Author: Anonymous

41.  A patient with a head injury has an arterial blood pressure is 92/50 mm Hg and an intracranial pressure of 18 mm Hg.  Which action by the nurse is appropriate?  

54.  Which intervention would the nurse predict to be of least benefit for hypotension when the patient is in cardiogenic shock following acute myocardial infarction?

10. The charge nurse is observing a new staff nurse who is assessing a patient with a possible spinal lesion for sensation.  Which action indicates a need for further teaching about neurologic assessment?  

40.  A patient with right-sided weakness that started 1 hour ago is admitted to the emergency department and all these diagnostic tests are ordered.  Which order should the nurse act on first?  

60. A 78-kg patient with septic shock has a pulse rate of 120 beats/min with low central venous pressure.  Urine output has been 30 mL/hr for the past 3 hours.  Which order by the health care provider should the nurse question?

50. Systemic inflammatory response syndrome (SIRS) is characterized by all of the following except:

13.  During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:

34.  A patient has a systemic blood pressure (BP) of 120/60 mm Hg and an intracranial pressure of 24 mm Hg.  The nurse determines that the cerebral perfusion pressure (CPP) of this patient indicates  

49. An older client with cardiogenic shock is cool and clammy.  Hemodynamic monitoring indicates a high systemic vascular resistance (SVR).  Which intervention should the nurse anticipate?

8.  The nurse is admitting a client with possible Haemophilus influenzae—meningitis. It is MOST important for the nurse to take which of the following actions?