A client is unstable and receiving dopamine to increase blood pressure. Which of the following
are interventions that the nurse administering dopamine would employ? (Select all that apply.)
Verify dosage and pump settings with another RN.
Administer through an intact peripheral line.
Measure urine output every hour.
Use an intravenous controller or pump.
Assess vital signs every hour.
The nurse receives a client from the post-anesthesia unit with a new onset of sinus tachycardia
and a heart rate of 118 beats per minute. To which reasons does the nurse relate the increased
heart rate? (Select all that apply.)
Blood loss
Anxiety
Fever
Sleep
Hypoglycemia
The nurse is alerted to a client’s telemetry monitor. After assessing the following ECG, what is
the nurse’s priority intervention?
Prepare for intubation
Perform defibrillation
Administer atropine
Start a large-bore IV
The nurse is caring for a client on a med-tele unit who was admitted with complaints of
intractable nausea and vomiting. The client has had 3 bouts of emesis over the past 4 hours, and
the most recent telemetry strip looks like this:
Which action should the nurse take first?
call a code blue
administer ondansetron 4mg. IVP
Call the provider
check the client
A client with disseminated intravascular coagulation (DIC) has a critically low fibrinogen level
and is beginning to hemorrhage. To increase the amount of fibrinogen in the body, the nurse
anticipates administering which blood product?
Cryoprecipitate
Albumin
Fresh frozen plasma
Packed red blood cells
A 78-year-old man has confusion and temperature of 104° F (40° C). He is a diabetic with
purulent drainage from his right heel. After an infusion of 3 L of normal saline solution, his
assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8
L/minute; and PAWP 4 mm Hg. This patient's symptoms are most likely indicative of:
sepsis.
multiple organ dysfunction syndrome.
septic shock.
systemic inflammatory response syndrome.
The nurse is obtaining a history from a client diagnosed with hypertrophic cardiomyopathy.
What information obtained from the client is indicative of hypertrophic cardiomyopathy?
a parent has the same disorder
a history of alcoholism
a history of amyloidosis
a long-standing history of hypertension
The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client
diagnosed with DIC. Which would be an appropriate goal?
The client will use lemon-glycerin swabs for oral care
The client's clot formations will resolve in two days
The client's urine output will be > 30 mL per hour
The saturation of the client's dressings will be documented
A nurse is caring for a 14-year-old client who was admitted with cellulitis and has been ordered
warm compresses. The nurse delegates the treatment to the unlicensed assistive personnel
(UAP). The compress causes a first-degree burn to the area. Which actions should the nurse
initiate? (Select all that apply.)
Complete an incident report regarding the event.
Notify the healthcare provider of the injury.
Document the injury describing the UAP's actions.
Initiate a disciplinary action toward the UAP.
Place ice compresses on the injured area.
A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the
following signs would the nurse recognize as positive indicators? (Select all that apply.)
Radiating chest pain
Hypertension
A systolic bruit
An abdominal pulsatile mass
Low back pain
Lower abdominal pain