]

Question 5 of 5

Which finding should the nurse document as primary manifestation of osteoporosis in an older woman?

Correct Answer: A

Rationale: Osteoporosis causes vertebral compression, leading to height loss. B is not typical, C/D are secondary or unrelated. [Level: Comprehension]

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