A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denial of chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
Question 2A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first?
a. Apply personal protective equipment.
b. Notify local law enforcement officials.
c. Obtain universal donor blood.
d. Prepare the client for emergency surgery.
Question 3A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.
Question 4A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
Question 5A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority?
a. Document the findings in the client's chart.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
Question 6A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?
a. High glucose is common in shock and needs to be treated.
b. Some of the medications we are giving are to raise blood sugar.
c. The IV solution has lots of glucose, which raises blood sugar.
d. The stress of this illness has made your spouse a diabetic.
Question 7A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings.
What action does the nurse delegate next to the UAP?
a.
Assess the client for pain or discomfort.
b.
Measure urine output from the catheter.
c.
Reposition the client to the unaffected side.
d.
Stay with the client and reassure him or her.
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